Frequently Asked Questions

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

Utilization Management

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.

Medication Therapy Management (MTM)

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.

Click here for more information on medication therapy management.

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. For additional information, please contact Tufts Medicare Preferred.

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.

Important Medicare Enrollment Dates and Plans

Please consult the important Medicare enrollment dates below for the times during the calendar year that you are able to enroll.

Important: If you are enrolled in a MA Plan, PACE Plan, or Medicare Part D Plan, enrollment in Tufts Health Plan Medicare Preferred will result in disenrollment from your current plan.

  1. October 15 through December 7 is the Annual Election Period for Medicare Advantage plans and Prescription Drug Plans (PDPs). During this time period, anyone wishing to join a Medicare Advantage plan or a Prescription Drug Plan, or switch to a different plan, may do so. The change in coverage requested during this period will begin on January 1 of the next year.
  2. January 1 – February 14 of each year is the Annual Disenrollment Period (Not applicable to PDP). During this period, anyone already enrolled in a Medicare Advantage Plan can switch to Original Medicare. If you choose to switch to Original Medicare during this period, you can also enroll in a separate Medicare prescription drug plan at the same time.
  3. Special Election Period. Anyone who qualifies for extra help or moves in/out of the plan’s service area may join or switch Medicare Advantage plans. Other circumstances may also qualify as a Special Election Period

 

Important Note:
When you first become eligible for Medicare, you can enroll three months before your 65th birthday, the month of your 65th birthday, and three months after your 65th birthday. In case you are disabled, you can apply for Medicare benefits at any time provided you have been eligible for Social Security disability benefits.

If you have retiree health care coverage through an employer, the enrollment rules are different. Call the employer or their benefits administrator for information.

If You Are Thinking About Switching Plans, We Can Help

  1. We can help you determine which plan is right for you
  2. Our Customer Relations team knows how our plans work and can answer your questions
  3. Call us at 1-800-701-9000 (TTY 1-800-208-9562) Monday – Friday, 8:00 a.m.– 8:00 p.m. (From October 15 – February 14, representatives are available 7 days a week, 8:00 a.m. – 8:00 p.m.) After hours and on holidays, please leave a message and a representative will return your call on the next business day.
  4. There are only certain times during the year when you can switch plans. See above for enrollment period information.

Remember, you do not need to make a change to your plan. You will automatically be a member in the same plan for the next plan year, unless you decide to make a change.

Please note: If you receive your benefits from a current or former employer, please contact your benefits administrator regarding plan options and enrollment information.

Things To Consider When Choosing A Plan:

  1. What you can afford
  2. Your health and your age
  3. How often you use health services
  4. What is most important to you; lower monthly payments or lower copays
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.

 

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

 

OUTPATIENT CARE
8. Doctor Office Visitspg 20 - Includes Copay for Physical Exam
9. Chiropractic Servicepg 20 - Includes Copay for Manual Manipulation of the Spine
10. Podiatry Servicepg 22 - Includes Copay for Medically Necessary Foot Care
11. Outpatient Mental Health Carepg 24 - Includes Copay for Medicare-covered Visit
12. Outpatient Substance Abuse Carepg 26 - Includes Copay for Medicare-covered Visit
13. Outpatient Services and Surgerypg 26 - Include Copay for Medicare-covered Ambulatory or Hospital Visit (i.e., injectible, intravenous, or oral chemotherapy)
14. Ambulance Servicepg 28 - Includes Copay for Medicare-covered Ambulance Benefits
15. Emergency Carepg 28 - Includes Copay for Medicare-covered Emergency Room Visit
16. Urgently Needed Carepg 30 - Includes Copay for Medicare-covered Urgently Needed Care (Primarily Out-of-Area Care)
17. Outpatient Rehabilitation Servicespg 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 Equipmentpg 32 - Includes cost sharing for Wheelchairs, Oxygen, etc.
19. Prosthetic Devicespg 32 - Includes cost sharing for Braces, Artificial Limbs & Eyes, etc.
20. Diabetes Self-Monitoring Training, Nutrition Therapy, and Suppliespg 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 Servicespg 36 - Includes copays for Lab Services, Diagnostic Procedures and Tests, X-rays, Diagnostic Radiology Services, Therapeutic Radiology Services
22. Cardiac and Pulmonary Rehabilitation Servicespg 38 - No Copay for Medicare-covered Services

 

PREVENTIVE SERVICESHealth reform legislation eliminated out-of-pocket cost sharing for most Medicare-covered preventive services.
23. Preventive Services and Wellness/Education Programspg 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)
 Screening and behavioral counseling interventions in primary care to reduce alcohol misue
 Screening for depression in adults
 Screening for sexually transmitted infections (STI) and high intensity behavioral counseling to prevent STIs
 Intensive behavioral counseling for Cardiovascular Disease (bi-annually)
 Intensive behavior therapy for obesity
 Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)
24. Kidney Disease and Conditionspg 48 - $0 Copay for renal dialysis and kidney disease education services

 

PRESCRIPTION DRUGS 
25. Drugs Covered under MedicarePart B pg 50 - No Copay
Drugs Covered under Medicare Part Dpg 51 - Plans With and Without Coverage
Retail Pharmacy Copayspg 56 - Plans With and Without Coverage
Long Term Care Pharmacy Copayspg 62 - Plans With and Without Coverage
Mail Order Copayspg 66 - Plans With and Without Coverage
Coverage gap/Donut Hole Copayspg 72 - Plans With and Without Coverage
Catastrophic Coverage Copayspg 74 - Plans With and Without Coverage
Out-of-Network Coverage Copayspg 74 - Plans With and Without Coverage
Out-of-Network Coverage Gap Copayspg 80 - Plans With and Without Coverage
Out-of-Network Catastrophic Copayspg 82 - Plans With and Without Coverage

 

OTHER BENEFITS 
26. Dental Servicespg 94 - Preventive Dental Not Covered
27. Hearing Servicespg 94 - Includes Copay for Medicare-covered Diagnostic Hearing Exams and Annual Hearing Test
28. Vision Servicespg 96 - Includes Copay for Medicare-covered Diagnostic and Routine Eye Exams
29. Over-the-Counter Itemspg 98 - Not Covered
30. Routine Transportationpg 98 - Not Covered
31. Acupuncturepg 98 - 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:

ESSEX, SUFFOLK:

Subsidy

HMO Prime Rx Plus

HMO Prime Rx

HMO Value Rx

HMO Basic Rx

HMO Saver Rx

100%

$184.70

$164.20

$128.40

$46.30

 

75%

$190.90

$167.10

$131.00

$48.70

 

50%

$197.20

$170.00

$133.60

$51.10

 

25%

$203.40

$173.00

$136.30

$53.50

 

BARNSTABLE, BRISTOL, MIDDLESEX, NORFOLK, PLYMOUTH:

Subsidy

HMO Prime Rx Plus

HMO Prime Rx

HMO Value Rx

HMO Basic Rx

HMO Saver Rx

100%

$160.70

$140.20

$107.40

$26.30

 

75%

$166.90

$143.10

$110.00

$28.70

 

50%

$173.20

$146.00

$112.60

$31.10

 

25%

$179.40

$149.00

$115.30

$33.50

 

HAMPDEN, HAMPSHIRE

Subsidy

HMO Prime Rx Plus

HMO Prime Rx

HMO Value Rx HMO Saver Rx

100%

$82.70

$62.20

$33.40 

75%

$88.90

$65.10

$36.00 

50%

$95.20

$68.00

$38.60 

25%

$101.40

$71.00

$41.30 

WORCESTER:

Subsidy

HMO Prime Rx

HMO Value Rx

HMO Basic Rx HMO Saver Rx

100%

$167.70

$128.90

$54.30 

75%

$171.00

$132.20

$57.20 

50%

$174.40

$135.50

$60.20 

25%

$177.70

$138.80

$63.10 

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, step therapy exceptions, quantity limit exceptions, tier exceptions and coverage of non-formulary or new-to-market drugs. 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 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).

Page last updated 10-29-13

Where can I view the Tufts Health Plan Medicare Preferred website's legal, security, and privacy practices?

To view the Tufts Health Plan Medicare Preferred website's legal, security, and privacy practices, please click here.

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