One Care Policies & Procedures

Your Tufts Health One Care Member Handbook, also known as the Evidence of Coverage, includes most of the information provided below and much more. You can print a copy of the Member Handbook or call us toll-free at 1-855-393-3154 (TTY: 711), seven days a week, from 8 a.m. to 8 p.m., to get a copy of the Member Handbook or any of the other attachments on this website sent to you. (Please note: our hours shift to Monday through Friday, from April 1 through September 30). 

You can also access all materials using the One Care documents and forms plan pages:

View Documents Page 
View Forms Page  

 

Policies & Procedures

  • Your Rights and Responsibilities — As a Tufts Health Plan member, you have certain rights and responsibilities.
  • Appeals — As a Tufts Health Plan member, you can file an appeal with us about a decision we make.
  • Complaints — As a Tufts Health Plan member, you can complain to MassHealth (link opens outside Tufts Health Plan's website) or the Centers for Medicare & Medicaid Services (CMS) (link opens outside Tufts Health Plan's website) if you’re unhappy about something we do.
  • Grievances — As a Tufts Health Plan member, you have the right to file a complaint with Tufts Health Plan if you are unhappy about something we do.
  • Notice of Privacy Policy — This policy explains how we protect our members’ information.
  • Advance Directives — Sometimes people are unable to make health care decisions for themselves. Before that happens to you, you can fill out a written form, called an advance directive, to give someone the right to make health care decisions for you. This form can also be used to give your doctors written instructions about how you want them to handle your health care if you become unable to make decisions for yourself. There are different types of advance directives and different names for them. Examples are a living will and a power of attorney  for health care.
  • Out-of-Network Coverage Guidelines — These guidelines list the rules for using out-of-network providers and facilities.
  • Contract Termination Information — This document explains that Medicare and the Executive Office of Health and Human Services (EOHHS) must approve the Tufts Health One Care contract each year.
  • Notice of Availability — We can provide information to you in over 300 languages.
  • Prior Authorization Criteria for Prescription Drugs — This document helps you follow the correct prior authorization process for your prescription drugs.
  • Step-Therapy Criteria for Prescription Drugs — This information helps you understand the step-therapy criteria for your prescription drugs.
  • Prescription Drug Transition Policy — This policy outlines the steps involved in transitioning your prescription drugs onto our plan.
  • Best Available Evidence Policy — In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. This policy outlines the process in place should this situation occur.
  • Fraud and Abuse — This information explains health care fraud and abuse.