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MEDICAL BENEFIT SUMMARY GRID: TUFTS HEALTH TOGETHER (MASSHEALTH) CAREPLUS ABBREVIATIONS BH = Behavioral health IN = In-network MM = Medical management team at Tufts Health Plan NPIN = Nonpreferred in-network OON = Out-of-network PA = Prior authorization PCP = Primary care provider Benefit year = October 1 – September 30 Service Abortion Acupuncture Acute inpatient stay Annual co-payment maximum per calendar year per member Medical and BH = $0 Pharmacy = $250 Please note: • Providers must submit prior authorization requests, if required, five business days prior to the service start date. All services rendered by NPIN or OON providers require prior authorization. • Some members may require a PCP referral for specialty services. If we require prior authorization, we do not require a referral as well. Coverage/Limits/Conditions Covered Covered for pain relief or anesthesia for up to 20 visits per benefit year. Also covered if medically necessary to treat substance abuse. Covered if medically necessary Adult day care Adult foster care Allergy shots Ambulatory surgery/ Same-day surgery/ Outpatient surgery/ Surgical day care Anesthesia services Not covered Not covered Covered if medically necessary Covered if medically necessary when surgical procedure performed at IN outpatient facility. Includes outpatient, surgical, and related diagnostic and medical/dental services. Covered if medically necessary. For additional PA requirements, see pain management. Apnea monitor Covered if medically necessary Audiologist Autologous chondrocyte implant of the knee Exams and evaluations covered if medically necessary Covered if medically necessary 6032E 07197 Related payment policy Co-payment $0 $0 PA required? None IN and OON Acute Inpatient Hospital Admissions $0 IN and OON Not covered Not covered $0 $0 Not covered Not covered OON IN for certain services (see specific entries) OON: All Anesthesia Services, Obstetric Anesthesia Services Durable Medical Equipment (DME) $0 IN $0 OON: All $0 $0 OON IN and OON Medical Benefit Summary Grid: Tufts Health Together (MassHealth) — CarePlus 1 Service Benign prostatic hypertrophy (BPH) treatments Biofeedback Bone density test Coverage/Limits/Conditions Covered if medically necessary Breast pumps Cardiac catheterization Cardiac rehabilitation Care management Chemotherapy/ Radiation therapy Chiropractic services Cholycystectomy Cosmetic surgery Court-ordered services CPAP/BiPAP Custodial care Day habilitation Dental, emergency Dental, nonemergency 6032E 07197 Co-payment $0 PA required? IN and OON Not covered Covered if medically necessary. PA not required IN, except for members younger than 50 or members whose test frequency exceeds one test every two years. Not covered $0 Not covered IN: See coverage conditions at left Breast pumps, one per birth or as medically necessary, including double electric pumps, are provided to expectant and new mothers as specifically prescribed by their attending physicians and consistent with the provisions of the Affordable Care Act of 2010 and Section 274 of Chapter 165 of the Acts of 2014. Covered if medically necessary Covered if medically necessary Covered when provided by Tufts Health Plan care managers Covered if medically necessary $0 Covered for up to 20 office visits per benefit year. Includes chiropractic manipulative treatments, office visits or any combination thereof. Covered if medically necessary Not covered Covered if medically necessary, except for court-ordered lab services May cover continuous positive airway pressure machine (CPAP) and bilevel positive airway pressure machine (BiPAP) if medically necessary after sleep study completed and reviewed Not covered Not covered Covered if medically necessary. Includes emergency dental services and oral surgery by a physician as a result of an injury, accident or other condition. Covered by MassHealth if medically necessary for preventive and basic services to prevent and control dental disease and maintain oral health Related payment policy OON: All IN: Electric hospitalgrade pumps OON: All pumps Chiropractic Services DME $0 $0 $0 IN and OON OON None $0 OON $0 OON $0 Not covered $0 IN and OON Not covered IN and OON $0 IN and OON Not covered Not covered $0 Not covered Not covered None $0 Contact MassHealth at 800.841.2900 Medical Benefit Summary Grid: Tufts Health Together (MassHealth) — CarePlus 2 Service Diabetes education Diagnostic procedures Coverage/Limits/Conditions Covered if medically necessary. Includes educational and training services by a physician or other provider (registered nurses, physician assistants, nurse practitioners and licensed dietitians) to treat prediabetes or diabetes. Covered if medically necessary. Includes colonoscopy, endoscopy, sigmoidoscopy and gastroscopy. Durable medical equipment (DME) Covered if medically necessary. Includes labs, X-rays, EKGs, EEGs and ultrasounds. Covered if medically necessary. Includes labs, drugs, tubing change, adapter change, training related to hemodialysis and peritoneal dialysis (intermittent, continuous cycling and continuous ambulatory). Covered if medically necessary. Not covered when courtordered or legally required. Covered if medically necessary. Includes medical and surgical supplies. Emergency services Covered for emergency medical and BH services Exams/ Other treatment Experimental services Not covered, including services related to or for the purpose of employment, education, licensing or court order Not covered. See our list of experimental and investigational procedures. Covered for basic services. Includes birth control and intrauterine devices (IUDs). Infertility services and their treatment not covered, including in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), reversal of voluntary sterilization and sperm banking. Vaccine and administration covered for members ages 19–49 if medically necessary. Flu vaccine delivered intranasally by spray. Covered if medically necessary Covered if medically necessary Diagnostic testing Dialysis services Drug screening Family planning FluMist Gastric bypass surgery Genetic testing 6032E 07197 Related payment policy Co-payment $0 PA required? None $0 $0 OON Endoscopy: IN and OON OON: All services except labs IN and OON Drug Screening $0 OON DME $0 Emergency Room Services $0 Not covered IN: See payment policy OON: All Nebulizers: None Notification required within 24 hours, if admitted Not covered Not covered Not covered $0 None $0 OON $0 $0 IN and OON IN and OON $0 Genetic Testing Medical Benefit Summary Grid: Tufts Health Together (MassHealth) — CarePlus 3 Service Hearing aids Hepatitis B vaccine Holter monitor Home health care services Home infusion therapy Hospice care Human papillomavirus (HPV) vaccine Hysterectomy Immunization services Infertility services Inpatient chronic or rehabilitation care 6032E 07197 Coverage/Limits/Conditions Covered if medically necessary. Includes loan and purchase of hearing aids, ear molds, ear impressions, batteries, accessories and aid/instruction in the use, care and maintenance of the hearing aid. Covered if medically necessary for adults ages 19 and older. Vaccine and administration covered. Covered if medically necessary Related payment policy Co-payment $0 PA required? IN and OON Vaccine and Immunization Services DME $0 OON $0 Covered if medically necessary, after an inpatient stay, and if member demonstrates a need for nursing or therapy services. Includes associated DME, part-time or intermittent skilled nursing care, physical/occupational/speech therapies, and part-time or intermittent home health aide services. Covered if medically necessary Covered if medically necessary for terminally ill members, if provider agrees not to continue with a curative treatment program. Nursing, medical and social services covered. Covered if medically necessary for males and females ages 19–26 Covered if medically necessary Covered if medically necessary. Vaccine administration covered. Covered for adults ages 19 and older when required for school. State-supplied serum not covered unless state supply exhausted. Not covered if required for traveling outside U.S. Covered only for the diagnosis of infertility and treatment of an underlying medical condition. Other infertility services and their diagnosis/treatment not covered, including in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), reversal of voluntary sterilization and sperm banking. Covered if medically necessary. Daily inpatient rehabilitative services provided for up to 100 days per benefit year. Home Health Care Services $0 IN: See payment policy OON: All IN only if request is for daily visits or for requests greater than 6 months and OON Vaccine and Immunization Services Vaccine and Immunization Services $0 $0 IN and OON IN and OON $0 None $0 $0 IN and OON None $0 IN and OON $0 IN and OON Medical Benefit Summary Grid: Tufts Health Together (MassHealth) — CarePlus 4 Service Inpatient hospitalization Coverage/Limits/Conditions Covered if medically necessary Institutional care Knee Arthroscopy Laboratory services Not covered Covered if medically necessary Covered if medically necessary. Includes blood tests, urinalysis, Pap smears, and throat cultures to maintain health and diagnose, treat and prevent disease. Covered. IN or OON providers must submit a Prenatal Registration Form to MM. Maternity care/ Prenatal visits/ Nurse midwife services Myringotomy with Tubes Nuclear cardiology Nurse practitioner services Nutritional counseling Nutritional supplements Observation day Organ/Bone marrow transplants Orthotics 6032E 07197 Related payment policy Not covered $0 $0 PA required? IN and OON Elective admissions: Submit PA form 5 business days prior to admission Not covered IN and OON None $0 None $0 IN and OON $0 IN and OON $0 NPIN and OON $0 IN and OON DME $0 IN and OON Observation Services $0 $0 IN: Stays longer than 48 hours OON: All IN and OON $0 IN and OON Facility Maternity Services Covered if medically necessary Covered if medically necessary. Submit PA requests to National Imaging Associates. Not covered unless credentialed for billing as a PCP Covered if rendered by an accredited provider (physician, licensed dietitian, licensed nutritionist, registered nurse, physician assistant or nurse practitioner). Includes nutritional, diagnostic, therapy and counseling services for a medical condition. Covered if medically necessary and prescribed for a medical condition. Not covered for nutritional supplements covered by Women, Infants, and Children (WIC) Nutrition Program. Covered if medically necessary Covered if medically necessary. Experimental and investigational transplants not covered. Covered if medically necessary. Includes nondental braces and other mechanical or molded devices to support or correct any defect of form or function of the human body. Includes repairs. Limit one pair of shoes per 12-month period. Shoe inserts covered for diabetics only. Radiology Imaging Services Nurse Practitioner as a Primary Care Provider Orthotic Services Co-payment $0 Medical Benefit Summary Grid: Tufts Health Together (MassHealth) — CarePlus 5 Service Outpatient hospital services Over-the-counter (OTC) drugs Oxygen/Respiratory therapy equipment Pacemaker implant Pain management Percutaneous vertebroplasty and kyphoplasty Personal care attendant/items Personal emergency response systems (PERS) Pharmacy Physician assistant services Physician services 6032E 07197 Coverage/Limits/Conditions Covered if medically necessary Covered if requested with a prescription written by an IN or OON physician. Must be obtained at a participating pharmacy. Examples include: • Aspirin/Acetaminophen/Ibuprofen • Allergy medication/Decongestant • Tobacco cessation products • Diabetic supplies (e.g., strips, lancets) • Multivitamins and iron/calcium supplements Covered if medically necessary. Includes ambulatory oxygen systems and refills, aspirators, compressor-driven nebulizers, intermittent positive pressure breathers, oxygen, oxygen gas, oxygen-generating devices and oxygen therapy equipment rental. Covered if medically necessary Covered if medically necessary Covered if medically necessary Related payment policy Co-payment $0 Contraceptive agents: $0 Covered OTC drugs: $0–$3.65 for a 30-day supply PA required? See specific service for PA requirement No DME $0 IN: See payment policy OON: All Anesthesia Services $0 $0 $0 IN and OON IN and OON IN and OON Not covered Not covered Not covered Covered if medically necessary $0 OON Co-payments for one-month supply via participating pharmacies. Co-payments due at time of service. No co-payment for: • Birth control and family-planning supplies • Members while pregnant or up to 60 days after giving birth • Prescription diabetes/asthma supplies Not covered unless credentialed for billing as a PCP $0 as indicated $1–$3.65 (Tier 1) $3.65 (Tier 2) Tufts Health Plan pharmacy co-payments See our Preferred Drug List (PDL) for PA requirements $0 NPIN and OON Covered, including PCP and specialty services with the exception of podiatry and orthotics. Some members may require PCP referral for specialty services. $0 PCP: NPIN and OON Specialist: NPIN and OON Medical Benefit Summary Grid: Tufts Health Together (MassHealth) — CarePlus 6 Service Podiatry Coverage/Limits/Conditions Covered for medical conditions. Includes routine foot care for diabetics. Private-duty nursing Prosthetics Not covered Covered. Includes evaluation, fabrication, fitting, provision of prosthesis and repairs. Covered if medically necessary Pulmonary function test Pulmonary rehabilitation Radiation therapy, internal selective Radiology/X-rays Shoulder arthroscopy Shingles vaccine Sinusotomy endoscopic – frontal and maxillary sinus Skilled nursing facility Sleep study Specialist Spinal cord/Dorsal column stimulation/Elective spinal procedures Stress test Temporomandibular joint (TMJ) treatment 6032E 07197 Related payment policy Podiatry Services Co-payment $0 Prosthetic Services Not covered $0 PA required? IN: Nondiabetic routine care OON: All Not covered IN and OON $0 None Covered if medically necessary $0 OON Covered if medically necessary $0 IN and OON $0 $0 $0 IN: See coverage conditions at left OON: All IN and OON None Covered if medically necessary $0 IN and OON Covered if medically necessary when received in an inpatient setting for up to 100 days per benefit year Covered if medically necessary Covered if medically necessary. Some members may require PCP referral for specialty services. Covered if medically necessary $0 IN and OON $0 $0 OON NPIN and OON: All $0 IN and OON $0 $0 OON IN and OON Covered if medically necessary. MRIs, MRAs, CAT scans, nuclear cardiology and PET scans require PA. Contact National Imaging Associates to request PA. Covered if medically necessary Covered only for members older than 60 Covered if medically necessary Covered for surgery if medically necessary. Not covered for physical therapy, corrective devices and/or other treatments. Radiology Imaging Services, Therapeutic Radiology Services Vaccine and Immunization Services Specialty Services Referral Requirement Medical Benefit Summary Grid: Tufts Health Together (MassHealth) — CarePlus 7 Service Therapy — physical, occupational, speech and hearing Coverage/Limits/Conditions Covered if medically necessary Related payment policy Outpatient Therapy Co-payment $0 PA required? IN: After initial evaluation and 11 visits for PT and OT IN: After 30 visits for ST and hearing Tobacco cessation Transportation, emergency Transportation, nonemergency Transsexual surgery Upper GI endoscopy Urgent care Vaccines Vasectomy Vision care — Tufts Health Plan providers Vocational rehabilitation 6032E 07197 Covered for individual and group tobacco-cessation counseling rendered by an IN provider. Includes specific medications obtained from a pharmacy. Covered if medically necessary Covered for transport to an out-of-state location farther than a 50-mile radius of the Massachusetts border. MassHealth covers in-state nonemergency transportation or transport within a 50-mile radius of the Massachusetts border. Covered if medically necessary Covered if medically necessary Covered if medically necessary IN and OON Covered if medically necessary. Vaccine administration covered. Covered for adults ages 19 and older when required for school. State-supplied serum not covered unless state supply exhausted. Not covered if required for traveling outside U.S. Covered, except for reversal of voluntary sterilization Covered for routine eye examinations from participating providers once every 24 months for nondiabetic members and members ages 21 and older, and once every 12 months for diabetic members and members younger than 21. MassHealth covers all nonmedical vision care, including certain eyeglasses or contact lenses, vision training and other visual aids. Contact lens fittings not covered. Not covered $3.65 for pharmacy medications Ambulance Transport Services Ambulance Transport Services Vaccine and Immunization Services Vision Services OON: All OON $0 None $0 IN and OON $0 $0 $0 IN and OON IN and OON None, if billed with place-of-service code 20 None $0 $0 $0 OON IN: Vision therapy OON: All Contact MassHealth at 800.841.2900 for wraparound benefits Not covered Medical Benefit Summary Grid: Tufts Health Together (MassHealth) — CarePlus Not covered 8 Service Wellness Wigs 6032E 07197 Coverage/Limits/Conditions See coverage conditions for family-planning, nutrition and maternity/prenatal/nurse midwife services Covered if medically necessary Related payment policy Co-payment $0 $0 Medical Benefit Summary Grid: Tufts Health Together (MassHealth) — CarePlus PA required? See specific service for PA requirement OON 9