Enrollment Materials - Coastline Elderly Services, Inc.

Now that you’re a Member:
• Go online and register for My Wellness Plan
• Search for Network Providers
• Review your benefits to better understand your plan
Questions? tuftshealthplan.com
|
1-800-462-0224
18533_1/10
Member Services 1-800-462-0224
705 Mount Auburn Street
|
|
tuftshealthplan.com
tuftshealthplan.com
Watertown, MA 02472
Online Tools
|
Member Discounts
|
Health Programs
Enrollment Materials
At a Glance
• A Summary of your Benefits
• My Wellness Plan
• Member Discounts
• Fitness Benefit
• Vision Care
• Other information specific to your plan
WELCOME TO TUFTS HEALTH PLAN
New Members—Register at Tuftshealthplan.com for fast access to your secure online account and personal benefit information.
Please complete all of the employee sections of this membership application in full. Failure to do so could delay
enrollment. You will receive your ID card and member
benefit document soon. Need a temporary ID? Use the
yellow copy of this completed form.
Member Sections
• Personal Information: Complete all enrollment information. If your plan (HMO, POS, or EPO) requires the
selection of a primary care provider (PCP), be sure to fill
out this section for all members, including dependents.
• Product Code: Please be sure to fill in the correct product code for the plan you have selected.
• Primary Care Provider: It is important that you choose
a PCP right away, if your plan requires one. Without
a PCP assignment, your in-network benefits may be
limited to emergency services only. To find a PCP, visit
tuftshealthplan.com and use the Doctor Search feature.
On this application you will indicate whether you are an
established patient of the PCP you have listed. You are
an established patient if you have seen the PCP routinely
in the past for your health care. If you are selecting a
new PCP, contact the doctor right away, introduce yourself as a new member, and find out if your doctor would
like to schedule a physical exam. Transfer your medical
records to your new PCP right away.
• Student/Child Dependents: If you have a student/
child dependent enrolling on your plan (age 19 and over
in Rhode Island; 19 or 21 and over in Massachusetts,
depending on employer) you must certify their status
on initial enrollment and again as requested by Tufts
Health Plan. Dependent certification forms can be
obtained and submitted at tuftshealthplan.com.
• Other Health Coverage: If you have other insurance
(including Medicare), please check the correct box and
fill in the additional information about your other insurance. If you do not have other insurance, be sure to
check the No box.
Employer Section
Your employer must fill out this section.
When the Application is Complete
• Employee keeps the yellow copy (also your temporary ID)
• Employer keeps the pink copy
• Tufts Health Plan receives the original white copy
Tufts Health Plan
P.O. Box 9186
Watertown, MA 02471-9186
If You Need Emergency Care
In an emergency, go to the nearest medical facility or call
911. An emergency is a serious injury or the onset of a
serious condition that prevents you from taking the time
to call your PCP, if your plan requires one.
Notices
By enrolling, you agree to and understand that if you or any
of your enrolled dependents obtain a health care benefit or
payment that you know you are not entitled to receive, or if
you knowingly present or cause to be presented with fraudulent intent a claim that contains a false statement, you can
be liable for the full amount of the health care benefit or
payment made and for reasonable attorney’s fees and costs,
including cost of investigation.
Tufts Health Plan arranges for the provision of health
care services but does not provide health care services.
Tufts Health Plan arranges for the provision of health care
through agreements with independent community-based
health care professionals working in private offices and
with hospitals throughout the Tufts Health Plan service
area. These providers are independent contractors and
not employees, agents, or representatives of Tufts Health
Plan.
Product Codes
Write the corresponding letter in the product box in
the member section of the enrollment application.
A - HMO Premium
B - HMO Value
C - HMO Basic
D - HMO Choice Copay
E - Advantage HMO
G - Advantage HMO
Saver
H - POS
I - POS Choice Copay
J - EPO
K - EPO Choice Copay
L - PPO
M - Advantage PPO
O - Advantage PPO
Saver
We speak 140 languages.
Call Member Services.
P - Navigator by Tufts
Health Plan
Q - Carelink
R - HMO Select 15
S - HMO Select 20
T - Advantage HMO
Select 750
U - Advantage HMO
Select 2000
W - Rhode Island
Healthpact
RIC - Rhode Island
Conversion
Need Help?
If you need assistance selecting a PCP, visit tuftshealthplan.com and use the Doctor
Search feature. If you need
help filling out this form, call
a member services specialist.
Member Services:
1-800-462-0224
18079-1/10
10????.indd 1
2/10/10 11:04 AM
MEMBER ENROLLMENT FORM
Please print clearly or type. Please be sure application is completed in full to ensure enrollment. Enrollment/Eligibility • PO Box 9186 • Watertown, Massachusetts 02471-9186
FAILURE TO COMPLETE AREAS MARKED IN BLUE WILL CAUSE A DELAY IN ENROLLMENT.
EMPLOYER SECTION
Group/Company Name________________________________________________________________________ Group Number_______________________________________________________
Office Location________________________________________ Date of Hire____________________________________ Effective Date of Coverage____________________________________
Type of Enrollment: ❏ New Hire ❏ Open Enrollment ❏ COBRA ❏ New Group ❏ Qualifying Event (MUST specify)___________________ Qualifying Event Date______________________________
MEMBER SECTION
PRODUCT (Select corresponding letter from the list on the front page) _________ Other _______________________________________
Last Name_________________________________________________ First Name_________________________________________ Middle Initial______ Primary Language________________________
Employee Social Security Number (required)_______________________________
Date of Birth (MM/DD/YYYY)_______ / _______ / _______________ Gender: ❏ Male ❏ Female
Mailing (Home) Address___________________________________________________ City_______________________________ State_____ ZIP___________ Home Telephone ( ____ ) ______________
Marital Status: ❏ Single ❏ Married ❏ Divorced ❏ Domestic Partner Type of Coverage Requested: ❏ Individual ❏ Family ❏ Other______________________ Work Telephone ( ____ ) ______________
Primary Care Provider (HMO, POS, EPO only) First Name___________________
Members Enrolling
(First name, include last name, if different)
Sex
M/F
Last Name_____________________________
PCP ID# _______________ Are you an established patient of this PCP? ❏ Yes ❏ No
Date of
Birth
Social Security Number
If dependent is age 19 or over,
please check one
Choose a Primary Care Provider for
each member (HMO, POS, EPO only.
Include first and last name)
Check
if currently
used for
primary care
Full time
student
Disabled
IRS
Dependent
❏ Spouse
❏ Domestic Partner
❏
❏
❏
-
-
❏
Child/Dependent
❏
❏
❏
-
-
❏
Child/Dependent
❏
❏
❏
-
-
❏
Child/Dependent
❏
❏
❏
-
-
❏
Child/Dependent
❏
❏
❏
-
-
❏
Child/Dependent
❏
❏
❏
-
-
❏
PCP ID #
Please check if you are using additional membership applications for additional dependent children. ❏
Do you or someone else covered under this insurance policy have other health insurance coverage at the same time your Tufts Health Plan policy is in effect? ❏ Yes
❏ Yes (Medicare)
❏ No
Name of Health Plan_____________________________________________ Name of Plan Holder___________________________________ Health Plan Number____________________ Effective Date______________________
Names of Family Members Covered___________________________________ Is spouse employed? ❏ Yes ❏ No
If yes, Name and Address of Employer _____________________________________________________________
The information supplied on this form is true and complete. I authorize my employer to make necessary payroll deductions, if any, for my share of Tufts Health Plan coverage. I assign benefits to Tufts Health Plan providers, which means that Tufts Health Plan is authorized to make payments directly to Tufts Health Plan providers for services rendered to me (us). I grant Tufts Health Plan any legal right that I (we) may have to recover the cost of services for an illness or injury caused by someone else when these services have been or
will be paid by Tufts Health Plan. I understand that calls to the member services department may be monitored for quality assurance. I understand that the benefits for which I (we) are eligible are those described in the applicable member benefit documents.
Signature (required)_____________________________________ Date____________ Benefits Dept. Signature__________________________________ Telephone__________________________ Date____________
WHITE - TUFTS HEALTH PLAN COPY
10????.indd 2
PINK - EMPLOYER COPY
YELLOW - SUBSCRIBER COPY. Please keep yellow copy as your temporary Tufts Health Plan ID.
2/10/10 11:04 AM
DISCOVER THE CONVENIENCE OF
FIND A DOCTOR
Search for physicians and
primary care providers in
your plan’s network
Research provider
credentials, qualifications,
experience and more
Understand the difference
between Tufts Health Plan’s
provider networks
Learn how to customize
your search preferences
Search other types of
participating providers
like mental health,
vision, fitness centers,
acupuncture, and more
Your secure Tufts Health Plan
member Web site
Enter a primary care
provider’s last name for
direct access to detailed
information
Note: This guide is based on a typical member experience. Actual features may vary based on your plan.
18580-1/10
My Wellness Plan
It’s easy to register!
Make the most of your coverage and get instant access
to your plan.
1. Go to tuftshealthplan.com
2. Click “Register Today”
3. Enter the requested information to create your new
username and password
Log in for instant access to your secure online account.
VISIT MY WELLNESS PLAN TODAY
MANAGE YOUR COVERAGE
Taking an active role in your health care puts you in the driver’s seat.
Welcome to My Wellness Plan—your online resource for getting the
information you need, when you need it.
View a summary of your plan’s coverage
and copay amounts
PERSONAL HOME PAGE
Check the status of claims and print
your Explanation of Benefits (EOB)
Clear navigation
Easy access to
common
transactions
Print forms, order ID cards, change
account preferences and more
Confirm any needed referrals
Learn how you can save on products and services
including diet, fitness, health and wellness
Access information about our wide range of
health programs
Find a vision provider and learn about discounts
Access your pharmacy coverage (if applicable)
TAKE CHARGE OF YOUR HEALTH
Receive reminders for important preventive
health screenings
Track your most important health measurements
- Look up health topics in the Healthwise Knowledgebase
- Compare cost and quality of hospitals to help you
decide where to receive care
- Calculate average cost information for hundreds of
treatments and procedures
Help improve your health by completing this
confidential personal health assessment
Access health
assessment tools
Bookmark online health
resources
Update personal
information
Note: This guide is based on a typical member experience. Actual features may vary based on your plan.
Personalize your account with health topics that
matter to you
HOW to use your pharmacy benefit
Confirm that your medication is on our list of
covered drugs.
Go to tuftshealthplan.com and click on “Pharmacy”
on the Members tab.
On the Pharmacy screen, click on the link that
applies to you:
n Massachusetts employer-based plans
n Rhode Island employer-based plans
n Select Network plans
Search for the name of your medication. If your
medication is not listed, call our Member Services
Department at the number printed on your ID card.
Step 2
Step 1
Here are step-by-step instructions on how to fill a prescription for the first time.
Follow these four easy steps every time you receive a prescription for a new medication.
Check whether any of the
following apply to your
medication:
n PA: Prior authorization
n NC: Non-covered
n STPA: Step therapy
n DL: Dispensing limitation
n SP: Designated specialty pharmacy
Step 3
Step 4
If your medication has the following:
n PA (prior authorization) or NC (non-covered): Contact the provider who has written your
prescription. If your provider believes a drug with a PA or NC is necessary for your treatment, he
or she may submit a request for coverage by faxing a Universal Pharmacy Medical Review Request
Form to Tufts Health Plan. We will cover the medication if it meets our medical necessity coverage guidelines. If the request is approved, you will be covered for your prescription. If it is not
approved, you can appeal the decision.
n
S TPA (step therapy): Check the step therapy document in the Pharmacy section at
tuftshealthplan.com/members to confirm the step your drug is on. If you have not previously taken
the steps required by our pharmacy coverage, and your provider believes the drug prescribed for
you is medically necessary, he or she may request coverage by submitting a Universal Pharmacy
Medical Review Request Form.
n
L (dispensing limitation): You are covered for up to the amount posted in our list of covered
D
drugs. If your provider believes it is necessary for you to take more than the DL amount posted
on the list, he or she may submit a Universal Pharmacy Medical Review Request Form to request
coverage.
n
S P (designated specialty pharmacy): Call the designated specialty pharmacy provider indicated
in your online search or contact the Tufts Health Plan Member Services Department at the number on
your ID card to help ensure you receive your medication without interruption.
Check the cost of your covered medication.
Covered drugs are grouped in three tiers, or levels, of cost:
n Tier 1: You pay the lowest copayment; includes most generic drugs
n Tier 2: You pay the middle copayment; includes brand-name drugs
n Tier 3: You pay the highest copayment; includes the most-costly covered brand-name drugs not
included in Tier 2
Check the specifics of your pharmacy coverage to see if a deductible applies.
Our List of Covered Drugs
The list of medications covered by our pharmacy
benefit is called our formulary. Most drugs are
included on our formulary.
We use a variety of approaches to manage the
pharmacy benefit. Our goal is to balance quality, safety, and affordability so that you and your
provider can make decisions for your care that are
right for you.
Some of these approaches include the 3-tier pharmacy copayment, prior authorization, step therapy,
dispensing limitations, and designated specialty
pharmacy programs.
top 200 covered drugs
This is a list of the 200 medications most used by Tufts Health Plan members. This is not a complete list of drugs
covered by the Tufts Health Plan pharmacy benefit. For a complete list, visit tuftshealthplan.com. For more detailed
benefit information, please review your benefit summary or member benefit document.
TIER 1 COPAYMENT
Acetaminophen-Codeine
Acyclovir
Albuterol Sulfate
Inhalation SolutionDL
Alendronate Sodium
Allopurinol
Alprazolam
Amitriptyline HCl
Amlodipine Besylate
Amoxicillin
Amoxicillin Trihydrate - Potassium Clavulanate
Amphetamine Salt Combo
Apri
Atenolol
Aviane
Azithromycin
Benzonatate
Betamethasone
Dipropionate
Bupropion HCl SR
Bupropion XL
Buspirone HCl
Butalbital-APAP-Caffeine
Carisoprodol
Carvedilol
Cephalexin
Chlorhexidine Gluconate
Ciprofloxacin HCl
Citalopram HBr
Clarithromycin
Clindamycin HCl
Clindamycin Phosphate
Clobetasol Propionate
Clonazepam
Clonidine HCl
ClotrimazoleBetamethasone
Colchicine
Cyclobenzaprine HCl
Dextroamphetamine-
Amphetamine Mixed Salts ER
Diazepam
Diclofenac Sodium
Digoxin
Diltiazem ER
Divalproex Sodium
Doxazosin Mesylate
Doxycycline Hyclate
Enalapril Maleate
Erythromycin
Estradiol
Finasteride 5mg
Fluconazole
Fluocinonide
Fluoxetine HCl
Fluticasone Propionate
Nasal SprayDL
Folic Acid
Furosemide
Gabapentin
Gemfibrozil
Glipizide
Glipizide ER
Glyburide
Hydrochlorothiazide
Hydrocodone-
Acetaminophen
Hydrocortisone
Hydroxychloroquine Sulfate
Hydroxyzine HCl
Ibuprofen
Indomethacin
Iophen-C NR
Isosorbide Mononitrate
Kariva
Ketoconazole
Labetalol HCl
Lamotrigine
Levora-28
Levothyroxine Sodium
Levoxyl
Lisinopril
Lisinopril-HCTZ
Lithium Carbonate
Lorazepam
Lovastatin
Low-Ogestrel
Lutera
Medroxyprogesterone Acetate
Metformin HCl
Metformin HCl ER
Methotrexate
Methylphenidate HCl
Methylprednisolone
Metoclopramide HCl
Metoprolol Succinate
Metoprolol Tartrate
Metronidazole
Microgestin FE
Minocycline HCl
Mirtazapine
Mupirocin Ointment
Naproxen
Necon 1/35
Neomycin-Polymyxin-HC
Nifedipine ER
Nortriptyline HCl
Nystatin
Ocella
OmeprazoleDL
Ondansetron HClDL, NM
Oxycodone HCl
Oxycodone-Acetaminophen
PA
Pantoprazole SodiumDL,ST
Paroxetine HCl
Penicillin V Potassium
Potassium Chloride
Pravastatin Sodium
Prednisolone Sodium Phosphate
Prednisone
Prenatal Plus
Propoxyphene Napsylate-
APAP
Propranolol HCl
Quinapril HCl
Ranitidine HCl
Reclipsen
Risperidone
Sertraline HCl
Simvastatin
Sodium Fluoride
Spironolactone
Sprintec
Sulfamethoxazole-
Trimethoprim
Sumatriptan SuccinateDL, NM
Tamoxifen Citrate
Temazepam
Terazosin HCl
Topiramate
Tramadol HCl
Trazodone HCl
Tretinoin topicalPA
Triamcinolone Acetonide
Triamterene-HCTZ
Trinessa
Tri-Sprintec
Trivora-28
Venlafaxine HCl
Verapamil HCl
Warfarin Sodium
Zolpidem TartrateDL, NM
Zovia 1-35E
NasonexDL
Niaspan
Novolog Vials
Nuvaring
One Touch Ultra Test Strips
OxycontinDL, NM
Plavix
Proair HFADL
Seroquel
Singulair
SpirivaDL
StratteraDL
SuboxoneNM
TamifluDL, NM
Tricor
Vagifem
Ventolin HFADL
PA
VytorinST
Xalatan
Yaz
Diovan
Diovan HCT
LexaproSTPA
PA
LipitorST
Premarin
Proventil HFADL
Synthroid
Topamax
Valtrex
ViagraDL, NM
PA
ZetiaST
TIER 2 copayment
Abilify
Actos
Advair DiskusDL
Asacol
Avelox
Concerta
PA
CrestorST
PA
Effexor XRST
EpipenDL, NM
Evista
Flomax
Flovent HFADL
Humalog Vials
Januvia
Lantus Vials
LidodermPA, DL
TIER 3 copayment
PA
ActonelST
Adderall XR
Benicar
CelebrexPA
CialisDL, NM
Cozaar
PA
CymbaltaDL, ST
Detrol LA
Please note: A drug’s tier placement may change at any time during the year.
DL The list of Top 200 Covered Drugs is current as of January 29, 2010.
Dispensing Limitation: This drug has a dispensing limitation because of potential safety and utilization concerns. This means that you are only covered for a certain quantity of a drug
within a given time period.
PA Prior Authorization: This drug requires a prior authorization to promote safety and affordability. If your provider believes it is medically necessary for you to take the drug, he/she can
submit a request to Tufts Health Plan. If approved, Tufts Health Plan will cover the medication.
ST Step Therapy: Step therapy is an automated form of prior authorization which uses previous claims history for approval at the pharmacy. Step therapy programs help encourage the
clinically proven use of appropriate, cost-effective therapies first, before other, possibly more expensive treatments may be covered.
NM
This drug is not suitable for mail order because the dispensing limitation is less than a 90-day supply.
PA
where to fill your prescription
You have the following options when filling
prescriptions:
1. To obtain most covered medications, go
to any of the more than 63,000
CVS Caremark-participating pharmacies,
which include retail chain stores,
inde­pendent pharmacies, and designated
specialty pharmacies, in addition to
CVS/pharmacy locations.
2. Fill prescriptions for designated specialty
medications at participating designated
specialty pharmacies.
3. Use the CVS Caremark mail-order
pharmacy service for most covered
maintenance medications and you may
save on up to a 90-day supply. Maintenance
medications are those you refill each month
for conditions such as diabetes, high blood
pressure, and asthma.
If you choose to use the CVS Caremark
mail-order pharmacy service, here’s how
to get started:
n Be sure you have any necessary approvals
in place. Then call CVS Caremark Customer
Service toll free at 1-800-581-5300. If your
medication does not need an approval, you will
be transferred to CVS Caremark’s FastStartSM
service, which will get you started with the
mail-order service. You will need the following
when you make the call:
• Your Tufts Health Plan ID card
• Medication name
• Your physician’s name and phone number
• Shipping address
• Credit card information and expiration date
Once you begin receiving medications by mail,
you can order refills easily online or by phone.
Please note: Please note: In general,
mail-order service is not recommended for
medications that have dispensing limitations
of less than a 90-day supply. Please check
to see whether your medication has any
dispensing limita­tions before following the
instructions for using the CVS Caremark
mail-order pharmacy service.
Tufts Health Plan and CVS Caremark
As our pharmacy benefits manager, CVS Caremark reviews and processes your claims when you purchase prescription medications. Members
covered by our pharmacy benefit may fill prescriptions at any of the more than 63,000 CVS Caremark-participating pharmacies, which
include retail chain stores, independent pharmacies, and designated specialty pharmacies, in addition to CVS/pharmacy locations. The CVS
Caremark Mail Service Pharmacy is available for members who take maintenance medications.
For more information
Tufts Health Plan Member Services 1-800-462-0224
tuftshealthplan.com
19380_2/10
Routine Vision Care Coverage and Eyewear Discounts
The EyeMed Vision Care Network
Tufts Health Plan offers coverage for routine eye exams
and other vision care services through the EyeMed
Vision Care network of more than 22,000 private
practice and optical retail locations.
EyeMed offers the freedom to choose a vision care provider from an extensive nationwide network of private
practice optometrists, ophthalmologists, opticians, and
well-known optical retailers, including:
• LensCrafters
• Sears Optical
• Target Optical
• JCPenney Optical
• most Pearle Vision locations
To receive coverage for routine eye exams, you must
visit an optometrist or ophthalmologist in the EyeMed
network.
To find a vision care provider or to determine if
your existing eye doctor is in the EyeMed network,
click on Doctor Search on the Members tab at
tuftshealthplan.com. Under Find a Provider by Type,
select Routine Eye Care.
As a Tufts Health Plan member, you and your plan
dependents are eligible to receive discounts on vision
correction and eyewear from EyeMed participating
providers.
|
• Save 20% on the retail price of nonprescription
sunglasses.
• Save 15% on the retail price (or 5% on the
promotional price) of LASIK and PRK laser vision
correction.**
• Visit www.eyemedcontacts.com to order replacement
contact lenses at less than retail price. Have your
contacts shipped directly to your home or office.***
* Discount program not available on select frame brands. Retail price may vary by
location.
** EyeMed and LCA-Vision have arranged to provide this discount to all EyeMed
Vision Care members through the U.S. Laser Network. Members are entitled to a
15% discount on the usual and customary fees for LASIK and PRK procedures or a
5% discount on any promotional pricing, whichever has the greater value. Because
LASIK or PRK vision correction is an elective procedure performed by specially
trained providers, the discounts may not always be available from a provider in
your area. For a location near you and for the discount authorization, please call
1-877-5LASER6.
*** Members who receive a contact lens evaluation and fitting will be responsible for
these charges, which are exempt from the discount.
continued on reverse
Eyewear Discounts
tuftshealthplan.com
• Save 35% on the retail price of frames and receive
discount pricing on lenses and lens options, with the
purchase of a complete pair of eyeglasses.*
1-800-462-0224
Register at tuftshealthplan.com and start using
My Wellness Plan to manage your health and
well-being.
About Your Vision Care Benefit
What is a Routine Eye Exam?
A routine eye exam may include some of the following
covered services:
• A review of the history of your eyes and vision, along
with your general medical history and history of
medications
• A discussion of any specific vision problems you may
have or reasons for your visit
Non-routine eye examinations and services may require
a referral for an ophthalmologist from your primary
care provider, depending on your plan. Log in to My
Wellness Plan to learn more about your benefit.
Learn more about your vision care coverage
To find out more about your coverage, log in to
My Wellness Plan at tuftshealthplan.com. If you have
additional questions, call EyeMed Vision Care at
1-866-504-5908.
• An examination of the inside and outside of your eyes
and of the areas surrounding the eyes
• Measurement of the pressure in your eyes
• Dilation of your eyes: enlarging your pupils so that
the eye doctor can examine the entire inside of your
eyes
• Measurement of the sharpness of your vision close up
and at a distance
• A test of your eyesight to determine a prescription for
eyeglasses or whether you are a candidate for contact
lenses
• A treatment plan and/or follow-up advice
Other vision care services
In addition to routine eye exams, covered vision care
services include those used to diagnose, treat, or
monitor medical eye diseases and conditions, such as
glaucoma or diabetes, as well as any necessary periodic follow-up eye exams. Optometrists in the EyeMed
network may provide some of these services. If you do
need such services, ask your selected vision care
provider how regularly you should be seen.
tuftshealthplan.com
18581_2/10
|
1-800-462-0224
Eye Care Practitioners
Optometrists (O.D.s) are specialists
licensed to perform routine eye
examinations and certain diagnostic
and therapeutic eye care services, and
to prescribe glasses or other corrective
devices.
Ophthalmologists are physicians
(M.D.s) who perform eye examinations,
treat disease, perform surgical or other
procedures, and prescribe glasses or
other corrective devices.
Opticians dispense corrective eyewear
materials, such as contact lenses,
spectacle lenses, low vision aids, or
ophthalmic prosthetics.
Tufts Health Plan Member Discounts
Save on Memberships, Services, and Products that Promote Well-being
Tufts Health Plan wants to help you achieve your wellness
goals with discounts on fitness center memberships,
nutritional supplements, mind and body treatments, and
a variety of services related to good health.
Hospital-Based Health and Wellness Seminars
Save up to 30% on wellness seminars and workshops at
participating facilities. Topics include smoking cessation,
stress management, aging, and parenting.
Click on Member Discounts on the Members tab at
tuftshealthplan.com to learn more about the following
savings.
Natural Therapies
Learn more about aromatherapy, homeopathic remedies, meditation, yoga, and other natural remedies at
ChooseHealthy.com, and save up to 40% on purchases.
NUTRITION
Nutrition Counseling
In addition to your health plan coverage for medically
necessarily counseling, you can receive 25% off the cost
of unlimited visits with a registered dietitian or licensed
nutritionist in our network. Learn more about diets that
promote good health.
WeightWatchers®
Pay no joining fee for the traditional Weight Watchers
program and receive a $10 discount on the price of
a Weight Watchers Deluxe At Home Kit. Join Weight
Watchers Online and receive a $10 discount.
NutriSystem®
Save $30 on your introductory order of NutriSystem’s
28-Day Favorites Package when you order through
GlobalFit, part of our fitness network. Visit
globalfit.com/diet for more information.
Dietary and Nutrition Supplements
Save up to 40% on a wide variety of vitamins, supplements, and popular energy and protein bars through
ChooseHealthy.com. Standard shipping is also free for
members.
MIND AND BODY
Acupuncture and Massage Therapy
Save 25% on acupuncture treatments and massage
therapy. To find a participating provider, click on
Member Discounts at tuftshealthplan.com
tuftshealthplan.com
|
1-800-462-0224
FITNESS
As a member of Tufts Health Plan, you are eligible to
save on initiation and membership fees for participating
fitness facilities and programs.
• Save 20% on annual memberships and pay no initiation fee at Tufts Health Plan network fitness centers
in Massachusetts, New Hampshire, and Rhode Island.
The network includes 80 health and fitness centers.
• Save up to 60% on annual membership fees at any
GlobalFit network fitness facility. There are over 8,000
GlobalFit locations nationwide to choose from.
continued on reverse
• Save 50% when you join a participating New England
Curves® club.
• Save 10% on personal training packages at Fitness
Together and receive a free initial fitness evaluation.
• Save 20% on Appalachian Mountain Club membership
rates and receive discounts on accommodations,
subscriptions and programs.
• Members 18 and younger pay no membership fee to
enroll at participating Boys & Girls Clubs in Massachusetts and Rhode Island. Young members also receive a
20% discount on the cost of most programs.
• As an alternative to annual memberships, you and
your family can visit a fitness center in the Tufts
Health Plan network and pay a small copayment
($3 - $6) for each visit, up to five visits a month.
New Balance Discount
New Balance of Burlington and Mashpee, Massachusetts,
offers members a 15% discount on fitness-related
apparel, footwear, and accessories.
MORE SAVINGS
Eyewear
With the EyeMed Vision Care program, members can
receive 35% off the retail price of frames, along with
discounts on lenses and lens options, with the purchase
of a complete pair of eyeglasses from a participating
EyeMed provider. EyeMed Vision Care also offers a
contact lens replacement program, 20% off the retail
price of nonprescription sunglasses, and 15% off the
retail price (or 5% off the promotional price) of LASIK
and PRK laser vision correction. Programs are available
through EyeMed Vision Care participating providers.
Home Instead Senior Care
Do you or an elderly family member need home support
services, such as light housekeeping or meal preparation?
Receive a $100 one-time credit towards charges for
these and other non-medical home care services through
participating offices. A free home-safety inspection is
also provided once you contract for services. It includes
a review of the home entrance, kitchen, bathrooms,
and more.
Register at tuftshealthplan.com and start using My Wellness Plan to manage your health and well-being.
tuftshealthplan.com
18582-1/10
|
1-800-462-0224
Fitness Rewards
Reward Yourself with Fitness Rebates and Discounts
As an incentive to our members to get fit and stay healthy,
Tufts Health Plan offers a number of opportunities to
save on fitness center initiation and membership fees at
a wide range of fitness centers both in and out of our
network.
Fitness Club Rebate - $150
Getting a $150 rebate on your fitness center membership
is simple. Complete at least four consecutive months
of membership in Tufts Health Plan and at a qualified
fitness center.* Then, submit the Fitness Rebate Form,
along with proof of fitness center membership and
proof of payment, and we’ll reimburse up to $150 of
your fitness club fees for the year.
The rebate applies once per family, per year, after you
have incurred up to $150 of fitness club membership
fees and have met the eligibility requirements. The
fitness reimbursement is paid to the Tufts Health Plan
subscriber.
Fitness Networks
Save even more when you join a fitness center in the
Tufts Health Plan network. Click on Fitness Centers on
the Member Discounts page of tuftshealthplan.com to
learn more about the following discounts.
• Save 20% on annual memberships and pay no initiation fee at any of our 80 Tufts Health Plan network
fitness centers in Massachusetts, New Hampshire,
and Rhode Island.
• Save up to 60% on annual membership fees at any
GlobalFit network fitness facility. There are over 8,000
GlobalFit locations nationwide to choose from.
• Save 50% when you join a participating New England
Curves® club.
• Save 10% on personal training packages at Fitness
Together and receive a free initial fitness evaluation.
tuftshealthplan.com
|
1-800-462-0224
• Members 18 and younger pay no membership fee to
enroll at participating Boys & Girls Clubs in Massachusetts and Rhode Island. Young members also receive a
20% discount on the cost of most programs.
As an alternative to annual memberships, you and your
family can visit a fitness center in the Tufts Health Plan
network and pay a small copayment for each visit, up to
five visits a month.
• Up to 5 years of age: Free
• Ages 6 to 15: $3 per visit
• Ages 16 and older: $6 per visit
* A qualified fitness center is a facility with cardiovascular and strengthtraining equipment and facilities for improving physical fitness. Facilities
and programs that are NOT considered qualified fitness centers include
martial arts centers, gymnastics facilities, country clubs, aerobic or
pool-only facilities, sports teams and leagues, and tennis clubs. Fees for
personal trainers, sports instructors, yoga classes, and exercise equipment
are also excluded from the rebate.
continued on reverse
Register at tuftshealthplan.com and start using
My Wellness Plan to manage your health and
well-being.
Fitness rebate Form
Please print clearly. Required sections are marked in blue. Retain a copy of all receipts and documents for your records. Please be sure to sign the
form. To qualify for the fitness rebate, you must complete four consecutive months of membership in Tufts Health Plan and at a qualified fitness
center each year you apply.
1. Member’s Tufts Health Plan ID#
3. Member’s Date of Birth
Sex: q M q F
5. Subscriber’s Name:
Address:
Telephone: (
)
2. Member’s Name (Last, First, Middle Initial)
/
/
4. Member’s Relationship to Subscriber
q Self q Spouse q Child q Other
6. Fitness Club Name:
Address:
Telephone: (
)
-
7. In what setting did the member receive treatment?
(e.g., office, ER, hospital, clinic, ambulance, etc.)
Fitness Club
-
8. Outside the USA:
NA
In what country was the member seen? ____________
NA
In what language was the bill written? ______________
NA
In what currency was the bill paid? ________________
9. DIAGNOSIS: What were you seen for?
Diagnosis Code: 799
10.
Description: General
A
B
C
Year of fitness club Procedure code and/or description of procedures, services, or supplies provided
membership
* T4220 Health club membership, annual
Amount paid
*
*
11. Total Amount Paid: _____________
12. Proof of fitness club membership:
q A copy of your fitness club member agreement
13. Proof of payment (check one):
q An itemized receipt from the fitness club, showing the dates of membership and dollar amounts paid
q Copies of receipts for fitness club membership dues
q A credit card statement or receipt
q A statement from the fitness club on the fitness club’s letterhead, with an authorized signature, indicating payment was made
Receipts or statements should include the name of the subscriber and indicate charges for at least four consecutive months of membership.
14. Signature is required:
I attest that the above information is true and accurate, and the services were received and paid for in the amount requested
as indicated above. I acknowledge that if any information on this form is misleading or fraudulent, my coverage may be
cancelled and I may be subject to criminal and/or civil penalties for false health care claims. I also understand that Tufts Health
Plan may request any additional information it deems necessary to verify that services were received and payment was made.
I understand that the $150 fitness rebate may be considered taxable income.
______________________________________________________________________
Member signature INTERNAL USE ONLY
Representative’s Name/Extension:
Please submit this form and all documentation to:
Tufts Health Plan
Member Reimbursement Claims, PO Box 9191
Watertown, MA 02471-9191
18583-1/10
Corporate Receipt Date:
___________
Date
Our Quality Report Card
When it comes to your health plan, quality counts.
You want a plan that provides quality coverage and access to
the best health care providers and hospitals around.
I’m proud to be able to say Tufts Health Plan—a local, nonprofit plan with a national reputation for excellence—is one
of America’s best.
Our health plans hold the National Committee for Quality Assurance’s (NCQA’s) highest Accreditations. NCQA is a
private, nonprofit organization whose mission is to improve
health care quality.
And I’m thrilled to tell you that a recent ranking by NCQA
and U.S. News & World Report—in America’s Best Health
Insurance Plans for 2009-101—awarded Tufts Health Plan
five stars on an impressive array of quality measures. (Plans
received ratings of 1 to 5 stars.)
 Member Satisfaction
James Roosevelt, Jr.
President and CEO
 Treatment

Satisfaction with physicians

Diabetes

Personal doctor

Blood pressure control (140/90)

Specialists

Retinal eye exams

Care received

Glucose testing

Satisfaction with health plan services

Glucose control

LDL cholesterol control
 Prevention

Children and adolescents

Monitoring kidney disease

Well-child visit, infants

Heart disease

Well-child visits for ages 3-6

Beta blocker after heart attack

Access for children ages 7-11

LDL cholesterol screening

Adolescent well-care visits ages 12-21

Mental and behavioral health

Timeliness of prenatal checkups

Cancer screening

Breast cancer screening

Cervical cancer screening

Colorectal cancer screening

Early immunizations
tuftshealthplan.com
19497-1/10
These quality rankings—achieved from among a field of some
487 participating health plans from across the nation—are an
impressive accomplishment. They recognize our outstanding
performance in clinical quality and member satisfaction.
But most importantly, they reflect our commitment to your
health and well-being.
Thank you for being a Tufts Health Plan member. I hope
you’ll be well!
|
1-800-462-0224
1
U.S. News/NCQA America’s Best Health Insurance Plans 2009-10.
“America’s Best Health Insurance Plans” is a trademark of U.S. News &
World Report.
Tufts Health Plan Service Area
Save on Memberships, Services, and Products that Promote Wellbeing
The Tufts Health Plan service area includes a standard
service area and an extended service area.
Standard Service Area
The standard service area includes all of Massachusetts
(except Martha’s Vineyard and Nantucket), all of Rhode
Island (except Block Island), and towns in New Hampshire
in which contracted primary care physicians (PCPs) are
located and that are a reasonable distance from contracted specialists who provide the most-often used
services, such as behavioral health practitioners,
surgeons and OB/GYNs.
Extended Service Area
The extended service area includes Martha’s Vineyard,
Nantucket, Block Island, and towns in Connecticut, New
Hampshire, New York, and Vermont that surround the
standard service area and are located a reasonable distance from contracted PCPs and specialists who provide
the most-often used services, such as behavioral health
practitioners, surgeons and OB/GYNs.
Duchess
(NY)
Our network includes approximately 25,000 physicians
and 90 hospitals. Visit our Web site at
tuftshealthplan.com for a current list of our network
providers.
Standard Service Area
Counties with some towns in the Standard Service Area
and some towns in the Extended Service Area
Counties with some towns in the Extended Service Area
To determine whether your zip code is part of the service area, please visit
tuftshealthplan.com, click “Doctor Search” on the Members tab, then click
“Service by Zip Code to see if your town is within the Tufts Health Plan service
area.”
Please note that the products Tufts Health Plan offers through the
Commonwealth Health Insurance Connector cover a smaller service area
and use the Tufts Health Plan Select Network.
tuftshealthplan.com
|
1-800-462-0224
MASSACHUSETTS
Abington
Accord
Acton
Acushnet
Adams
Agawam
Allston
Amesbury
Amherst
Andover
Arlington
Arlington Heights
Ashburnham
Ashby
Ashfield
Ashland
Ashley Falls
Assonet
Athol
Attleboro
Attleboro Falls
Auburn
Auburndale
Avon
Ayer
Babson Park
Baldwinville
Barnstable
Barre
Becket
Bedford
Belchertown
Bellingham
Belmont
Berkley
Berkshire
Berlin
Bernardston
Beverly
Billerica
Blackstone
Blandford
Bolton
Bondsville
Boston
Boxborough
Boxford
Boylston
Braintree
Brant Rock
Brewster
Bridgewater
Brighton
Brimfield
Brockton
Brookfield
Brookline
Brookline Village
Bryantville
Buckland
Burlington
Buzzards Bay
Byfield
Cambridge
Canton
Carlisle
Carver
Cataumet
Centerville
Charlemont
Charlestown
Charlton
Charlton City
Charlton Depot
Chartley
Chatham
Chelmsford
Chelsea
Cherry Valley
Cheshire
Chester
Chesterfield
Chestnut Hill
Chicopee
Chilmark
Clinton
Cohasset
Colrain
Concord
Conway
Cotuit
Cummaquid
Cummington
Cuttyhunk
Dalton
Danvers
Dartmouth
Dedham
Deerfield
Dennis
Dennis Port
Devens
Dighton
Douglas
Dover
Dracut
Drury
Dudley
Dunstable
Duxbury
East Boston
East Bridgewater
East Brookfield
East Dennis
East Falmouth
East Freetown
East Longmeadow
East Mansfield
East Orleans
East Otis
East Princeton
East Sandwich
East Taunton
East Templeton
East Walpole
East Wareham
East Weymouth
Eastham
Easthampton
Easton
Edgartown
Elmwood
Erving
Essex
Everett
Fairhaven
Fall River
Falmouth
Fayville
Feeding Hills
Fiskdale
Fitchburg
Florence
Forestdale
Foxboro
Framingham
Franklin
Gardner
Georgetown
Gilbertville
Gill
Glendale
Gloucester
Goshen
Grafton
Granby
Granville
Great Barrington
Green Harbor
Greenbush
Greenfield
Groton
Groveland
Hadley
Halifax
Hamilton
Hampden
Hanover
Hanscom AFB
Hanson
Hardwick
Harvard
Harwich
Harwich Port
Hatfield
Hathorne
Haverhill
Haydenville
Heath
Hingham
Hinsdale
Holbrook
Holden
Holland
Holliston
Holyoke
Hopedale
Hopkinton
Housatonic
Hubbardston
Hudson
Hull
Humarock
Huntington
Hyannis
Hyannisport
Hyde Park
Indian Orchard
Ipswich
Jamaica Plain
Jefferson
Kingston
Lake Pleasant
Lakeville
Lancaster
Lanesboro
Lawrence
Lee
Leeds
Leicester
Lenox
Lenox Dale
Leominster
Leverett
Lexington
Lincoln
Linwood
Littleton
Longmeadow
Lowell
Ludlow
Lunenburg
Lynn
Lynnfield
Malden
Manchaug
Manchester
Manomet
Mansfield
Marblehead
Marion
Marlborough
Marshfield
Marshfield Hills
Marstons Mills
Mashpee
Mattapan
Mattapoisett
Maynard
Medfield
Medford
Medway
Melrose
Mendon
Menemsha
Merrimac
Methuen
Middleboro
Middlefield
Middleton
Milford
Mill River
Millbury
Millers Falls
Millis
Millville
Milton
Milton Village
Minot
Monponsett
Monroe Bridge
Monson
Montague
Monterey
Monument Beach
Nagog Woods
Nahant
Nantucket
Natick
Needham
Towns indicated in black make up our standard service area
Needham Heights
New Bedford
New Braintree
New Salem
New Town
Newbury
Newburyport
Newton
Newton Center
Newton Highlands
Newtonville
Nonantum
Norfolk
North Adams
North Amherst
North Andover
North Attleboro
North Billerica
North Brookfield
North Carver
North Chatham
North Chelmsford
North Dartmouth
North Dighton
North Eastham
North Easton
North Egremont
North Falmouth
North Grafton
North Hatfield
North Marshfield
North Oxford
North Pembroke
North Reading
North Scituate
North Truro
North Uxbridge
North Waltham
North Weymouth
Northampton
Northborough
Northbridge
Northfield
Norton
Norwell
Norwood
Nutting Lake
Oak Bluffs
Oakham
Ocean Bluff
Onset
Orange
Orleans
Osterville
Otis
Oxford
Palmer
Paxton
Peabody
Pembroke
Pepperell
Petersham
Pinehurst
Pittsfield
Plainfield
Plainville
Plymouth
Plympton
Pocasset
Prides Crossing
Princeton
Provincetown
Quincy
Randolph
Raynham
Raynham Center
Reading
Readville
Rehoboth
Revere
Richmond
Rochdale
Rochester
Rockland
Rockport
Roslindale
Rowe
Rowley
Royalston
Russell
Rutland
Sagamore
Sagamore Beach
Salem
Salisbury
Sandwich
Saugus
Savoy
Scituate
Seekonk
Sharon
Sheffield
Shelburne Falls
Sheldonville
Sherborn
Shirley
Shrewsbury
Shutesbury
Siasconset
Silver Beach
Somerset
Somerville
South Barre
South Carver
South Chatham
South Dartmouth
South Deerfield
South Dennis
South Easton
South Egremont
South Grafton
South Hadley
South Hamilton
South Harwich
South Lancaster
South Lee
South Orleans
South Walpole
South Wellfleet
South Weymouth
South Yarmouth
Southampton
Southborough
Southbridge
Southfield
Southwick
Spencer
Springfield
Sterling
Still River
Stockbridge
Stoneham
Stoughton
Stow
Sturbridge
Sudbury
Sunderland
Sutton
Swampscott
Swansea
Taunton
Templeton
Tewksbury
Thorndike
Three Rivers
Topsfield
Townsend
Truro
Turners Falls
Tyngsborough
Tyringham
Upton
Uxbridge
Vineyard Haven
Waban
Wakefield
Wales
Walpole
Waltham
Ware
Wareham
Warren
Warwick
Watertown
Waverley
Wayland
Webster
Wellesley
Wellesley Hills
Wellfleet
Wendell
Wendell Depot
Wenham
West Barnstable
West Boxford
West Boylston
West Bridgewater
West Brookfield
West Chatham
West Chesterfield
West Chop
West Dennis
West Falmouth
West Groton
West Harwich
West Hatfield
West Hyannisport
West Medford
West Millbury
West Newbury
West Newton
West Roxbury
West Springfield
West Stockbridge
West Tisbury
West Townsend
West Wareham
West Warren
West Yarmouth
Westborough
Westfield
Westford
Westminster
Weston
Westport
Westport Point
Westwood
Weymouth
Whately
Wheelwright
White Horse Beach
Whitinsville
Whitman
Wilbraham
Williamsburg
Williamstown
Wilmington
Winchendon
Winchendon Springs
Winchester
Windsor
Winthrop
Woburn
Woods Hole
Woodville
Worcester
Woronoco
Worthington
Wrentham
Yarmouth Port
CONNECTICUT
Abington
Ashford
Ballouville
Broad Brook
Brooklyn
Canaan
Central Village
Colebrook
Danielson
Dayville
East Canaan
East Granby
East Hartford
East Hartland
East Killingly
East Windsor
East Windsor Hill
East Woodstock
Eastford
Ellington
Enfield
Fabyan
Falls Village
Granby
Grosvenor Dale
Lakeville
Ledyard
Manchester
Moosup
Mystic
Norfolk
North Granby
North Grosvenordale
North Stonington
Old Mystic
Oneco
Pawcatuck
Plainfield
Pomfret
Pomfret Center
Poquonock
Preston
Putnam
Quinebaug
Riverton
Rogers
Salisbury
Simsbury
Somers
Somersville
South Willington
South Windsor
South Woodstock
Stafford
Stafford Springs
Staffordville
Sterling
Stonington
Suffield
Taconic
Tariffville
Thompson
Tolland
Vernon Rockville
Voluntown
Wauregan
West Granby
West Hartland
West Mystic
West Suffield
Willington
Windsor
Windsor Locks
Winsted
Woodstock
Woodstock Valley
NEW HAMPSHIRE
Amherst
Atkinson
Auburn
Barnstead
Barrington
Bedford
Bennington
Bow
Brookline
Candia
Chester
Chichester
Concord
Contoocook
Danville
Deerfield
Derry
Dover
Dublin
Dunbarton
Durham
East Candia
East Derry
East Hampstead
East Kingston
Epping
Epsom
Exeter
Fitzwilliam
Francestown
Fremont
Goffstown
Greenfield
Greenland
Greenville
Hampstead
Hampton
Hampton Falls
Hancock
Henniker
Hinsdale
Hollis
Hooksett
Hudson
Jaffrey
Kingston
Lee
Litchfield
Londonderry
Loudon
Lyndeborough
Madbury
Manchester
Merrimack
Milford
Mont Vernon
Nashua
New Boston
New Castle
New Ipswich
Newfields
Newington
Newmarket
Newton
Newton Junction
North Hampton
North Salem
Northwood
Nottingham
Pelham
Peterborough
Pittsfield
Plaistow
Portsmouth
Raymond
Rindge
Rochester
Rollinsford
Rye
Rye Beach
Salem
Sandown
Seabrook
Somersworth
Strafford
Stratham
Suncook
Temple
Troy
Weare
West Chesterfield
West Nottingham
Wilton
Winchester
Windham
NEW YORK
Ancramdale
Austerlitz
Berlin
Brainard
Canaan
Chatham
Cherry Plain
Copake
Copake Falls
Craryville
Cropseyville
East Chatham
East Nassau
Ghent
Grafton
Hillsdale
Hollowville
Hoosick
Hoosick Falls
Millerton
New Lebanon
Old Chatham
Petersburg
Philmont
Sand Lake
Spencertown
Stephentown
West Copake
West Lebanon
RHODE ISLAND
Adamsville
Albion
Ashaway
Barrington
Block Island
Bradford
Bristol
Carolina
Central Falls
Charlestown
Chepachet
Clayville
Coventry
Cranston
Cumberland
East Greenwich
East Providence
Exeter
Fiskeville
Forestdale
Foster
Glendale
Greene
Greenville
Harmony
Harrisville
Hope
Hope Valley
Hopkington
Jamestown
Johnston
Kenyon
Kingston
Lincoln
Little Compton
Manville
Mapleville
Middletown
Narragansett
Newport
North Kingstown
North Providence
North Scituate
North Smithfield
Oakland
Pascoag
Pawtucket
Peace Dale
Portsmouth
Providence
Prudence Island
Riverside
Rockville
Rumford
Saunderstown
Shannock
Slatersville
Slocum
Smithfield
Tiverton
Wakefield
Warren
Warwick
West Greenwich
West Kingston
West Warwick
Westerly
Wood River Junction
Woonsocket
Wyoming
VERMONT
Bennington
Brattleboro
Jacksonville
Marlboro
Newfane
North Bennington
North Pownal
Pownal
Putney
Readsborough
Shaftsbury
Stamford
Vernon
West Halifax
Whitingham
Wilmington
Towns indicated in blue make up our extended service area
Utilization Management for Quality Care
tion review decisions. Tufts Health Plan uses criteria for
determining coverage for medically necessary services
and to conduct utilization review activities. The criteria
are developed with input from practicing physicians
in our service area and in accordance with standards
adopted by national accreditation organizations. They
are updated annually or more often, as new treatments,
applications, and technologies are adopted as generally
accepted professional practices.
Tufts Health Plan may perform prospective, concurrent,
and retrospective reviews of health care services. Prospective review is used to determine whether proposed
treatment is medically necessary before treatment begins. Concurrent review monitors the course of treatment as it occurs and determines when the treatment
is no longer medically necessary. Retrospective review
evaluates care provided to members after the care
has been provided and is sometimes used to more
accurately determine the appropriateness of health
care services provided to members.
Specialty Case Management
Members with severe illness or injury often benefit from
working with a nurse in Tufts Health Plan’s specialty
case management programs. The goal of specialty case
management is to support the member and the provider,
when appropriate, to develop an individualized plan of
care that seeks to identify and address potential barriers to care. Education on the illness, support for self
management, symptom management, and coordination
of care, including community services when needed, are
a few of the member-centered opportunities the nurse
and member may discuss.
Utilization Management
Tufts Health Plan has a utilization management (UM)
program. The purpose of the program is to control
health care costs by evaluating whether health care
services provided to members are medically necessary
and provided in the most appropriate and efficient
manner. Utilization management is sometimes referred
to as utilization review.
Your Tufts Health Plan primary care physician or other
network provider typically is responsible for obtaining
authorization and coordinating utilization management
decisions. Network physicians, providers, and hospitals
understand UM requirements that apply to services
being received.
When a member is identified as a candidate for specialty
case management services, a Tufts Health Plan nurse
case manager will contact the member to gather
information on his or her health care needs and discuss
active enrollment in the program. Participation is
voluntary and has no effect on the member’s benefits.
Please refer to your benefit document for details about
our UM process. You can call a member specialist to
determine the status or outcome of pending utiliza-
Register at tuftshealthplan.com and start using My Wellness Plan to manage your health and well-being.
tuftshealthplan.com
18532-1/10
|
1-800-462-0224
notice of privacy practices
This notice describes how medical
information about you may be used
and disclosed and how you can get
access to this information. Please
review it carefully.
Introduction
Tufts Health Plan strongly believes in safeguarding the
privacy of our members’ protected health information
(PHI). PHI is information which:
• Identifies you (or can reasonably be used to identify you);
and
• Relates to your physical or mental health or condition,
the provision of health care to you or the payment for
that care.
We are required by law to maintain the privacy of your
PHI and to provide you with notice of our legal duties and
privacy practices with respect to your PHI. This Notice of
Privacy Practices describes how we may collect, use and
disclose your PHI, and your rights concerning your PHI.
This Notice applies to all members of Tufts Health Plan’s
insured health benefit plans, including: HMO plans; Tufts
Health Plan Medicare Preferred plans; and insured POS
and PPO plans. It also applies to all members of health
plans insured by Tufts Insurance Company (a Tufts Health
Plan affiliate). Unless your employer has notified you
otherwise, this Notice of Privacy Practices also applies to
all members of self-insured group health plans that are
administered by a Tufts Health Plan entity.
How We Obtain PHI
As a managed care plan, we engage in routine activities
that result in our being given PHI from sources other than
you. For example, health care providers—such as physicians
and hospitals—submit claim forms containing PHI to enable
us to pay them for the covered health care services they
have provided to you.
How We Use and Disclose Your PHI
We use and disclose PHI in a number of ways to carry out
our responsibilities as a managed care plan. The following
describes the types of uses and disclosures of PHI that
federal law permits us to make without your specific
authorization:
• Treatment: We may use and disclose your PHI to health
care providers to help them treat you. For example, our
care managers may disclose PHI to a home health care
agency to make sure you get the services you need after
discharge from a hospital.
• Payment Purposes: We use and disclose your PHI for
payment purposes, such as paying doctors and hospitals for covered services. Payment purposes also include
activities such as: determining eligibility for benefits;
reviewing services for medical necessity; performing utilization review; obtaining premiums; coordinating benefits; subrogation; and collection activities.
• Health Care Operations: We use and disclose your PHI
for health care operations. This includes coordinating/
managing care; assessing and improving the quality
of health care services; reviewing the qualifications
and performance of providers; reviewing health plan
performance; conducting medical reviews; and resolving grievances. It also includes business activities such
as: underwriting; rating; placing or replacing coverage; determining coverage policies; business planning;
obtaining reinsurance; arranging for legal and auditing
services (including fraud and abuse detection programs);
and obtaining accreditations and licenses.
• Health and Wellness Information: We may use your
PHI to contact you with information about appointment
reminders; treatment alternatives; therapies; health care
providers; settings of care; or other health-related benefits, services and products that may be of interest to
you. For example, we might send you information about
smoking cessation programs.
• Organizations That Assist Us: In connection with
treatment, payment and health care operations, we may
share your PHI with our affiliates and third-party “business associates” that perform activities for us or on our
behalf, for example, our pharmacy benefit manager. We
will obtain assurances from our business associates that
they will appropriately safeguard your information.
• Plan Sponsors: If you are enrolled in Tufts Health Plan
through your current or former place of work, you are
enrolled in a group health plan. We may disclose PHI
to the group health plan’s plan sponsor— usually your
employer—for plan administration purposes. The plan
sponsor must certify that it will protect the PHI in
accordance with law.
• Public Health and Safety; Health Oversight: We may
disclose your PHI to a public health authority for public
health activities, such as responding to public health
investigations; when authorized by law, to appropriate
authorities, if we reasonably believe you are a victim of
abuse, neglect or domestic violence; when we believe
in good faith that it is necessary to prevent or lessen a
serious and imminent threat to your or others’ health or
safety; or to health oversight agencies for certain activities such as audits, disciplinary actions and licensure
activity.
• Legal Process; Law Enforcement; Specialized
Government Activities: We may disclose your PHI in the
course of legal proceedings; in certain cases, in response
to a subpoena, discovery request or other lawful process; to law enforcement officials for such purposes as
responding to a warrant or subpoena; or for specialized
governmental activities such as national security.
• Research; Death; Organ Donation: We may disclose
your PHI to researchers, provided that certain established measures are taken to protect your privacy. We
may disclose PHI, in certain instances, to coroners, medical examiners and in connection with organ donation.
• Workers’ Compensation: We may disclose your PHI
when authorized by workers’ compensation laws.
• Family and Friends: We may disclose PHI to a family
member, relative or friend—or anyone else you identify—
as follows: (i) when you are present prior to the use or
disclosure and you agree; or (ii) when you are not
present (or you are incapacitated or in an emergency
situation) if, in the exercise of our professional judgment and in our experience with common practice, we
determine that the disclosure is in your best interests. In
these cases we will only disclose the PHI that is directly
relevant to the person’s involvement in your health care
or payment related to your health care.
• Personal Representatives: Unless prohibited by law, we
may disclose your PHI to your personal representative,
if any. A personal representative has legal authority to
act on your behalf in making decisions related to your
health care. For example, a health care proxy, or a parent or guardian of an unemancipated minor are personal
representatives.
• Mailings: We will mail information containing PHI to
the address we have on record for the subscriber of your
health benefits plan. We will not make separate mailings
for enrolled dependents at different addresses, unless
we are requested to do so and agree to the request. See
below “Right to Receive Confidential Communications”
for more information on how to make such a request.
• Required by Law: We may use or disclose your PHI
when we are required to do so by law. For example, we
must disclose your PHI to the U.S. Department of Health
and Human Services upon request if they wish to determine whether we are in compliance with federal privacy
laws. If one of the above reasons does not apply, we will
not use or disclose your PHI without your written
permission (“authorization”). You may give us written
authorization to use or disclose your PHI to anyone
for any purpose. You may later change your mind and
revoke your authorization in writing. However, your
written revocation will not affect actions we’ve already
taken in reliance on your authorization. Where state or
other federal laws offer you greater privacy protections,
we will follow those more stringent requirements. For
example, under certain circumstances, records that contain information about alcohol abuse treatment; drug
abuse prevention or treatment; AIDS-related testing or
treatment; or certain privileged communications may
not be disclosed without your written authorization.
In addition, when applicable we must have your written authorization before using or disclosing medical or
treatment information for a member appeal. See below,
“Who to Contact for Questions or Complaints,” if you
would like more information.
How We Protect PHI Within Our Organization
Tufts Health Plan protects oral, written and electronic PHI
throughout our organization. We do not sell PHI to anyone.
We have many internal policies and procedures designed to
control and protect the internal security of your PHI. These
policies and procedures address, for example, use of PHI by
our employees. In addition, we train all employees about
these policies and procedures. Our policies and procedures
are evaluated and updated for compliance with applicable
laws.
Your Individual Rights
The following is a summary of your rights with respect to
your PHI:
• Right of Access to PHI: You have the right to inspect
and get a copy of most PHI Tufts Health Plan has about
you. Under certain circumstances, we may deny your
request. If we do so, we will send you a written notice
of denial describing the basis of our denial. We may
charge a reasonable fee for the cost of producing and
mailing the copies. Requests must be made in writing
and reasonably describe the information you would like
to inspect or copy.
• Right to Request Restrictions: You have the right to
ask that we restrict uses or disclosures of your PHI to
carry out treatment, payment and health care operations; and disclosures to family members or friends. We
will consider the request. However, we are not required
to agree to it and, in certain cases, federal law does
not permit a restriction. Requests may be made verbally
or in writing to Tufts Health Plan.
• Right to Receive Confidential Communications: You
have the right to ask us to send communications of
your PHI to you at an address of your choice or that we
communicate with you in a certain way. For example,
you may ask us to mail your information to an address
other than the subscriber’s address. We will accommodate your request if you state that disclosure of your
PHI through our usual means could endanger you; your
request is reasonable; it specifies the alternative means
or location; and it contains information as to how payment, if any, will be handled. Requests may be made
verbally or in writing to Tufts Health Plan.
• Right to Amend PHI: You have the right to have us
amend most PHI we have about you. We may deny your
request under certain circumstances. If we deny your
request, we will send you a written notice of denial. This
notice will describe the reason for our denial and your
right to submit a written statement disagreeing with
the denial. Requests must be in writing to Tufts Health
Plan and must include a reason to support the requested
amendment.
• Right to Receive an Accounting of Disclosures: You
have the right to a written accounting of the disclosures
of your PHI that we made in the last six years prior to
the date you request the accounting. However, except
as otherwise provided by law, this right does not apply
to (i) disclosures we made for treatment, payment or
health care operations; (ii) disclosures made to you or
people you have designated; (iii) disclosures you or your
personal representative have authorized; (iv) disclosures made before April 14,
2003; and (v) certain other disclosures, such as disclosures for national security
purposes. If you request an accounting more than once in a 12-month period,
we may charge you a reasonable fee. All requests for an accounting of disclosures must be made in writing to Tufts Health Plan.
• Right to This Notice: You have a right to receive a paper copy of this Notice
from us upon request.
• How to Exercise Your Rights: To exercise any of the individual rights described
above or for more information, please call a member services specialist at
1-800-462-0224 (TDD: 1-800-815-8580) or write to:
Corporate Compliance Department
Tufts Health Plan
705 Mount Auburn Street
Watertown, MA 02472-1508
Effective Date of Notice
This Notice takes effect August 13, 2007. We must follow the privacy practices
described in this Notice while it is in effect. This Notice will remain in effect until
we change it. This Notice replaces any other information you have previously
received from us with respect to privacy of your medical information.
Changes to This Notice of Privacy Practice
We may change the terms of this Notice at any time in the future and make the
new Notice effective for all PHI that we maintain—whether created or received
before or after the effective date of the new Notice. Whenever we make an
important change, we will send subscribers an updated Notice of Privacy
Practices. In addition, we will publish the updated Notice on our Web site at
tuftshealthplan.com.
Who to Contact for Questions or Complaints
If you would like more information or an additional paper copy of this Notice,
please contact a member services specialist at the number listed above. You can
also download a copy from our Web site at www.tuftshealthplan.com. If you believe
your privacy rights may have been violated, you have a right to complain to
Tufts Health Plan by calling the Privacy Officer at 1-800-208-9549 or writing to:
Privacy Officer
Corporate Compliance Department
Tufts Health Plan
705 Mount Auburn Street
Watertown, MA 02472-1508
You also have a right to complain to the Secretary of Health and Human
Services. We will not retaliate against you for filing a complaint.
Tufts Health Plan is the trade name for Tufts Associated Health Maintenance Organization, Inc. It is also a trade
name for Total Health Plan, Inc. and Tufts Benefit Administrators, Inc. in each entity’s capacity as an administrator for self-funded group health plans; and for Tufts Insurance Company.
© 2007 Tufts Associated Health Plans, Inc. All rights reserved.
tuftshealthplan.com
18128-1/10
|
1-800-462-0224