Frequently Asked Questions

Below you'll find the most frequently asked questions. If you don't find the information you're looking for, contact us.

• Thinking about joining?
• Already a member?

Non-Members Eligible for Group Coverage

Why should I become a Tufts Health Plan member?

Healthcare is something you never want to worry about; you just want to know you have the best possible coverage and care available to your family. With Tufts Health Plan, that's what we believe you get. For more than 20 years, we have been committed to providing a higher standard of health care coverage, even helping to improve the quality of care provided.

Tufts Health Plan has been an innovator in health care throughout our history. We were the first to introduce discounts for exercise programs to keep our members healthy, and we pioneered many medical management programs that resulted in better quality care for new mothers, people with complex diseases, and more.

Of course, you want to know your health plan will be there for you—long term. We've been providing coverage to members in Massachusetts for more than 20 years. So you can rest assured we're sticking around.

With Tufts Health Plan, can I see any doctor?

That depends on the type of coverage that your employer has chosen. With some plans, you must choose a Primary Care Provider from among the thousands in the Tufts Health Plan network and he or she would provide or authorize your care. Then you would be covered and would only be responsible for a copayment for authorized services. There are some products that allow you to receive care from a doctor who is not part of the network, but you would be responsible for deductibles and coinsurance.

How do I find out if my doctor is part of the Tufts Health Plan network?

You can check our online provider directory, prospective CareLink members choose from a national provider network including more than 400,000 doctors and 4,200 hospitals.  You can also call and speak to a Member Services coordinator at
(800) 442-0422.

or speak to a Member Services coordinator at
(800) 442-0422.

If I join Tufts Health Plan, how can I find out what my costs will be?

There are hundreds of copayment structures available within the different coverage choices we offer. Your employer determines which coverage option(s) you will receive, what your copayments will be for office visits and other services, and what your premium contribution will be. The information is specific to your coverage will be provided by your benefits administrator.

Members

What should I do in an emergency?

Seek medical care at the nearest emergency medical facility. If needed, call 911 or your local number for emergency medical services number. You don't need to notify Tufts Health Plan before you receive emergency care. However, if you receive outpatient emergency care at an emergency facility, you or someone acting on your behalf should notify your PCP within 48 hours of receiving care. You are encouraged to contact your PCP so your PCP can provide or arrange for any follow-up care that you may need. Any follow-up care must be arranged by your PCP if you are an HMO or EPO member, or if you are a POS member and want to receive coverage at the authorized level of benefits. If you are admitted as an inpatient, you or someone acting on your behalf must call your PCP or Tufts Health Plan within 48 hours after receiving care to receive coverage at the authorized or in-network level of benefits.

There may be a copayment and/or coinsurance for emergency visits. Please see your plan document for more details.

What exactly is an emergency?

An emergency is an illness or medical condition,whether physical or mental, that manifests itself by symptoms of sufficient severity including severe pain that the absence of prompt medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine to result in:

• Serious jeopardy to a member's physical and/or mental health (or with respect to a pregnant member, the member's or her unborn child's physical or mental health); or
• Serious impairment to bodily functions; or
• Serious dysfunction of any bodily organ or part; or with respect to a pregnant woman who is having contractions, inadequate time to effect a safe transfer to another hospital before delivery, or a threat to the safety of the member or her unborn child in the event of transfer to another hospital before delivery

What if I need urgent medical attention while traveling?

You are covered for urgent care you receive when traveling. Urgent care means care that is needed to prevent serious deterioration of health. Examples of conditions requiring urgent care include: a sprained ankle, broken bone(s), an earache, strep throat, high fever, or a cut requiring stitches. If you seek urgent care while traveling, you or someone acting on your behalf should notify your PCP within 48 hours after receiving care. You are encouraged to contact your PCP so your PCP can provide or arrange for any follow-up care that you may need. Any follow-up care must be arranged by your PCP if you are an HMO or EPO member, or if you are a POS member and want to receive coverage at the authorized level of benefits.

How do I choose my doctor?

That depends on your plan. If you are an HMO, EPO, or POS member, you choose your PCP from the extensive Tufts Health Plan network. (PPO members are not required to select a PCP.)  CareLink members choose from a national provider network including more than 400,000 doctors and 4,200 hospitals

If you need help finding a PCP, you may search for a network physician by accessing our find a doctor search function, or you can contact us.

You can view physician profiles that include information on a provider's education and training, awards, publications, and malpractice and disciplinary history at the Massachusetts Board of Registration in Medicine online physician profile site. You can also call 617-727-0773, or contact the Massachusetts Board of Registration in Medicine, 10 West Street, Boston, MA, 02111.

Here are some important questions to ask when you are selecting a PCP for yourself or a family member:

• What clinical training or background are you looking for in a PCP? For example, a physician who has received family practice training provides medical care to all age groups, and can provide care in specialties such as obstetrics, internal medicine, and pediatrics. A pediatrician is trained in diagnosing and treating infants and children, as well as monitoring their development. A doctor of internal medicine, also called an internist, has been trained in diagnosing and treating diseases and disorders in adults.
• The Tufts Health Plan Web site provider search function can give you information on a PCP's education, training, gender, and whether the PCP speaks any foreign languages. Or you may get that information by calling member services.
• Is it more important that your PCP's office is closer to your home or to where you work?
• To what hospital(s) does the PCP admit patients? If hospitalization is necessary, many people prefer local community hospitals since they provide a broad range of medical services, from cardiac care to surgery to pediatric, obstetrical, and gynecological care. Community hospitals also offer high-quality emergency services and diagnostic tests.
• If you needed specialty care, whom will the PCP select to provide that specialty care? (See the specialty care description that follows.)
• Is the PCP also a specialist (e.g., cardiologist)? Perhaps you would prefer a PCP who has additional training in a particular field of medicine because you may have an ongoing condition that requires special care.
• Who covers for the PCP if the PCP is out of the office? Would you be comfortable being seen by one of these covering physicians?
• If you need lab or X-ray services, where would they be performed? How does the PCP notify patients of test results?
• Does the PCP's office contact patients about scheduling preventive appointments?

What if I need to be hospitalized?

Except in an emergency, if you need hospitalization, most likely you will be admitted to your PCP's affiliated hospital, unless the treatment you require is not available there. This same hospital admitting procedure applies if you are admitted to a hospital by a specialist.

What if I need a specialist?

If you are an HMO member , your PCP will likely refer you to a specialist in his/her provider unit. The advantage of being referred is that your PCP and the specialist already have a working relationship, and this will help promote quality and continuity of care. In the event that a particular service is not available in your PCP's provider unit, your doctor will select and refer you to a Tufts Health Plan specialist in another provider unit. Your PCP may also consider any existing relationship you may have with a specialist. POS and EPO members will usually be referred to a specialist in the Tufts Health Plan network. (POS members can see specialists without a referral, but will be covered at the unauthorized level of benefits). PPO members can see specialists within the Tufts Health Plan network for covered services without a referral and be covered at the in-network level of benefits.

For coverage for non-emergency mental health and substance abuse, you should contact us.

For an annual GYN exam and medically necessary follow-up care, HMO and POS members do not need a referral. You may go to any Tufts Health Plan contracted women's health specialist, including an OB/GYN, family practitioner, or certified nurse midwife. You also do not need a referral for maternity care or for evaluating and treating acute or emergency GYN conditions.

Will my doctor always be a Tufts Health Plan network provider?

While we work to keep providers in our network, they do sometimes leave. The reasons include: provider retirement, a move out of the area, failure to reach contractual agreement with Tufts Health Plan, or failure to meet our credentialing standards. We regret any inconvenience these changes may cause.

Do Tufts Health Plan network providers work for Tufts Health Plan?

No. Tufts Health Plan arranges for the provision of health care services by contracting with physicians and other providers practicing in their private offices. Tufts Health Plan also contracts with hospitals and other health care facilities. All providers are independent contractors and not employees, agents, or representatives of Tufts Health Plan.