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Introduction

Welcome to Spirit by Tufts Health Plan™ (“Spirit”). We are pleased you have chosen this Exclusive Provider Option (EPO) health plan. We look forward to working with you to help you meet your health care needs. This Member Handbook describes the Spirit health care plan. Please note that italicized words in this document have special meanings. These meanings are given in the “Definitions” section (see Part 9, pages 83-90).

Spirit is a self-funded plan, which means that the Group Insurance Commission (also referred to as “the GIC” or “Commission”) is responsible for the cost of the Covered Services you receive under it. The GIC has contracted with Tufts Health Plan. The Spirit Plan offers care from a network of Tufts Health Plan Providers that is smaller than that of the Navigator Plan. These Providers are known as Tufts Health Plan (“Tufts HP”) Spirit Providers. Tufts HP performs certain services, such as claims processing, but does not, however, insure plan benefits or determine your eligibility for benefits under the Spirit Plan.

This is an EPO plan, in which you are not required to designate a Primary Care Provider (PCP) (although you are encouraged to do so) or get a referral for specialty services. In order to receive coverage for Covered Services, however, you are required to obtain these services only from Tufts HP Spirit Providers (except as described below). This Member Handbook will help you find answers to your questions about your EPO benefits.

Tufts HP Spirit Plan Members have benefits for Covered Services according to the terms of this Member Handbook. The Plan covers your medical and prescription drug benefits. Your EAP/Mental Health and Substance Abuse benefits are included in this plan, but administered by United Behavioral Health (UBH)/OptumHealth Behavioral Solutions.

Medical and Prescription Drug Plan - Tufts Health Plan administers Spirit, which provides the medical and prescription drug benefits described in this Member Handbook. Spirit Members are required to receive medical services and prescription drugs only from Tufts Health Plan Spirit Providers.* The only exceptions are for Emergency care services, or Urgent Care services provided to you while you are traveling, which are covered whether or not they are provided by a Tufts Health Plan Spirit Provider. To find out which Providers are Tufts HP Spirit Providers, you can either:

  • look in the Tufts HP Spirit Provider Directory;

  • call the Member Services Department at 1-800-870-9488; or

  • check out the web site at /gic.

*Important Note: If you need specialty care that is not available from a Tufts HP Spirit Provider, with the approval of an Authorized Reviewer you may receive care from a non-Plan Provider. Please see “Covered Services Not Available from a Tufts HP Spirit Provider in Part 3 (page 30) for more information about how these services are covered. Please note that such Covered Services received from non-Plan Providers are not covered unless approved by an Authorized Reviewer.

Introduction, Continued

Medical and Prescription Drug Plan (continued)

For Outpatient medical care, Covered Services provided by a Tufts Health Plan Spirit Provider are covered. Your Office Visit Copayment will vary depending on the type of physician who provides your care:

  • Office visits to PCPs (including general practitioners, family practitioners, internal medicine specialists, pediatric primary care providers, nurse practitioners, primary care physicians who are also specialists, or obstetrician/gynecologists), are subject to a $20 Copayment.

  • If you seek care at a Limited Service Medical Clinic (walk-in-retail clinic), a $20 Copayment will apply per visit.

  • Massachusetts Tufts HP Spirit Providers who are specialists (either adult or pediatric) in the following 13 specialties have been rated based on quality and cost-efficiency standards and then placed into three tiers (for more information about the standards used for placing these specialists into tiers, check out the web site at /gic). These specialties are cardiology; dermatology; endocrinology; gastroenterology; general surgery; neurology; obstetrics/gynecology; ophthalmology; orthopedics; otolaryngology; pulmonology; rheumatology; and urology. The Copayments at these three tiers apply as follows to these Providers:

  • Copayment Tier 1 Specialist:  Excellent – subject to $25 Copayment per office visit

  • Copayment Tier 2 Specialist: Good – subject to $35 Copayment per office visit

  • Copayment Tier 3 Specialist: Standard – subject to $45 Copayment per office visit

  • Office visits to all other specialists (either adult or pediatric) are subject to a $35 Copayment:

  • specialists in specialties not rated by Tufts Health Plan; and

  • specialists with insufficient data to evaluate.

  • Please note that Copayments for urgent care services vary depending upon type of Provider (PCP vs. Specialist) and location in which services are rendered (for example, Provider’s office, Limited Service Medical Center, urgent care center, or Emergency room).

For a list of Tufts HP Spirit Providers (including their Specialist Tiers, if applicable), please refer to the Web site at /gic or to the Provider Directory.

Inpatient hospital stays at Tufts Health Plan Spirit Hospitals for Obstetric Services, Pediatric Services, or Adult Medical and Surgical Services are grouped into Inpatient Hospital Copayment Levels based on the quality-cost score each hospital receives for each of these types of services (see Part 10, pages 91-94, for more information about the standards used for grouping the hospitals).

  • Hospitals with an excellent quality and cost-efficiency rating are grouped in Inpatient Copayment Tier 1 and require a $300 Copayment per admission (subject to the Inpatient Care Copayment Maximum).

  • Hospitals with a good quality and cost-efficiency rating are grouped in Inpatient Copayment Tier 2 and require a $700 Copayment per admission (subject to the Inpatient Care Copayment Maximum).

Please see “Benefit Overview” (page 12) and “Plan and Benefit Information” (pages 26-28) for further details on your coverage and costs for medical services under this Plan. Covered Services that are not provided by a Tufts HP Spirit Provider are not covered, except for Emergency care or Urgent Care while traveling. In addition, if the Covered Services you require are not available from any Tufts HP Spirit Provider, you may, with the approval of an Authorized Reviewer receive care from a non-Plan Provider. Please see “Covered Services Not Available from a Tufts HP Spirit Provider” on page 30 for more information.

Prescription drug benefits that are available and the requirements that each Member needs to follow in order to obtain these benefits are described in Part 5 (see pages 39-69).

Introduction, Continued

Medical and Prescription Drug Plan (continued)

The Member Services Department is committed to excellent service. Your satisfaction with Spirit is important to us. If at any time you have questions, please call the Member Services Department which will be happy to help you. Calls to the Member Services Department may be monitored by supervisors to assure quality service.

EAP/Mental Health and Substance Abuse Plan – This plan is administered by United Behavioral Health (UBH)/OptumHealth Behavioral Solutions. You and your covered family Members are automatically eligible for a full range of confidential and professional Enrollee Assistance Program (EAP), mental health and substance abuse services that are administered by UBH/OptumHealth Behavioral Solutions. Legal, family mediation and financial counseling services, grief counseling, and referrals to self-help groups and child or elder care services are among the many services available through the EAP. For mental health or substance abuse services or in an emergency, UBH/OptumHealth Behavioral Solutions can help you access a conveniently located network Provider. UBH/OptumHealth Behavioral Solutions benefit information is located on pages 95-117 of this booklet.

Member Identification Card

Members must present their member identification card (member ID card) to Providers when they receive Covered Services in order for benefits to be administered properly. Each member ID card contains the following information:

  • The amounts you must pay for certain Covered Services under the Spirit Plan (for example, your Copayments for Emergency room visits or for office visits);

  • the toll-free Tufts Health Plan telephone number to call if you have questions about your medical and prescription drug coverage under the Spirit Plan; and

  • the toll-free United Behavioral Health/OptumHealth Behavioral Solutions telephone number to call if you have questions related to the EAP/Mental Health and Substance Abuse coverage under this plan.

Tufts Health Plan Address And Telephone Directory

TUFTS HEALTH PLAN

705 Mount Auburn Street

Watertown, Massachusetts 02472-1508

Hours: Monday – Thursday 8:00 a.m. to 7:00 p.m. E.S.T.

Friday 8:00 a.m. to 5:00 p.m. E.S.T.

IMPORTANT PHONE NUMBERS:

Emergency Care

If you are experiencing an Emergency, you should seek care at the nearest Emergency facility. If needed, call 911 for emergency medical assistance. If 911 services are not available in your area, call the local number for emergency medical services.

If you have an urgent medical need and cannot reach your physician, you should seek care at the nearest emergency room.

Liability Recovery

Call the Liability and Recovery Department at 1-888-880-8699, extension 1098 for questions about coordination of benefits and workers’ compensation. For example, call the Liability and Recovery Department if you have any questions about how Tufts Health Plan (Tufts HP) coordinates coverage with other health care coverage that you may have. The Liability and Recovery Department is available from 8:30 a.m. – 5:00 p.m. Monday through Thursday and from 10:00 – 5:00 p.m. on Friday.

For questions related to subrogation (when someone else's fault caused your illness or injury, such as injuries from an auto accident), call the Member Services Department at 1-800-870-9488.

Member Services Department

Call the Member Services Department at 1-800-870-9488 for general questions, benefit questions, and information regarding eligibility for enrollment and billing.

Services for Hearing Impaired Members

If you are hearing impaired, the following services are provided:

Massachusetts Relay (MassRelay) 1-800-720-3480

Telecommunications Device for the Deaf (TDD)

If you have access to a TDD phone, call 1-800-868-5850 to reach the Member Services Department.

IMPORTANT ADDRESSES:

Appeals and Grievances Department

If you need to call Tufts HP about a concern or appeal, contact the Member Services Department at 1-800-870-9488. To submit your appeal or grievance in writing, send your letter to:

Tufts Health Plan

Attn: Appeals and Grievances Department

705 Mount Auburn Street

P.O. Box 9193

Watertown, MA 02471-9193

Web site

For more information about Tufts Health Plan and to learn more about the self-service options that are available to you, please see the Tufts Health Plan Web site at .

Translating Services

Translating services for 140 languages

Interpreter and translator services related to administrative procedures are available to assist Members upon request. For information, please call the Member Services Department.

Member Services

1-800-870-9488

TDD

Telecommunications Device for the Deaf: 1-800-868-5850

Table of Contents

INTRODUCTION 2

SPIRIT BY TUFTS HEALTH PLAN (MEDICAL AND PRESCRIPTION

DRUG PLAN) 11

Part 1 – Benefit Overview 12

Part 2 – Plan and Benefit Information 26

- Copayments 26

- Day Surgery Copayment Maximum 27

  • Inpatient Care Copayment Maximum 27

  • Deductible 27

  • Coinsurance 28

Part 3 – How Your Health Plan Works 29

- How the Plan Works 29

- The Spirit Network 29

- Continuity of Care 31

- Emergency Care 31

- Financial Arrangements between Tufts Health Plan and Tufts HP Providers 32

- Member Identification Card 32

- Utilization Management 33

Part 4 – Enrollment and Termination Provisions 35

- Enrollment 35

- Effective Date 35

- Adding Dependents 36

- Additional Information About Newborn Children 37

- When Coverage Ends 38

Part 5 – Covered Services 39

- When health care services are Covered Services 39

- Your Costs for Covered Services 39

Emergency Care 40

- Emergency Room 40

- Physician’s office 40

Table of Contents, Continued

MEDICAL AND PRESCRIPTION DRUG PLAN, continued

Part 5 – Covered Services, continued

Outpatient Care 40

- Autism spectrum disorders – diagnosis and treatment 40

- Cardiac rehabilitation 41

- Coronary Artery Disease Program 41

- Diabetes self-management training and educational services 41

- Early Intervention services for a Dependent Child 41

- Family planning procedures, services, and contraceptives 42

- Hemodialysis 42

- Infertility services 43

- Maternity Care 44

- Outpatient medical care 44

- Allergy injections 44

- Allergy testing and treatment 44

- Chemotherapy 44

- Cytology examinations (Pap smears) 44

- Diagnostic or preventive screening procedures 44

- Diagnostic imaging 44

- EKG testing 44

- Human leukocyte antigen testing 44

- Laboratory tests 44

- Mammograms 44

- Medically Necessary diagnosis and treatment of speech,

hearing and language disorders 44

- Neuropsychological testing provided for a medical condition 45

- Nutritional counseling 45

- Office visits to diagnose and treat illness or injury 45

- Outpatient surgery in physician’s office 45

- Radiation therapy and x-ray therapy 45

- Voluntary second or third surgical opinions 45

- Patient care services provided as part of a clinical trial (for cancer) 45

- Preventive health care 45

- Adults (age 18 and over) 45

- Children (under age 18) 46

- Routine annual gynecological exam 46

- Short-term physical and occupational therapy services 46

- Vision care services 46

- Routine eye exams 46

- Other vision care services 46

Oral Health Services 47

- Emergency care 47

- Oral surgery for dental treatment 47

- Oral surgical procedures for non-dental medical treatment 47

Day Surgery 47

Table of Contents, Continued

MEDICAL AND PRESCRIPTION DRUG PLAN, continued

Part 5 – Covered Services, continued

Inpatient Care 48

- Acute hospital services 48

- Bone Marrow Transplants for Breast Cancer, hematopoietic stem cell

transplants, and human solid organ transplants 48

- Maternity Care 49

- Patient care services provided as part of a clinical trial (for cancer) 50

- Reconstructive surgery and procedures 51

Other Health Services 52

- Ambulance services 52

- Extended care 52

- Home health care 53

- Hospice care services 53

- Injectable, infused or inhaled medications 54

- Medical Appliances and Equipment 55

- Personal Emergency Response System (PERS) 57

- Private Duty Nursing 57

- Scalp hair prostheses or wigs for cancer or leukemia patients 57

- Special medical formulas 57

- Spinal manipulation 58

  • Prescription Drug Benefit 59

- How Prescription Drugs Are Covered 59

- Prescription Drug Coverage Table 60

- What is Covered 62

- What is Not Covered 63

- Tufts Health Plan Pharmacy Management Programs 64

- Filling Your Prescription 66

Exclusions from Benefits 67

Part 6 – Continuation of Coverage 70

- Group Health Continuation Coverage under COBRA 70

- Death of Subscriber 73

- Nongroup Coverage under an Individual Contract 73

Part 7 – Member Satisfaction Process 74

- Internal Inquiry 74

- Grievances 74

- Administrative Grievance 74

- Administrative Grievance Timeline 75

- Clinical Grievances 75

- Internal Member Appeals 75

- Expedited Appeals 76

- External Review 77

- Bills from Providers 78

- Limitation on Actions 78

Table of Contents, Continued

MEDICAL AND PRESCRIPTION DRUG PLAN, continued

Part 8 -- Other Plan Provisions 79

- Subrogation 79

- Coordination of Benefits 81

- Use and Disclosure of Medical Information 82

- Additional Plan Provisions 82

Part 9 – Terms and Definitions 83

Part 10 – Spirit Plan Inpatient Hospital List 91

MENTAL HEALTH, SUBSTANCE ABUSE AND ENROLLEE ASSISTANCE PROGRAMS (ADMINISTERED BY UNITED BEHAVIORAL HEALTH) 95



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