Frequently Asked Questions

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What are the Tufts Medicare Preferred HMO plan Quality Assurance Policies and Procedures?

To help monitor quality of care and manage health care costs, Tufts Health Plan Medicare Preferred conducts utilization management activities for all its members. The goal of utilization management is to be sure the care for which members receive coverage is medically necessary, covered by Tufts Health Plan Medicare Preferred and provided by a qualified provider. Utilization management may be conducted in several ways, including preauthorization review, concurrent review (while you are receiving care), and retrospective review (after care has been provided). Tufts Medicare Preferred HMO also includes case management services for medically complex situations in which the member is likely to require extensive coordination of services.

We offer medication therapy management programs at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors. We offer medication therapy management programs for members that meet specific criteria. We may contact members who qualify for these programs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Remember, you do not need to pay anything extra to participate.

If you are selected to join a medication therapy management program, we will send you information about the specific program, including information about how to access the program.

What is a Tufts Medicare Preferred HMO plan Coverage Determination?

When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination. For prescription drug related questions only, call 7 days a week 8:00 a.m. - 8:00 p.m. You, your physician or your appointed representative may file a coverage determination, including an exception, by calling Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562) Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 15 - Feb 14). After hours and on holidays, please leave a message and a representative will return your call the next business day, or by writing to:

Attn: Precertification Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to: 1-617-972-9409.

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

How do I file a coverage determination, including an exception?

You, your physician or your appointed representative may file a coverage determination by calling Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562) Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 15 - Feb 14). After hours and on holidays, please leave a message and a representative will return your call the next business day, or by writing to:

Attn: Precertification Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to: 1-617-972-9409.

If you are requesting a formulary or tiering exception, your physician must provide a statement to support your request. Your physician can submit the request using our Universal Pharmacy Form (found here) or the Medicare Part D Coverage Determination Request Form (found here). The form asks your physician for information regarding your diagnosis, what other drug(s), if any, has been prescribed for the diagnosis and why it has not worked, and other questions. Your physician should send the completed form to:

Attn: Precertification Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to: 1-617-972-9409.

Your physician can also provide an oral supporting statement by calling Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562) Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 15 - Feb 14). Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC.

How do I find additional information about coverage determinations?

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

Find a copy of your HMO Plan Evidence of Coverage document here.

If you have questions about any of this processes, or if you want to inquire about the status of a coverage determination request, you, your physician or your appointed representative may contact us at 1-800-701-9000 (TTY 1-800-208-9562) Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 15 - Feb 14). After hours and on holidays, please leave a message and a representative will return your call the next business day.

What is a Tufts Medicare Preferred HMO plan Organization Determination?

An organization determination is our initial decision about whether we will provide the medical care or service you request, or pay for a service you have received. If our initial decision is to deny your request, you may appeal the decision. When we make an "organization determination," we are giving our interpretation of how the benefits and services that are covered for members of the Plan apply to your specific situation. Please refer to your EOC for additional details.

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

Where can I find a copy of Tufts Health Plan Medicare Preferred's Privacy Notice?

Our Privacy Notice can be found here.

What are my Rights and Responsibilities on Disenrollment?

Ending your membership in Tufts Medicare Preferred HMO or Supplement plans may be voluntary (your own choice) or involuntary (not your own choice):

* You might leave our plan because you have decided that you want to leave. There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. Your Evidence of Coverage (EOC) document tells you when you can end your membership in the plan. The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. See your Evidence of Coverage (EOC) document for additional details.

* There are also limited situations where you do not choose to leave, but we are required to end your membership. Your Evidence of Coverage document tells you about situations when we must end your membership.

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends. If you leave a Tufts Medicare Preferred HMO plan, it may take time before your membership ends and your new Medicare coverage goes into effect. (See your Evidence of Coverage docment for information on when your new coverage begins.) During this time, you must continue to get your medical care through our plan.

If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership. You can also look in your Evidence of Coverage document for information about how to make a complaint.

Where can I find additional information on benefits, service area, conditions/limitations, out-of-network coverage, appeals/grievances, prescription drug quality assurance, contract termination and disenrollment rights and responsibilities?

Please refer to:

Plan service area - Evidence of Coverage

Conditions/limitations - Evidence of Coverage

Out-of-network coverage - Evidence of Coverage

Coverage Determination, Appeals and Grievances - Evidence of Coverage, Chapter 9 for HMO Plans with Rx (Chapter for HMO Plans with No Rx)

Prescription drug quality assurance - Evidence of Coverage

Potential for contract termination - Evidence of Coverage

Disenrollment rights and responsibilities - Evidence of Coverage

How much are my copays for medical, hospital and other benefits with my Tufts Medicare Preferred HMO plan?

Every Medicare Advantage Plan is required to include a document called a "Summary of Benefits" in your enrollment kit.  We've provided an easy to use index below to help you find copays, deductibles and coverage information on each benefit covered under our Tufts Medicare Preferred HMO plans.  When the government created this document, they numbered every benefit category in a specific order and labeled them as items 1 through 31.  This was designed to help consumers compare coverage not only within Tufts Medicare Preferred HMO product lines (Basic, Value and Prime) but our competitors as well.

Each column in the "Summary of Benefits" represents a specific product line offered by Tufts Medicare Preferred HMO - Basic, Value or Prime. Each row represents a specific benefit covered by our products including medical, hospital, prescription and wellness benefits. Please use this index to find the copays, cost sharing and coverage information on each benefit covered in each of our Tufts Medicare Preferred HMO plans. Click here to find a copy of the HMO Summary of Benefits.

 

SERVICE	PAGE NUMBER
IMPORTANT INFORMATION
1. Premium and Other Important Information	pg 6 - Includes out-of-pocket limit
INPATIENT CARE
2. Doctor and Hospital Choice	pg 8 - Includes Description of Referrals
3. Inpatient Hospital Care	pg 10 - Includes Copay for Hospital, Substances Abuse and Rehabilitation Services
4. Inpatient Mental Health Care	pg 14 - Includes Copay for Psychiatric and Lifetime Limit
5. Skilled Nursing Facility Care	pg 16 - Includes Copay and Days Covered in Each Benefit Period
6. Home Health Care	pg 18 - Includes Copay for Intermittent Skilled Nursing Care, Home Health Aid Services and Rehabilitation Services
7. Hospice Care	pg 18 - Medicare-certified Hospice

 

OUTPATIENT CARE
8. Doctor Office Visits	pg 20 - Includes Copay for Physical Exam
9. Chiropractic Service	pg 20 - Includes Copay for Manual Manipulation of the Spine
10. Podiatry Service	pg 22 - Includes Copay for Medically Necessary Foot Care
11. Outpatient Mental Health Care	pg 24 - Includes Copay for Medicare-covered Visit
12. Outpatient Substance Abuse Care	pg 26 - Includes Copay for Medicare-covered Visit
13. Outpatient Services and Surgery	pg 26 - Include Copay for Medicare-covered Ambulatory or Hospital Visit (i.e., injectible, intravenous, or oral chemotherapy)
14. Ambulance Service	pg 28 - Includes Copay for Medicare-covered Ambulance Benefits
15. Emergency Care	pg 28 - Includes Copay for Medicare-covered Emergency Room Visit
16. Urgently Needed Care	pg 30 - Includes Copay for Medicare-covered Urgently Needed Care (Primarily Out-of-Area Care)
17. Outpatient Rehabilitation Services	pg 30 - Includes Copay for Medicare-covered Occupational Therapy, Physical Therapy, Speech & Language Therapy, Respiratory Therapy, Social/Psychological Services and more.

 

OUTPATIENT MEDICAL SERVICES AND SUPPLIES
18. Durable Medical Equipment	pg 32 - Includes cost sharing for Wheelchairs, Oxygen, etc.
19. Prosthetic Devices	pg 32 - Includes cost sharing for Braces, Artificial Limbs & Eyes, etc.
20. Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies	pg 34 - Includes copays for Glucose Monitors, Test Strips, Lancets, Screening Tests, Self Monitoring Training, Retinal Exam, Glaucoma Test, Foot Exam, and Therapeutic Soft Shoe
21. Diagnostic Test, X-Rays, Lab Services, and Radiological Services	pg 36 - Includes copays for Lab Services, Diagnostic Procedures and Tests, X-rays, Diagnostic Radiology Services, Therapeutic Radiology Services
22. Cardiac and Pulmonary Rehabilitation Services	pg 38 - No Copay for Medicare-covered Services

 

PREVENTIVE SERVICES	Health reform legislation eliminated out-of-pocket cost sharing for most Medicare-covered preventive services.
23. Preventive Services and Wellness/Education Programs	pg 40 - No Copay for Medicare-covered Screenings (separate Office Visit Copay may apply) includes:
	Abdominal Aortic Aneurysm Screening
	Bone Mass Measurement
	Cardiovascular Screening
	Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)
	Colorectal Cancer Screening
	Diabetes Screening
	Influenza Vaccine
	Hepatitis B Vaccine
	HIV Screening
	Breast Cancer Screening (Mammogram)
	Medical Nutrition Therapy Services
	Personalized Prevention Plan (Annual Wellness Visits)
	Pneumococcal Vaccine
	Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only)
	Smoking Cessation (Counseling to stop smoking)
	Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)
	HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for a test
	The following supplemental education/wellness programs: Written health education materials, including newsletters, nutritional benefit, health club membership/fitness classes
24. Kidney Disease and Conditions	pg 48 - $0 Copay for renal dialysis and kidney disease education services

 

PRESCRIPTION DRUGS
25. Drugs Covered under Medicare	Part B pg 50 - No Copay
Drugs Covered under Medicare Part D	pg 52 - Plans With and Without Coverage
Retail Pharmacy Copays	pg 56 - Plans With and Without Coverage
Long Term Care Pharmacy Copays	pg 62 - Plans With and Without Coverage
Mail Order Copays	pg 62 - Plans With and Without Coverage
Coverage gap/Donut Hole Copays	pg 66 - Plans With and Without Coverage
Catastrophic Coverage Copays	pg 68 - Plans With and Without Coverage
Out-of-Network Coverage Copays	pg 68 - Plans With and Without Coverage
Out-of-Network Coverage Gap Copays	pg 70 - Plans With and Without Coverage
Out-of-Network Catastrophic Copays	pg 74 - Plans With and Without Coverage

 

OTHER BENEFITS
26. Dental Services	pg 82 - Preventive Dental Not Covered
27. Hearing Services	pg 82 - Includes Copay for Medicare-covered Diagnostic Hearing Exams and Annual Hearing Test
28. Vision Services	pg 84 - Includes Copay for Medicare-covered Diagnostic and Routine Eye Exams
29. Over-the-Counter Items	pg 86 - Not Covered
30. Routine Transportation	pg 86 - Not Covered
31. Acupuncture	pg 86 - Not Covered

This table lists some of the features of our plans. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please download a copy of our Summary of Benefits document or call Tufts Health Plan Medicare Preferred and ask for a copy. 

Do you need extra help lowering your Medicare Prescription Drug Plan costs?

If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium and drug costs will be lower. When you join a plan offered by Tufts Health Plan Medicare Preferred, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. The premiums listed do not include any Part B premium the member may have to pay. The premiums listed are for both medical services and prescription drug or Part D benefits only.

The HMO Premium Changes Low Income Subsidy form can be found here.

Beneficiaries interested in qualifying for extra help with Medicare Prescription Drug Plan costs should call:

1. The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778
2. 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048 (24 hours a day/7 days a week) or
3. Your State Medicaid Office

Best Available Evidence Policy

Does your medication require prior authorization?

Some medications may require prior authorization. This form is used to request coverage for medications that require prior authorization, exceptions for non-covered drugs, or tier exceptions. Your physician must be involved in filling out this form since he or she will need to provide information regarding the medical necessity of your request.

The Universal Pharmacy Form can be found here.

The alternative Coverage Determination Request form can be found here.

Who do I call to report Fraud, Waste, and Abuse?

Click here for information about Tufts Health Plan's Fraud, Waste and Abuse Hotline.

What do I do if I have a complaint concerning a Tufts Medicare Preferred HMO plan?

Tufts Health Plan Medicare Preferred is dedicated to providing its members with comprehensive health care coverage. However, there may be times when you have concerns or problems related to your coverage or care. In these instances, you have the right to make formal complaints to Tufts Health Plan Medicare Preferred. If you make a complaint, we must be fair in how we handle it, and you cannot be disenrolled or penalized in any way.

There are two types of formal complaints you can make. They are appeals and grievances. In this document, we will explain the differences between the two types of complaints and provide a high-level description of the processes for each. Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

What is the Tufts Medicare Preferred HMO plan Appeals Policy?

We encourage you to let us know right away if you have questions, concerns, or problems related to your Medicare Adavantage Plan which covers Medical and Hospital Services and/or Medicare Part D Prescription Drug Benefits. A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled or penalized in any way if you make a complaint. Your Evidence of Coverage (EOC) addresses how to file an appeal about your Medicare Advantage Plan which covers Medical and Hospital Services and addresses how to file an appeal about your Medicare Part D Prescription Drug Benefits. These sections give the rules for making complaints in different types of situations.

An "appeal" is a complaint you make when you want us to reconsider and change a decision we've made about a request for authorization of services or payment of a denied claim. For example, you can file an appeal if: we refuse to cover or pay for services or Part D drugs you think we should cover; we or one of our plan providers refuses to give you a service you think should be covered; we or one of our plan providers reduces or cuts back on services or benefits you have been receiving, or stops your coverage of a service or benefit too soon.

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

What is the Tufts Medicare Preferred HMO plan Grievance Policy?

A "grievance" is a complaint you make if you have any other type of problem with Tufts Medicare Preferred HMO plan or one of our plan providers. For example, you would file a grievance if you have a problem with the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office or pharmacy.

If you have a complaint, we encourage you to call Customer Relations and we will try to resolve the complaint over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a Formal Standard Grievance Process. You must file a grievance either orally or in writing no later than 60 days after the event. We must notify you of our decision no later than 30 calendar days after receiving the complaint. We may extend this timeframe by 14 days at your request, or if we feel it is justified and in your best interest. You can also request an expedited grievance that we must respond to within 24 hours of your complaint.

For more detailed information about appeals and grievances information for both Medicare Advantage and Part D prescription drug benefits, please see your Evidence of Coverage booklet that you receive as a Tufts Medicare Preferred HMO member, or call Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 15 - Feb 14). After hours and on holidays, please leave a message and a representative will return your call the next business day.

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

How do I file a grievance or appeal about my Tufts Medicare Preferred HMO plan?

You, your physician or your appointed representative (find the Authorization of Representative form here) may file a grievance or appeal by calling Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562) Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 15 - Feb 14). After hours and on holidays, please leave a message and a representative will return your call the next business day, or by writing to:

Attn: Appeals & Grievance Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to: 1-617-972-9405 or 1-617-972-9487.

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

How do I find additional information about my Tufts Medicare Preferred HMO plan grievance or appeal?

Please see your Evidence of Coverage: Complaints about Medical Services and Benefits: Complaints about Prescription Drug Benefits of your Evidence of Coverage (EOC) for more information on our grievance and appeals process.

Find your copy of the HMO Plan  Evidence of Coverage document here.

If you have questions about this process, or if you want to inquire about the status of a grievance or appeal request, you, your physician or your appointed representative may contact us at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 15 - Feb 14). After hours and on holidays, please leave a message and a representative will return your call the next business day.

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

How do I appoint a representative to help with a claim and authorize them to act on my behalf?

Every individual enrolled in a Tufts Health Plan Medicare Preferred plan has the right to appoint an individual to act as their representative in connection with a claim or asserted right under title XViii (18) of the Social Security act (the “act”) and related provisions of title Xi (11) of the act.

You can authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with an appeal, wholly in your stead. It is important to understand that personal medical information related to your appeal may be disclosed to the representative that you indicate on the attached form.

Where do I send this form?

Send this form to the same location where you are sending (or have already sent) an appeal if you are filing an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial determination or decision..

Attn: Appeals & Grievance Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to: 1-617-972-9405 or 1-617-972-9487.