Frequently Asked Questions (FAQs)

The One Care program is a collaborative initiative between MassHealth and the Centers for Medicare & Medicaid Services (CMS) to integrate care for people who are eligible for both Medicare and Medicaid.

Tufts Health One Care is our Medicare-Medicaid One Care plan for people ages 21 – 64. Tufts Health Plan launched Tufts Health One Care to provide enrollees who live in Middlesex, Suffolk, Worcester, Bristol, Plymouth or Norfolk counties with access to One Care's comprehensive care delivery system.

Yes. Individuals may opt out of One Care, but they must notify MassHealth of their decision not to participate in the program.

Yes. Tufts Health One Care enrollees who live in Worcester, Suffolk or Middlesex counties may seek care from a contracted Tufts Health Plan PCP or specialist in another county. Please use our Find a Doctor or Hospital search to determine which providers are in-network for Tufts Health One Care.

No. There are no co-payments for Tufts Health One Care enrollees.

Yes. MassHealth and the Centers for Medicare & Medicaid Services (CMS) require ADA training and compliance. You can contact our ADA compliance manager at adacompliance@point32health.org with questions or to request a list of ADA resources. You can also find more information about ADA training at the state's One Care learning website.

No. We will let you know if this interface is available in the future.

You can learn more about One Care from any of the following resources:

• One Care: MassHealth plus Medicare website
• One Care learning website
• Tufts Health One Care training document

The Executive Office of Health and Human Services (EOHHS) and the Centers for Medicare & Medicaid Services (CMS) require providers and office staff to complete comprehensive training on the program. This training program has two tracks:

Track one

• A training series developed by UMass Medical School and MassHealth to provide foundational information on the One Care program, which is designed to improve health care quality through person-centered, coordinated care.
• To learn more about this training series, please visit the One Care learning website.

Track two

• Our Tufts Health One Care plan-specific training fulfills your Tufts Health Plan training requirement. The training document explains your day-to-day interactions with us and includes topics regarding our model of care and administrative processes.
• Once you have read the document, you must submit the requested information at the bottom of the training page to receive credit and fulfill your training requirement.

You must complete both training program tracks to meet One Care requirements, and we will record and submit your participation in the Tufts Health One Care training to both EOHHS and CMS.

Yes. All contracted providers and staff, including providers outside of Worcester, Suffolk and Middlesex counties, must fulfill the Tufts Health One Care training requirement.

Although we only cover enrollees who live in Worcester, Suffolk and Middlesex counties at this time, enrollees may seek health care services from contracted providers in other counties.

If you have not already completed the Tufts Health One Care provider training, you can access our training document. Please note: To fulfill your training requirement, you must submit the requested information at the bottom of the training page.

At this time, you only need to read our training document regardless of the county in which you practice. Tufts Health Plan may require additional training in the future and will inform you of the required training by including notification in the Provider Update newsletter and or additional content on the training page.

 

No. If you are currently a Tufts Health Plan provider, you will not need to re-credential for Tufts Health One Care.

Yes. If you have not done so already, you will need to sign a separate contract amendment before you can start seeing Tufts Health One Care enrollees. If you would like to become a contracted provider for Tufts Health One Care, get started by joining our network.

You need to sign a contract amendment. If you are not sure if your practice has contracted for Tufts Health One Care, please contact Provider Services at 888.257.1985.

Before delivering care, please always check member eligibility and let your patient know that you are an out-of-networkprovider.

We only cover care rendered by in-network providers, with the following exceptions:

• Emergency, urgent, or post-stabilization care
• Family-planning services from a MassHealth-contracted family-planning services provider
• Services uniquely available from an out-of-network provider, with prior authorization
• Kidney dialysis services rendered by a Medicare-certified dialysis facility, if the enrollee is outside the plan's service area for a short time

When enrollees first join Tufts Health One Care, they may continue seeing their current providers for 90 days or until an alternative care plan has been agreed upon. There are exceptions in which enrollees may continue to see their provider, such as if:

• The enrollee is currently in treatment for, or managing, chronic issues (like dialysis, home health, chemotherapy, and/or radiation), including previously authorized services or covered services; they may be able to keep seeing their provider beyond 90 calendar days with prior authorization
• The enrollee is in her second or third trimester of pregnancy; she may be able to keep seeing the provider up through delivery and her first follow-up checkup
• The enrollee is terminally ill; they may be able to keep seeing their provider while they are sick

If you provide a service covered by Tufts Health One Care, you can get started by joining our network. For more information on covered services, please see our medical and behavioral health benefit summary grids.

Examples of providers who may contract with Tufts Health One Care include, but are not limited to:

• Primary care providers (PCPs) and specialists
• Long-term supports (LTS) coordinators at community-based organizations
• Licensed mental health counselors and licensed social workers
• Masters-level behavioral health care providers

We will reimburse you for services rendered to Tufts Health One Care enrollees at the rate specified in yourTufts Health One Care provider contract.

No. The contract does not contain a "no cause" termination clause.

You can find a list of contracted providers using the Find a Doctor or Hospital search.

Yes. Enrollees are the center of the ICT and may choose their providers, designating any provider or individual as part of the ICT.

We reach out to enrollees once they enroll with Tufts Health One Care, but we do not provide care coordination until their coverage effective date. When we outreach, we will review any available claims data and schedule face-to-face assessments to prepare for transition-of-care issues.

No. Our business processes will not change if care coordination or clinical care management takes place at the PCP site. We will assess any site interested to ensure they have the necessary resources to coordinate care and partner with the site to provide the necessary support.

The Tufts Health One Care care team alerts the DMH when members enroll with Tufts Health Plan. We then assign a case worker to the enrollee's interdisciplinary care team (ICT).

Yes. An LTS coordinator helps coordinate an enrollee's care with the PCA.

The Tufts Health One Care care team processes requests for emergency and nonemergency transportation. We then submit an assessment of the requested transportation and issue an authorization, if appropriate.

Enrollees can call the DME providers directly with any issues with their product or they can have their dedicated clinical care manager call on their behalf.

All One Care enrollees must meet the following eligibility requirements:

• Eligibility for Medicare Parts A and B
• Eligibility for MassHealth Standard or CommonHealth
• No other comprehensive private or public health plan coverage

There are several ways you can check an enrollee's eligibility:

• Tufts Health Plan's secure Provider portal
• NEHEN or NEHENNet
• MassHealth Provider Service Portal
• Provider Services, from 8 a.m. to 5 p.m., at 888.257.1985

All enrollees will also have a Tufts Health One Care member ID card.

Primary care providers (PCPs) can check the enrollees in their panel through Tufts Health Plan's secure Provider portal. Remember, the enrollee must be in your panel on the date of service. Refer to the Tufts Health Public Plans Provider Manual for additional information. 
 

An enrollee's coverage is usually effective on the first day of the month following his or her enrollment. For example, if the enrollee joined during open enrollment on September 1, 2019, his or her coverage began on October 1, 2019.

If eligible individuals enroll when they are 64 or younger, they may remain in the One Care program as long as they remain eligible for both Medicare and Medicaid, and Tufts Health Plan waives the age requirement.

No. HDAP is for low-income individuals with HIV (500% of the Federal Poverty Level), usually recently unemployed or without other insurance. One Care covers anti-retrovirals, making HDAP unnecessary for One Care enrollees.

The One Care program combines the benefits of Medicare and Medicaid to create a more robust list of covered services, including a variety of long-term services and supports. For more details, see our medical and behavioral health benefit summary grids. If the benefit summary grids do not answer your question, please call Provider Services at 888.257.1985.

It depends on the service. Please check our medical and behavioral health benefit summary grids for the specific service.

Yes. You may render services before the assessment is completed.

No. Third-party liability rules still apply to Tufts Health One Care.

We require a primary care provider (PCP) referral for specialty services for members in certain provider systems. You can check which members require a referral, or the status of an existing referral request through Tufts Health Plan's secure Provider portal or by calling us at 888.257.1985. You can also look for "PCP referral required" on the member's ID card.

We require prior authorization for some services. For more information, see our medical and behavioral health benefit summary grids and payment policies.

Providers are responsible for obtaining referrals, when necessary.

The enrollee, their primary care provider (PCP), specialist, or any member of the interdisciplinary care team may request prior authorization.

The prior authorization process is almost the same. The only difference is that either the Tufts Health One Care enrollee or his or her provider may request prior authorization. To request prior authroization, please refer to the Utilization Management chapter of the Tufts Health Public Plans Provider Manual. For additional information, contact Provider Services at 888.257.1985.
 

 

Yes. The referral process is the same for Tufts Health One Care as it is for our other plans.

Yes. We allow 12 outpatient BH visits per benefit year without prior authorization for some Current Procedural Terminology (CPT) codes (90791, 90832, 90834, 90846, 90847, 90849). When submitting your claim, please select the appropriate CPT code that indicates the length of the session.

These 12 visits are separate from psychiatric medication visits, psychotherapy for crisis, groups, and collateral contacts, which are exempt from prior authorization. If your patient needs more than 12 outpatient BH visits, please request prior authorization one to three weeks prior to the last covered visit.

Yes. The prior authorization process for BH services is the same for Tufts Health One Care and our other plans.

We approve the initial evaluation and review the assessment to determine the number of visits, following MassHealth and CMS guidelines.

Yes. We will extend the five-day authorization window for DME.

Yes. We cover existing DME rentals under our continuity of care guidelines, but you must request prior authorization.

Yes, but you will need prior authorization before rendering care to a Tufts Health One Care enrollee.

The One Care program consolidates billing to make it easier for you to get paid. Please submit all claims toTufts Health Plan for services rendered to Tufts Health One Care enrollees.

Yes. Our claims process is the same for all our plans.

Please see the Claims Requirements and Dispute Guidelines chapter of the Tufts Health Public Plans Provider Manual for information about submitting claims electronically. A member of our e-business team can also work with you individually to help determine the electronic claim submission method that's right for you. Call Provider Services at 888-257-1985.

Please send all initial paper claims to us at:

Tufts Health Public Plans — Paper Claims Submissions
P.O. Box 189
Canton, MA 02021-0189

It depends on the service. Please see our payment policies for more detail about the specific service.

It depends on the service, as some services are covered by Medicaid. Please see our medical and behavioral health benefit summary grids for coverage information for the specific service.

Please see a comprehensive list of our payment policies. You can also call Provider Services at 888.257.1985 if you have additional questions.

We do not reimburse for day services for developmental disability providers. DDS will continue to pay for these services.

Pharmacy providers are responsible for filing pharmacy claims for Tufts Health One Care enrollees. If you need home infusion medication for a Tufts Health One Care enrollee, please send a prescription to the pharmacy. The pharmacy will then deliver the medication to the enrollee and bill Tufts Health Plan.

At present our service area includes Middlesex, Suffolk and Worcester counties. We currently have a strong provider network in all three counties and beyond to help us provide access to high-quality care for Tufts Health One Care enrollees. We hope that there will be an appropriate opportunity to expand into other areas in the future.

Yes. As a contracted provider for Tufts Health One Care, you are still considered in-network and may see Tufts Health One Care enrollees even if you are not located within Middlesex, Suffolk or Worcester counties.

Yes. All providers who are contracted for Tufts Health One Care are considered in-network, even if they are located outside of Middlesex, Suffolk and Worcester counties.

When enrollees first join Tufts Health One Care, they may continue seeing their current providers for 90 days or until an alternative care plan has been agreed upon. There are exceptions in which the enrollee may continue to see their provider beyond 90 days, such as if:

• The enrollee is currently in treatment for, or managing, chronic issues (like dialysis, home health, chemotherapy, and/or radiation), including previously authorized services or covered services; they may be able to keep seeing their provider beyond 90 calendar days with prior authorization
• The enrollee is in her second or third trimester of pregnancy; she may be able to keep seeing the provider up through delivery and her first follow-up checkup
• The enrollee is terminally ill; they may be able to keep seeing their provider while they are sick

We have a number of resources available to help answer your questions:

• Tufts Health One Care training document
• Tufts Health One Care overview
• Payment policies
• Tufts Health One Care pharmacy program

If you still have questions, please contact Provider Services at 888.257.1985.