Behavioral Health Overview

Outpatient coverage includes behavioral health and substance use disorder (BH/SUD) treatment, medication, evaluation and monitoring. The BH/SUD provider is responsible for obtaining any necessary authorization(s). For more information, refer to the Outpatient Behavioral Health/Substance Use Disorder Payment Policy.

Depending on the member’s plan type and structure, the member may be assigned to a specific designated facility (DF) or be required to go to one of Tufts Health Plan’s DFs. DF assignment is based on the member’s PCP selection. Depending on the Tufts Health Plan DF, payment for services can either be capitated or fee-for-service. A capitated DF is responsible for managing the care of members for whom they have received capitated payment. All Tufts Health Plan DFs are located in Massachusetts.

Facility Assignment by Plan Type

• HMO members must seek treatment at their assigned DF.
  • If a member is not assigned to a DF, the PCP arranges the member’s care
• EPO members can seek treatment at any Tufts Health Plan DF.
• POS members have two levels of benefits:
  • Authorized: services rendered at any Tufts Health Plan DF
  • Unauthorized: services rendered at any facility outside of the Tufts Health Plan DF system (contracting and noncontracting)
• PPO members also have two levels of benefits:
  • In-network: services rendered at any Tufts Health Plan contracted facility
  • Out-of-network: services rendered at any noncontracted facility
• CareLink^SM members’ coverage varies by plan design and depends on which party is the primary administrator. Verify the member’s benefit prior to rendering services.

For more information, refer to the Inpatient Behavioral Health/Substance Use Disorder Payment Policy.