Download medical benefit summary grid

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