Frequently Asked Questions

Here are some frequently asked questions about Tufts Health Direct, our focused-network plan for individuals and small groups:

How can I update my information?
You can update your contact information 24/7, like address (residential/mailing), phone number, or email address, through Tufts Health Member Connect, our self-service tool. All you need to create an account is your Tufts Health Plan member ID number and date of birth. If you do not know your member ID number, check your member ID card.

As a Tufts Health Direct member, you need to notify Tufts Health Plan and the Health Connector when your mailing address changes, or you could lose your health plan benefits. To update your mailing address, call us at 888-257-1985 (TTY: 888-391-5535), Monday through Friday, from 8 a.m. to 5 p.m., or call the Health Connector at 877-623-6765 (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m.

Do you have my doctor or specialist in your network?
If you are looking for a doctor or specialist in your area, use our Find a Doctor, Hospital, or Pharmacy tool to find primary care providers (PCPs), behavioral health (mental health and/or substance abuse) providers, specialists, and other health care providers near you.

To choose or change your PCP, or to check if your doctor needs to get prior authorization (permission) for you to get a service, log in to Tufts Health Member Connect, our self-service tool, or sign up if you don’t already have an account. All you need to create an account is your Tufts Health Plan member ID number and date of birth. If you do not know your member ID number, check your member ID card.

Can I order a new member ID card?
Yes, to order a new member ID card 24/7, log in to Tufts Health Member Connect, our self-service tool, or sign up if you don’t already have an account. All you need to create an account is your Tufts Health Plan member ID number and date of birth. Once you order your member ID card, you can expect to receive it in the mail within 10 business days.

How can I check the status of a claim or authorization?
To check the status of a claim or authorization 24/7, simply log in to Tufts Health Member Connect, our self-service tool, or sign up if you don’t already have an account. All you need to create an account is your Tufts Health Plan member ID number and date of birth. If you do not know your member ID number, check your member ID card.

Do I need to renew my Tufts Health Plan benefits?
You do not need to apply again to renew your coverage for 2016. Your membership will automatically renew as long as you continue to pay your monthly premium.

If there are changes to your eligibility criteria that may allow you to change your coverage type (e.g., qualifying event), call the Health Connector at 877-623-6765 (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m., or visit MAHealthConnector.org.

Do I have dental coverage?
Non-emergency dental services are not covered. Emergency dental services may be covered if medically necessary. This includes emergency dental and oral surgery by a physician as a result of an injury, accident, or other condition.

What pharmacy benefits do I have? Is my prescription covered?
We aim to provide high-quality, cost-effective options for drug therapy. We work with your providers and pharmacists to make sure we cover the most important and useful drugs for a variety of conditions and diseases.

Tufts Health Direct uses a Preferred Drug List (PDL) as our list of covered drugs. To quickly find out if we cover a specific drug, look it up in our PDL. We update the PDL every three months. The PDL applies only to drugs you get at retail, specialty, and mail-order pharmacies if covered under your plan level. The PDL does not apply to drugs you get if you are in the hospital.

Do I have any EXTRA benefits?
As a Tufts Health Direct member, you get access to high-quality, low-cost health care, plus EXTRAS, like a FREE $55 health rewards card for getting your yearly checkup.

What does cost sharing mean?
Cost sharing means that Tufts Health Direct members pay for a portion of their health care costs not covered by Tufts Health Plan. The amount or percentage you pay will depend on the Tufts Health Direct plan level you qualify for or select. Some examples of cost sharing include deductibles, co-payments, and co-insurance.

Learn more about Tufts Health Direct cost-sharing terms.

What is an annual deductible, integrated deductible, annual out-of-pocket maximum, co-insurance, or premium?
Learn more about Tufts Health Direct cost-sharing terms.

What is a benefit year?
A benefit year is the consecutive 12-month period during which health plan benefits are purchased and administered; deductibles, co-insurance, and the out-of-pocket maximums are calculated; and most benefit limits apply. Note, in some case, your first benefit year will not be a full 12 months.

How long does my membership last?
Once you enroll, your Tufts Health Direct membership will last as long as you continue to pay your monthly premium.

How does Tufts Health Plan manage my care?
We want to make sure you get the right care in the right place. Our care managers and clinicians look at some of the services your doctors think you need before you get them, to see if they are medically necessary and planned for the right type of facility. If necessary, we give your doctors prior authorization (permission) before you get certain services. We also review some of your services as you get them (such as if you go in the hospital) to make sure you get the best care. We work with you and your doctors to make a plan for when you leave a facility or stop getting services. Finally, we review your services after you get them to make sure you got the best quality care.

As part of our care-management program, if you have a physical disability or other special health condition such as a high-risk pregnancy, cancer, HIV/AIDS, or a behavioral health (mental health and/or substance abuse) concern, our clinicians can give you information, personalized resources (if eligible), and help coordinating your care. We also offer social care management services to help arrange, coordinate, and evaluate the services you may need; disease-management programs for asthma and diabetes; and health-coaching services if you have a chronic health condition.

For more on these services, check our Tufts Health Direct Member Handbook (PDF).

Are there services that Tufts Health Plan does not cover?
Yes; some services we do not cover include:

  • Cosmetic surgery
  • Hearing aids for members over age 21
  • Long-term care
  • Nonemergency dental services (excluding cleft palate/lip services for members under age 18
  • Nonemergency care when traveling outside the U.S.
  • Private-duty nursing
  • Vocational rehabilitation
  • Any service or supply that is not medically necessary

For a complete list of services we do not cover, check our Tufts Health Direct Member Handbook (PDF).

Where do I send my premiums (monthly payments)?
Once you enroll in Tufts Health Direct, you may receive a monthly invoice. If you prefer to write a check each month, you should send your premium to the address listed on your invoice.

For added convenience, you may be able to pay electronically and set up recurring payments, where you can authorize your monthly premium to be deducted directly from your checking account. This means not having to worry about writing and mailing a check every month.

For more information about Tufts Health Direct premium payments, check your invoice.

Who will have access to my health information?
We are required by law to keep your individual health information, known as protected health information (PHI), private and secure in our organization, including oral, written, and electronic PHI. We do this in a number of ways, such as using computer passwords and screensavers. Employees do not talk about your PHI in public areas, and are not allowed to see your PHI if they do not need it for their job. We make sure that people without permission do not see or change your records. You have the right to approve any release of your PHI, and to get your medical records from your health care provider.

For a copy of our Notice of Privacy Practices, call us at 888-257-1985 (TTY: 888-391-5535), Monday through Friday, 8 a.m. to 5 p.m. You can also find this information online and in our Tufts Health Direct Member Handbook (PDF).

More questions?

Call us at 888-257-1985, Monday through Friday, 8 a.m. to 5 p.m. We're happy to help.

 

 

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