Frequently Asked Questions (FAQs)

Tufts Health Direct


What is a Qualified Health Plan (QHP)?

QHPs provide subsidized and unsubsidized coverage to eligible members, per the Patient Protection and Affordable Care Act (ACA). Members may purchase unsubsidized coverage directly from insurers or through the Commonwealth Health Insurance Connector Authority (Health Connector) in the Massachusetts state-based marketplace. Subsidized ConnectorCare plans are only available through the Health Connector, and provide eligible Massachusetts residents with access to state and/or federal premium and cost-sharing subsidies.

Members may be eligible for subsidies, depending on their income level

Available subsidies Member income Tufts Health Direct plan level
  • Federal Premium Tax Credit

  • Federal cost-sharing reductions

  • State premium subsidies

  • State cost-sharing subsidies

0-250% of the federal poverty level (FPL)

ConnectorCare

  • Federal Premium Tax Credit

  • State premium subsidies

  • State cost-sharing subsidies

250-300% of the FPL

ConnectorCare

  • Federal Premium Tax Credit

300-400% of the FPL

Platinum
Gold
Silver
Bronze

  • No subsidies

More than 400% of the FPL

Platinum
Gold
Silver
Bronze


If your patient does not qualify for one of the above subsidies and they feel that the health care plans available to them are not affordable, please ask them to call the Health Connector at 877-MA-ENROLL to discuss their options.

What is Tufts Health Direct?

Tufts Health Direct is our QHP covering both subsidized and unsubsidized members. We offer multiple plan levels that all cover the same comprehensive benefit package but have different premiums and cost-sharing structures.

What does the member ID card look like?

The member ID card looks similar to our other Tufts Health Plan member ID cards and indicates the member's Tufts Health Direct plan level.

What are the plan levels for Tufts Health Direct?

We will offer multiple plan levels that all cover the same comprehensive benefit package but have different premiums and cost-sharing structures:

  • Direct Catastrophic
  • Direct Platinum
  • Direct Gold
  • Direct Silver
  • Direct Bronze
  • Direct ConnectorCare*

The member ID card will indicate the member's plan level. For more information on the deductibles, co-payments, and out-of-pocket maximums for Tufts Health Direct, see our medical and behavioral health benefit summary grids.

* Direct ConnectorCare members must meet income eligibility requirements.


Delivering Care and Getting Paid


How do I check if a patient is a Tufts Health Direct member?

You can verify Tufts Health Direct member enrollment through regular channels, including Tufts Health Plan's secure Provider portal, our online self-service tool; NEHEN or NEHENnet; or our Interactive Voice Response (IVR) system by calling us at 888-257-1985.

Always verify that your patient is a current Tufts Health Plan member at the time you render services. If you check a patient’s enrollment status in advance of an appointment, please also check again on the date of service.

Do Tufts Health Direct members require prior authorizations for services?

Tufts Health Direct members need prior authorizations for certain services. To find detailed information about prior authorization requirements, please refer to our medical and behavioral health benefit summary grids for Tufts Health Direct.

Medical and Behavioral health benefit summary grids:

Do I handle claims in the same way I currently do for other Tufts Health Plan plans?

Yes. The claims process is the same as for our other plans.

Do Explanations of Payment (EOPs) look the same?

Yes. The EOP for Tufts Health Direct is incorporated into the EOP you currently receive.

What information about Tufts Health Direct patients is available on Tufts Health Plan's secure Provider portal?

The same patient information that is available for other Tufts Health Plan patients is available for Tufts Health Direct patients on Tufts Health Plan's secure Provider portal, including:

  • Prior authorization and claim status
  • Member information
  • PCP panel reports, which are also available through NEHEN or NEHENnet
  • Remittance advice

If you do not currently have a Tufts Health Plan secure Provider portal login, begin the registration process.


Provider Network


How will I know which providers are in- or out-of-network?

You can use our online Find a Doctor, Hospital, or Pharmacy tool to search for in-network providers for Tufts Health Direct. When searching for in-network providers, please remember that a yellow yield sign indicates the provider is a nonpreferred in-network provider for whom we require prior authorization.

Does Tufts Health Direct cover services rendered by out-of-network providers?

Tufts Health Plan only covers the following services rendered to Tufts Health Direct members by out-of-network providers:

  • Emergency and post-stabilization care
  • Emergency transportation
  • Urgent care services rendered at a licensed urgent care facility
  • Unique, medically necessary services for which we grant prior authorization

We will not cover any other services rendered by out-of-network providers.

What should I do if I only have admitting privileges at an out-of-network facility? Can I still be in-network?

Yes, but you should direct your Tufts Health Direct patients to an in-network facility. If you must refer a member to an out-of-network facility for unique, medically necessary services, you will need to obtain prior authorization.

If a hospital is out-of-network, are all the physicians who admit there out-of-network too?

It varies for each facility. You can use our online Find a Doctor, Hospital, or Pharmacy tool to search for in-network providers for Tufts Health Direct.

How do I become contracted as a Tufts Health Direct provider?

If you are a provider interested in joining our network, the first step is to submit a letter of interest. Please submit a formal letter of interest to:

Tufts Health Plan
Attn: Director of Contracting
P.O. Box 9194
Watertown, MA 02471-9194

Learn more about joining our network.

Will I have the same provider relations representative I currently have for Tufts Health Plan?

Yes. Your provider relations representative will not change.


Member Benefits


If a patient is interested in enrolling in Tufts Health Direct, who should they contact?

Patients interested in enrolling in Tufts Health Direct should contact the Health Connector at 877-MA-ENROLL.

What are the benefits for Tufts Health Direct members?

Tufts Health Direct coverage includes office visits and screenings, wellness visits for infants and children, hospital care, treatment for mental health and substance use, and prescription drug coverage.

You can see detailed information about covered benefits in our medical and behavioral health benefit summary grids.

How much do Tufts Health Direct members pay out-of-pocket?

Your Tufts Health Direct patients may be eligible for state and/or federal subsidies. They may also be responsible for co-payments, co-insurance, and/or deductible amounts. For more information on the deductibles, co-payments, and out-of-pocket maximums for Tufts Health Direct, see our medical and behavioral health benefit summary grids.

What will happen to members who are in active treatment with an out-of-network provider?

Under certain conditions, we will allow members to continue treatment with an out-of-network provider if the provider agrees to our terms related to reimbursement, member co-payments (which cannot be higher than those listed in our medical and behavioral health benefit summary grids), quality, and additional Tufts Health Plan policies and procedures, including the terms and conditions set forth in the Member Handbooks. 

I have a question that isn't answered here. Who should I contact?

Please contact our provider services team at 888-257-1985.

Register Today

Provider Update Newsletter

Tufts Health Plan distributes its Provider Update* newsletter by email. In order to receive Provider Update, you must complete the online registration form.

*Copies of this information can be made available upon request by calling the appropriate Tufts Health Plan Provider call center.

Register Your Email