062524
Tufts Health RITogether
Member
Handbook
2024
7083 THP-OCR-NOTICE-06023
DISCRIMINATION IS
AGAINST THE LAW
Tufts Health Plan complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex.
Tufts Health Plan does not exclude people or treat them differently because of race,
color, national origin, age, disability, sex, sexual orientation, or gender identity.
Tufts Health Plan:
Provides free aids and services to people with disabilities to communicate effectively with us,
such as written information in other formats (large print, audio, accessible electronic formats, other
formats)
Provides free language services to people whose primary language is not English, such as
qualified interpreters and information written in other languages
If you need these services, contact Tufts Health Plan at 866.738.4116.
If you believe that Tufts Health Plan has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Tufts Health Plan
Attention: Civil Rights Coordinator, Legal Dept.
1 Wellness Way
Canton, MA 02021-1166
Phone: 888.880.8699 ext. 48000, [TTY number— 711 or 800.439.2370]
Fax: 617.972.9048
Email: OCRCoordinator@point32health.org
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the
Tufts Health Plan Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Phone: 800.368.1019, 800.537.7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
tuftshealthplan.com | 866.738.4116
We can give you information in other formats, such as braille and
large print, and also in different languages upon request.
List-Languages-THP-Number-03/19
6435 03219
For no-cost translation in English, call 866.738.4116.
Arabic .866.738.4116 ﻢﻗﺮﻟا ﻰﻠﻋ لﺎﺼﺗﻻا ﻰﺟﺮﯾ ،ﺔﯿﺑﺮﻌﻟا ﺔﻐﻠﻟﺎﺑ ﺔﯿﻧﺎﺠﻤﻟا ﺔﻤﺟﺮﺘﻟا ﺔﻣﺪﺧ ﻰﻠﻋ لﻮﺼﺤﻠﻟ
Chinese 若需免費的中文版本，請撥打 866.738.4116。
French Pour demander une traduction gratuite en français, composez le 866.738.4116.
German Um eine kostenlose deutsche Übersetzung zu erhalten, rufen Sie bitte die folgende Telefonnummer
an: 866.738.4116.
Greek Για δωρεάν μετάφραση στα ελληνικά, καλέστε στο 866.738.4116.
Haitian Creole Pou tradiksyon gratis nan Kreyòl Ayisyen, rele 866.738.4116.
Igbo Maka ntụgharị asụsụ n'Igbo na akwụghị ụgwọ, kpọọ 866.738.4116.
Italian Per la traduzione in italiano senza costi aggiuntivi, è possibile chiamare il numero 866.738.4116.
Japanese 日本語の無料翻訳については 866.738.4116 に電話してください。
Khmer (Cambodian) 866.738.4116
Korean 한국어로 무료 통역을 원하시면, 866.738.4116 로 전화하십시오.
Kru Inyu yangua ndonõl ni Kru sébèl 866.738.4116.
Laotian ສໍ າລັ ບການແປພາສາເປັ ນພາສາລາວທີ
່
ບໍ
່
ໄດ້ເສຍຄ່າໃຊ້ຈ່າຍ, ໃຫ້ໂທຫາເບີ 866.738.4116.
Navajo Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 866.738.4116.
نﺎﮕﯾار ﮫﻤﺟﺮﺗ یاﺮﺑ ﯽﺳرﺎﻓ ﮫﺑ هرﺎﻤﺷ ﮫﺑﻦﻔﻠﺗ 4116.738.668 .ﺪﯿﻧﺰﺑ ﮓﻧز Persian
Polish Aby uzyskać bezpłatne tłumaczenie w języku polskim, należy zadzwonić na numer 866.738.4116.
Portuguese Para tradução grátis para português, ligue para o número 866.738.4116.
Russian Для получения услуг бесплатного перевода на русский язык позвоните по номеру 866.738.4116.
Spanish Por servicio de traducción gratuito en español, llame al 866.738.4116.
Tagalog Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 866.738.4116.
Vietnamese Để có bản dịch tiếng Việt không phải trả phí, gọi theo số 866.738.4116.
Yorùbá Fún isẹ
́
ògbùfọ
̀
l'ọ
́
fẹ
̀
ní Yorùbá, pe 866.738.4116.
1
Here’s Where to Find Information You Want
Important Phone Numbers
HealthSource RI 855-840-4774
RI Department of Human Services 855-697-4347
UnitedHealthcare Dental/RIte Smiles 866-375-3257
RI Public Transit Authority (RIPTA) 401-784-9500, ext. 2012
Non-Emergency Transportation Broker 855-330-9131
RI Insurance Resource, Education, and Assistance
Consumer Helpline (RIREACH)
855-747-3224
RI Legal Services 401-274-2652
Tufts Health RITogether Member Services: 866-738-4116 (TTY: 711), Monday through
Friday, from 8 a.m. to 6 p.m., excluding holidays.
Please take a few minutes to fill in the information below.
My Primary Care Provider Name:
Telephone:
Address:
In a health care emergency, call 911 or go to the nearest emergency room.
If we have any significant change to the information found in this Member Handbook, we
will let you know at least 30 days before we make the change. Things included would be
changes in your benefits and how you get them.
2
Table of Contents
Overview of your Health Plan .............................. 3
Welcome to Tufts Health RITogether ......................... 3
Interpreter Services and Assistance in Other
Languages and Formats .......................................... 3
Tufts Health RITogether Coverage Area ................. 4
How Managed Care Works ......................................... 5
The Plan, Our Providers, and You ........................... 5
Confidentiality ......................................................... 5
Transition of Care (Continuity of Care) ................... 5
Member ID Cards ........................................................ 6
Your Tufts Health RITogether Member ID Card ...... 6
Your Rhode Island Medicaid (Anchor) ID Card ....... 6
Update Your Information ............................................ 7
How to Tell Us About Changes ................................ 7
Renew Your Medicaid Eligibility .............................. 7
Member Services ........................................................ 8
We Speak Your Language ........................................ 8
Need Print Material in Other Formats? .................. 8
How to get your healthcare ................................. 9
Your Primary Care Provider (PCP) ............................... 9
You Have Options .................................................... 9
Choosing Your PCP .................................................. 9
What your PCP can do for you: ............................... 9
Changing Your PCP ................................................ 10
Getting Care .............................................................. 10
Making an Appointment with Your PCP ............... 10
Annual Checkups ................................................... 10
Specialty Care ........................................................ 10
Getting a Second Opinion ..................................... 11
Urgent Care or Walk-In Center ............................. 11
Emergency Services .............................................. 12
Early Periodic Screening Diagnostic Treatment
(EPSDT) .................................................................. 12
Behavioral Health Services .................................... 13
Dental .................................................................... 13
Appointment Availability ...................................... 14
Special Programs to Keep You Healthy ................. 14
Out-of-Network/Out-of-Area Care ....................... 14
Prior Authorizations .............................................. 14
Non-Emergency Medical Transportation .............. 15
24/7 NurseLine ...................................................... 16
Your Healthcare Benefits ................................... 16
Medical Benefits ....................................................... 16
Description of Benefits from Tufts Health
RITogether............................................................. 17
Benefits from RI Medicaid .................................... 21
Extended Family Planning Benefits ....................... 22
Covered Medications and Pharmacy ........................ 23
Generic Drugs ........................................................ 23
Prior Approval ....................................................... 23
Prior Approval Denials .......................................... 23
Exclusions ............................................................. 23
New-to-Market Drugs ........................................... 24
Quantity Limits ..................................................... 24
Step Therapy Program .......................................... 24
Non-PDL drugs ...................................................... 24
90-Day Supply Program ........................................ 24
Out-of-Network Services .......................................... 25
Non-Covered Services ............................................... 25
Experimental and/or Investigational Services .......... 25
Tufts Health RITogether EXTRAS ......................... 26
Gift Cards to Use to Buy Kids’ Car Seats ................... 26
Rewards for Healthy Actions .................................... 27
For young members .............................................. 27
If you are a new parent ........................................ 27
If you have asthma ............................................... 28
If you have diabetes ............................................. 29
Fitness Reimbursement ............................................ 29
Integrated Care Management ............................ 30
Complex Care Management (CCM) Services ............ 30
Community Health Services ...................................... 31
Specific Care Management Services and Programs.. 31
Disease Management ........................................... 31
Health Needs Assessment .................................... 31
Maternal and Child Health ................................... 31
Short-Term Care Coordination ............................. 31
Transition of Care (ToC) Program ......................... 32
Plan Details ........................................................ 32
Member Rights and Responsibilities ........................ 32
Advance Directives ................................................... 33
Complaints, Grievances, and Appeals ................. 34
Complaints ................................................................ 34
Grievances ................................................................ 35
Appeals ..................................................................... 35
Urgent (Fast) Appeals ........................................... 36
External Appeals ................................................... 36
State Fair Hearing ................................................. 37
Complaints About the Appeal Process ................. 37
Other Health Plan Information ........................... 37
How to Disenroll from Tufts Health RITogether ....... 37
Coordination of Benefits (COB) ................................ 38
CurrentCare® ............................................................ 38
Rhode Island All-Payer Claims Database .................. 38
Fraud, Waste, and Abuse ................................... 38
Parity ................................................................. 39
Privacy Practices ................................................ 40
Compliance with State and Federal Laws: .......... 40
Definitions ......................................................... 41
3
Overview of your Health Plan
Welcome to Tufts Health RITogether
We are glad that you enrolled in Tufts Health RITogether, our Rhode Island Medicaid plan. This
handbook will be your guide to the full range of health care services that you may get. We
want to be sure you get off to a good start as a new member. To get to know you better, we
will get in touch with you in the next two or three weeks. You can ask us any questions you
have, or get help making appointments. If you need to speak with us before we call on you,
however, just call us at 866-738-4116 (TTY: 711), Monday through Friday, from 8 a.m. to 6
p.m., excluding holidays. Or you can also visit us at tuftshealthplan.com/RImember
.
Tufts Health Public Plans, Inc. is a licensed health maintenance organization (HMO) in
Massachusetts and Rhode Island doing business under the name, “Tufts Health Plan.”
Interpreter Services and Assistance in Other Languages and Formats
Do you have questions? Do you need this document translated? Do you want someone to read
this or other printed information to you? If so, call us at 866-738-4116 (TTY: 711), Monday
through Friday, from 8 a.m. to 6 p.m., excluding holidays. We have bilingual staff. We offer
translation services in 200 languages. We also can offer information in other formats, such as
large type size. All language services and other formats are free to members.
Many Tufts Health RITogether providers speak other languages. The languages providers speak
are listed in our Provider Directory. If you need an in-person interpreter, call your provider’s
office or Member Services at least 72 hours before your appointment to ask. Please ask for
sign language interpreters at least two weeks before your visit.
In a health care emergency, call 911
or go to the nearest emergency room.
4
Tufts Health RITogether Coverage Area
5
How Managed Care Works
The Plan, Our Providers, and You
• You may have heard about the changes in health care. Many consumers get their health
benefits through managed care organizations (MCOs) like Tufts Health RITogether. A
MCO provides a central home for your care. For example, if you were getting behavioral
health services using your Medicaid card, many of those services are now available
through Tufts Health RITogether.
• Tufts Health RITogether has a contract with the Rhode Island Executive Office of Health
and Human Services (EOHHS) to meet the health care needs of people with Medicaid. In
turn, we choose a group of health care providers to help us meet your needs. These
doctors and specialists, hospitals, labs, and other health care facilities make up our MCO
provider network. You will find a list, including the provider’s name, address, phone
numbers, professional qualifications, specialty, medical school attended, residency
completion, and board certification status, in our Provider Directory. If you do not have
a Provider Directory, call 866-738-4116 (TTY: 711), Monday through Friday, from 8 a.m.
to 6 p.m., excluding holidays, to get a copy, or visit our website at
tuftshealthplan.com/RImember
.
• When you join Tufts Health RITogether, one of our providers will take care of you. Most
of the time, that person will be your primary care provider (PCP). If you need to have a
test, see a specialist, or go into the hospital, your PCP will arrange it.
• If you need to talk to your PCP after hours or weekends, leave a message and how you
can be reached. Your PCP, or the provider covering for him/her, will get back to you as
soon as they are able.
Confidentiality
We respect your right to privacy. Tufts Health RITogether understands the trust needed
between you, your family, your doctors, and other care providers. Tufts Health RITogether
will never give out your medical or behavioral health information without your written
approval. The only person that will have your health information will be Tufts Health
RITogether, your Primary Care Provider, other providers who give you care, and anyone who
you have asked to talk about your care for you. Your PCP will always talk to you about referrals
to other providers. Tufts Health RITogether staff has been trained in keeping your information
private.
Transition of Care (Continuity of Care)
Tufts Health RITogether is responsible for making sure that all its members can keep getting
the care that they need. You can keep getting care from your provider for 180 days after
6
joining Tufts Health RITogether. You can see that provider even if that provider is not in our
network. After that time Tufts Health RITogether will work with you so you are referred to the
right providers that are in the network.
Member ID Cards
When you join Tufts Health RITogether, you will get a member ID card in the mail about 10
days after your effective date. Your ID card has important information about you and your
benefits. Your ID card also tells providers and pharmacists that you are a Tufts Health
RITogether member. Check to make sure the information on your ID card or your family
member’s ID card is right. If any information is wrong, please call Member Services at 866-738-
4116 (TTY: 711), Monday through Friday, from 8 a.m. to 6 p.m., excluding holidays. Please
note, each member will receive a unique Tufts Health RITogether member ID card.
Your Tufts Health RITogether Member ID Card
Your Rhode Island Medicaid (Anchor) ID Card
You will also get an RI Medicaid (anchor) card in a separate mailing from the state of Rhode
Island. Each family member who is enrolled will have their own card. For information about
your Rhode Island Medicaid ID card, call 855.MY.RIDHS (855-697-4347).
Always show both ID cards when you go to the PCP, hospital, pharmacy, or
other provider.
7
Update Your Information
It’s very important that we have your correct address, so you can receive mail from Tufts
Health RITogether and the RI Medicaid Program. Be sure to have your full name on your
mailbox (and other family members’ last name if it is different than your own). The post office
will not deliver mail if the last names on the mailbox do not match the last name on the
letter/envelope.
It’s very important to tell us if you have a change, in any of these:
• Name, address, phone number.
• If you move out of state.
• If you get married; if you change your last name.
• If you become pregnant.
• Family size (adding a new baby or adopting a child, death of a family member who is
enrolled, etc.)
• Change in income that could affect eligibility for Medicaid.
• If you have other health insurance.
You are required to report changes to HealthSource RI or the RI Department of Human
Services (DHS) within 10 days of the change.
How to Tell Us About Changes
Contact HealthSource RI to report any of these changes. If you have an account at
HealthSource RI, you can go online at www.healthsourceri.com
or call 855-840-4774 to make a
change. You can also visit the HealthSource RI walk-in center at 401 Wampanoag Trail, East
Providence, RI 02915. Business hours are Monday – Friday, 8:00 a.m. – 6:00 p.m.
If you, your child, or another family member has SSI or became eligible for Medicaid due to a
disability, please call the RI Department of Human Services (DHS) at 855-697-4347. You can
also contact your local DHS Office to report changes. Business hours are Monday – Friday, 8:30
a.m. – 4:00 p.m.
Renew Your Medicaid Eligibility
RI Medicaid will send you a notice about renewing your eligibility. If you receive this notice,
please answer promptly so your health coverage is not stopped. Be sure to answer all notices.
If you have questions about your notice, please call HealthSource RI or DHS.
8
Member Services
We want to make it as easy as possible for you to get the information and services you need
from Tufts Health RITogether. Check our website or call Member Services for more
information. We’re here for you!
Member Services: 866-738-4116 (TTY: 711), Monday through Friday, from 8 a.m. to 6 p.m.,
excluding holidays. After business hours, please leave a message and we will get back to you
soon.
Member Services can help you:
• Understand your benefits.
• Get a member ID card, if lost.
• Find a provider or urgent care clinic.
• Make a complaint or file a grievance or appeal.
Website: Go to tuftshealthplan.com/RImember to view plan details and helpful tools:
• Find a provider or pharmacy.
• Search for a drug on the Preferred Drug List.
• Get benefit details.
• View or download a Member Handbook.
We Speak Your Language
If you speak a language other than English, we can provide an interpreter or print materials in
your language. If you call Member Services, we can connect you with a representative who
speaks your language or an interpreter. If you need an in-person interpreter for a medical,
behavioral health, or dental appointment, we can arrange for one. Please call Member
Services at 866-738-4116 (TTY: 711), Monday through Friday, from 8 a.m. to 6 p.m., excluding
holidays, at least 72 hours before your appointment. If you need an American Sign Language
interpreter, please call at least 2 weeks prior to your appointment. All language services are
free to members.
Tufts Health RITogether’s Provider Directory indicates if a provider speaks other languages in
addition to English. To check the Provider Directory, visit tuftshealthplan.com/RImember
.
Need Print Material in Other Formats?
If needed, we can provide free printed material in other formats, including print materials in a
larger font, audio, or Braille. Please contact Member Services at 866-738-4116 (TTY: 711),
Monday through Friday, from 8 a.m. to 6 p.m., excluding holidays, to request materials in
other formats.
9
How to get your healthcare
Your Primary Care Provider (PCP)
Your primary care provider (PCP) is the health care professional who knows you best. Your PCP
works with you to keep you and your family healthy. As a member of Tufts Health RITogether,
you must have a PCP. Call your PCP first for any kind of health care need. In case of an
emergency, always call 911 or go to the nearest emergency room. You can call your PCP’s
office 24 hours a day, 7 days a week. PCPs must have an answering service that will contact
the provider on call who can help you.
You Have Options
You can choose your PCP from the following types of providers:
• Family doctor or general practitioner
• Internal medicine doctor (internist, geriatrician)
• Pediatrician
• Obstetrician/gynecologist (OB/GYN)
• Nurse practitioner (NP)
• Physician’s assistant (PA)
Choosing Your PCP
Check to see if your PCP is in Tufts Health RITogether’s network. If you don’t already have a
PCP when you join Tufts Health RITogether, you can choose one from our network. Each
member of your family can have his or her own PCP.
Our Provider Directory lists all the primary care providers in our network. It also tells you
where the provider’s office is, the phone number, the languages spoken, the hours the office is
open, if they are accepting new patients, and if their office is handicap accessible. To see the
directory, go to our website at tuftshealthplan.com
or call Member Services to ask for a copy
or for help picking a PCP. We also have a printed Provider Directory available upon request
that lists all Tufts Health RITogether providers by specialty and location.
After you select a PCP, please call Member Services to let us know. If you do not choose a PCP,
we will choose one for you.
What your PCP can do for you:
• Give you regular checkups and screenings.
• Arrange tests.
• Keep your medical records.
10
• Recommend and refer you to specialists.
• Write prescriptions.
• Help you get behavioral health services.
• Answer questions about your health care.
Changing Your PCP
You can change your PCP or your child’s PCP at any time. However, there’s value in staying
with the same PCP. As you get to know one another and develop trust, you can work through
your health issues with your PCP. If you need to change your PCP, call 866-738-4116 (TTY:
711), Monday through Friday, from 8 a.m. to 6 p.m., excluding holidays.
If your PCP leaves the Tufts Health RITogether network, we will send you a letter to let you
know. You can choose another PCP from our network. There are times when Tufts Health
RITogether will let you continue to get care from your PCP or specialist for some time after
he/she has left our network. This is called “continuity of care.” If you are pregnant or being
treated for an ongoing medical condition, we can work with your provider, so he/she can
continue to treat you longer. We will work with you and your provider to make sure you safely
change to another provider.
Getting Care
Making an Appointment with Your PCP
Call your primary care provider’s office to schedule an appointment.
Annual Checkups
You don’t have to be sick to go to your PCP (Primary Care Provider). Yearly checkups with your
PCP are important to keep you healthy. Plus, your PCP will make sure you get the necessary
screenings, tests, and shots you need. If you have a health problem, it’s easier to treat when
found early. Talk to your PCP about what is right for you and your family.
Specialty Care
Your provider (PCP) may refer you to a specialist. Some services may require a referral from
your PCP before getting care. Please check with your PCP before you see a specialist.
Specialists are providers with special training and work in a particular field of medicine.
Specialists include but are not limited to: cardiologists (heart doctors);
obstetricians/gynecologists who treat women’s health needs, including family planning and
pregnancy; ophthalmologists (eye doctors); podiatrists (foot doctors); and dermatologists (skin
doctors).
11
You do not have to see the specialist your PCP suggests. You can ask your PCP for the name of
another specialist. Or you are free to pick any network provider for specialty care. Not seeing
the specialist will not affect your future treatment by your PCP. You have a right to refuse the
treatment a specialist recommends. If that happens, contact your PCP to talk about other
options.
Ask your provider to help you get hospital services for health care that is not an Emergency. If
you need hospital services for an Emergency, don’t wait. Call 911 or go to the nearest
emergency room right away.
Getting a Second Opinion
A second opinion is when you want to see another provider to get his or her opinion or
recommendation for your health concern or problem. You can get a second opinion from a
network provider for any of your covered benefits. This is your choice. You are not required to
get a second opinion. A second opinion from an out-of-network provider is available with a
prior authorization.
Urgent Care or Walk-In Center
Urgent care centers are available when you need to see a provider for a non-life-threatening
condition, but your PCP isn’t available, or it is after clinic/office hours. Common health issues
that may be treated in an urgent care center include:
• Sore throat
• Ear infection
• Minor cuts or burns
• Flu
• Low-grade fever
• Sprains
If you or a family member has an urgent problem, call your PCP first. Your PCP can help you
get the right kind of care. Your PCP may tell you to go to an urgent care center (or the
emergency room).
If you feel your condition could be an emergency, don’t wait. Call 911 or go to your nearest
emergency room.
12
Emergency Services
An emergency is a life-threatening illness or injury. It can cause serious pain or harm to your
health if you do not receive treatment right away. Some examples of emergency conditions
include:
• Serious illness or trauma
• Broken bones
• Bleeding that will not stop
• Heart attack
• Poisoning
• Severe cuts or burns
• Behavioral health emergency such as drug overdose or threat of harm to self or others
You can go to any hospital for emergency care. Tufts Health RITogether covers any emergency
care you need throughout the United States and its territories. Within 24 hours after your visit,
you should call your PCP and let them know about your visit. You may need follow-up care.
If you need emergency care, call 911 or go to the nearest hospital. Emergency care does not
require a referral from your PCP or a prior authorization from us.
A provider may ask you to pay for care you get outside of our Coverage Area. You may ask us
to reimburse you if you pay for Emergency or Urgent Care. We do not cover any services
outside of the United States and its territories. This includes Emergency and Urgent care. We
will not reimburse you if you pay for services. Please call our Member Services Team at 866-
738-4116 (TTY: 711) for help with any bills that you get from a Provider.
Early Periodic Screening Diagnostic Treatment (EPSDT)
EPSDT stresses preventive and complete care. As they grow, infants, children, and younger
people should see their PCP often. It is important that they receive all suggested preventive
services and any medical treatment needed to help healthy growth.
Children up to age 21 should receive regular well-child check-ups of their physical and mental
health, growth, development, and dietary status. A well-child check-up includes:
• A complete health and growing history, including both physical and mental health
development assessments;
• Physical exam;
• Age-appropriate shots;
• Vision and hearing tests;
• Dental exam;
13
• Laboratory tests, including blood lead level assessments at certain ages; and
• Health education
Your child’s PCP will let you know how often you will need to bring your child in for a visit.
Behavioral Health Services
Behavioral health services include mental health and treatment for substance use problems.
Tufts Health RITogether contracts with behavioral health providers to provide these services.
To find a behavioral health provider, call Tufts Health RITogether Member Services at 866-738-
4116 (TTY: 711), Monday through Friday, from 8 a.m. to 6 p.m., excluding holidays. This
number is also on your Tufts Health RITogether member ID card. Your call is confidential.
Check the Provider Directory for a list of behavioral health providers. If you are not sure what
type of help you need or the type of provider, our Member Services representative can help
you.
If Tufts Health RITogether does not cover a counseling visit or referral services because of
moral or religious objections, we will let you know that the service is not covered by us. We
will also tell you how you can obtain information from the Executive Office of Health and
Human Services (EOHHS) about how to get these services.
If you are in immediate danger, call 911 or go to the nearest emergency room.
988 Lifeline
The 988 Suicide & Crisis Lifeline offers 24/7 crisis support for you and loved ones. Call or text
988 or chat at 988lifeline.org/chat to chat with a trained counselor for free
For TTY Users: Use your preferred relay service or dial 711, then 988.
BH LINK
BH Link provides immediate access to behavioral healthcare 24/7. If you or someone you love
is going through a mental health or substance use crisis, there is information, there is
compassion, there is help. Call 401-414-LINK (5465). Located at 975 Waterman Ave East
Providence, RI.
Dental
Dental services for children are provided through RIte Smiles. RIte Smiles is a dental plan for
children who are eligible for RI Medicaid born after May 1, 2000. To find a dentist who
participates with the RIte Smiles program, check the website for UnitedHealthcare Dental/RIte
Smiles (https://www.uhc.com/ritesmiles
) or call UnitedHealthcare Dental Member Services at
866-375-3257. All other members should use their Rhode Island Medicaid card (Anchor card)
when going to a Medicaid dental provider.
14
Appointment Availability
Appointment
Access Standard
After Hours Care Telephone 24 hours, 7 days a week
Emergency Care
Immediately or referred to an
emergency facility
Urgent Care Appointment Within twenty-four (24) hours
Routine Care Appointment Within thirty (30) calendar days
Physical Exam 180 calendar days
EPSDT Appointment Within 6 weeks
New member Appointment Thirty (30) calendar days
Non-Emergent or Non-Urgent Mental
Health or Substance Use Services
Within ten (10) calendar days
Special Programs to Keep You Healthy
If you have a health condition for a long time, like diabetes or heart disease, you may benefit
from our care management programs. Our nurse care managers can help you understand your
options, how to stay healthy, and keep a better quality of life. Care management helps
members with special needs get the services and care they need. Care managers work with
the health plan, providers, and outside agencies. See the Integrated Care Management section
beginning on page 30 for more information. Call our Member Services Department at 866-738-
4116 (TTY: 711), Monday through Friday, from 8 a.m. to 6 p.m., excluding holidays.
Out-of-Network/Out-of-Area Care
Other than emergency services and urgently needed care, all covered benefits, care, and
services provided out of area need to be approved by Tufts Health RITogether first. Sometimes
you may need care from a provider who is not in our network. This provider is out-of-network.
To see an out-of-network provider you will need prior authorization from Tufts Health
RITogether before you make an appointment. Your PCP should submit the request for review.
Call Member Services to learn more to find out if it will be covered in full. You may have to pay
for those services.
We do not cover any services outside of the United States and its territories, including
emergency services. We do not reimburse members for any of these expenses.
Prior Authorizations
Sometimes your provider must get permission from Tufts Health RITogether before giving you
a certain service or drug. This is called prior authorization or prior approval. This is the
15
provider’s responsibility. If the provider does not get prior authorization, you will not be able
to get the service or the drug.
We make utilization management (UM) decisions on the correct use of care for you based on
the services that are covered by your health plan. We follow clinical guidelines to make any
decisions. Local providers and internal staff help us create these guidelines. We review the
guidelines every year, and as needed.
We do not reward providers, internal staff, or anyone else for denying care. We do not offer
any money or rewards that could make them not want to provide you services.
We make decisions as quickly as your health needs require. This can take up to 14 days after
we get the request. Your provider can ask for a fast approval as needed. We respond to fast
approvals up to 72 hours after we get the request. We may add 14 more days if:
• you or your designated representative asks for more time;
• your provider asks for more time; or
• we need more time to get information.
We will notify you within 2 days if we need to extend the 72-hour time frame for a fast
approval. We will also tell you of your right to file a grievance if you disagree. If we do not act
within these time frames, you may request an appeal. Please see page 35 for details.
If you have questions about UM or want more information on how we determine the care we
authorize, please call us at 866-738-4116 (TTY 711), Monday through Friday, from 8 a.m. to 6
p.m., excluding holidays. Our staff is available to discuss UM issues during these business
hours, as well as to respond to voicemails and faxes. We will respond the next business day if
you leave a voicemail or send a fax when we are closed. We can also give you information in
different languages. We have bilingual staff available, and we offer translation services in 200
languages free to members.
Non-Emergency Medical Transportation
Transportation may be available for medical, dental, or other health-related appointments. If
family, friends, or neighbors cannot drive you to appointments, you have several options.
Rhode Island Public Transit Authority (RIPTA)
RIPTA has fixed-route bus services to most communities in Rhode Island. Routes are
available online at www.ripta.com
or by calling Customer Support at 401-781-9400. RIPTA
also offers flex services and the ADA Disabled Program.
16
Non-Emergency Medical Transportation Broker
Non-Emergency medical transportation is a covered benefit in RI Medicaid. The contracted
vendor for these services is MTM, Inc. Please contact MTM at 855-330-9131 (TTY 711),
Monday through Friday, 8 a.m. to 5 p.m., to arrange for rides to medical, dental, or other
health-related appointments. Bus tickets for appointments need to be requested seven (7)
business days prior to the appointment.
Van or taxi rides to medical appointments may be available for members who qualify.
Please allow 48 hours prior to your appointment. For example:
• Call Monday for a ride on Wednesday.
• Call Tuesday for a ride on Thursday.
• Call Wednesday for a ride on Friday, Saturday, or Sunday.
• Call Thursday for a ride on Monday.
• Call for Friday for a ride on Tuesday.
Mileage Reimbursement
If you qualify for transportation and you or someone else can drive you, you may get
money for gas. There are several rules and requirements.
Please contact MTM for more information. Tufts Health RITogether Member Services can also
help with setting up or coordinating transportation if you need it.
24/7 NurseLine
We have a NurseLine that is open 24 hours a day and seven (7) days a week. The NurseLine
can help you with information about symptoms, health concerns, treatment options, drugs,
procedures, and more. Call 800-285-3580 (TTY: 711) for support. The NurseLine does not
replace your primary care provider (PCP). The NurseLine should not be used in an emergency.
In an emergency, call 911 or go to the nearest emergency room.
Your Healthcare Benefits
Medical Benefits
You are eligible to receive these benefits with your Tufts Health RITogether ID card. You do not
have any cost sharing responsibilities. However, if a provider tells you a service is not covered
by Tufts Health RITogether, and you still get the service, you will have to pay for it. There are
some services that are not covered.
17
You should not be balanced billed by your provider for a covered service. Call Tufts Health
RITogether Member Services if you receive a bill.
Description of Benefits from Tufts Health RITogether.
For more detail on what is covered, call Member Services at 866-738-4116 (TTY: 711), Monday
through Friday, from 8 a.m. to 6 p.m., excluding holidays.
Covered service/benefit
Coverage
Provider services
Includes the services of primary care physicians, specialists,
obstetrician-gynecologists (OB/GYN), and other network
providers.
Services of other
practitioners
Includes the services of practitioners certified or licensed by
the state of Rhode Island, i.e., nurse practitioners, physician’s
assistants, social workers, registered dietitian nutritionists,
psychologists, and certified nurse midwives.
Annual wellness check-
ups and preventive
screenings, immunizations
Covered when provided by primary care providers (PCPs) in
the MCO network.
Telemedicine services
Covered for medically necessary services that are clinically
appropriate for your providers to deliver by telemedicine.
Common examples include, but are not limited to, seeing your
PCP or Behavioral Health provider through a video portal
arranged by the provider.
Eye care
Includes medically necessary treatment for illness and injury
to the eye. For adults: Routine eye exams and one pair of
glasses are covered once every 24 months. For members with
diabetes: Eye exams are covered once every 12 months. For
children under age 21: Eye exam and glasses are covered as
needed.
Foot care
Covered with a referral by an MCO physician/provider.
Group/Individual
education classes
The following group classes are covered: childbirth education,
parenting, smoking cessation, diabetes, asthma, nutrition,
lactation consultation, etc.
Early, Periodic Screening,
Diagnosis, and Treatment
(EPSDT) services
Screening, diagnosis and treatment services for children and
young adults up to age 21. Includes the initial and follow-up
visits. Includes inter-periodic screens as medically indicated.
18
Covered service/benefit
Coverage
Special education
Services covered for children with special needs or
developmental delays as stated in the child’s individual
education plan (IEP) are covered but not provided by Tufts
Health RITogether.
Lead program
Covered — includes home assessment and non-medical case
management. Services are provided by the state Department
of Health or lead centers for lead-poisoned children and not
Tufts Health RITogether.
School-based clinic
services
Covered if Medically Necessary at all designated sites.
Abortion services
Covered
Family planning services
Includes over-the-counter (OTC) family planning supplies,
including foam, condoms, spermicidal jelly or cream, and
sponges. Screenings for sexually transmitted infections (STIs)
and HIV are covered. You can go to any provider, including
out-of-network providers, for these services.
Prenatal and post-partum
care
Covered by MCO physician/provider.
Doula services
Covered – includes culturally specific services to support
pregnant individuals, improve birth outcomes, and support
new parents and families
Nutrition services
Covered by licensed registered dietitian nutritionists (RDNs)
for certain medical conditions. Referral by an MCO provider is
required.
Therapies
Covered as medically necessary. Includes physical therapy,
occupational therapy, speech and language therapy, hearing
therapy, respiratory therapy.
Lab tests, diagnostic
services, radiology
services
Covered when ordered by an MCO physician/provider.
Prescription drugs
Covered when ordered by an MCO physician/provider. Must
use generic drugs first. There is a limited number of brand
drugs that are approved; most require prior authorization.
Check the Preferred Drug List at
tuftshealthplan.com/member/tufts-health-
ritogether/pharmacy/overview-of-pharmacy.
19
Covered service/benefit
Coverage
Non-prescription drugs
(OTC)
Covered when your Tufts Health RITogether
physician/provider writes a prescription for one of the OTCs
listed on our OTC drug list. Also referred to as “over-the-
counter” drugs. Includes family planning supplies and nicotine
cessation supplies.
Durable medical
equipment
Covered when ordered by a network provider. Includes
surgical appliances, prosthetic devices, orthotic devices,
assistive technology, and other medical supplies.
Hospital care, inpatient
Covered as medically necessary. Includes Medicaid covered
services delivered in an inpatient hospital setting.
Hospital care, outpatient
Covered as medically necessary. Includes Medicaid covered
services delivered in an outpatient hospital setting. Includes
physical therapy, occupational therapy, speech therapy,
language therapy, hearing therapy, respiratory therapy, and
other Medicaid covered services delivered in an outpatient
hospital setting.
Emergency room services
Emergency room services are covered both in and out of state
for emergency situations. Prior authorization is not needed for
emergency care.
Emergency transportation
Covered as medically necessary.
Behavioral health services
Covered as medically necessary. Includes community-based
mental health and substance use counseling and treatment
services.
Behavioral health
services, intensive
Covered as medically necessary. Behavioral health and
substance use disorder treatment includes but is not limited
to the following: community-based narcotic treatment,
methadone, detoxification, emergency services intervention,
observation/crisis stabilization, acute inpatient services, acute
residential treatment, partial hospital programs, mental health
psychiatric rehabilitation residences (MHPRR), day programs,
intensive outpatient treatment programs, assertive
community treatment (ACT), integrated health homes (IHH),
community mental health center services, home-based
treatment services (HBTS), applied behavior analysis (ABA),
personal assistance services and supports (PASS), and respite.
Residential treatment does not include room and board.
Services also include administratively necessary days ordered
by the Department of Children, Youth and Families.
20
Covered service/benefit
Coverage
Court-ordered mental
health and substance use
services
Services are provided in-plan; includes transitional care
management services after court-ordered services end.
Preventive home health
services
Covered when ordered by a MCO physician/provider. Prior
authorization may be required. Services include homemaker
services, minor environmental modifications, physical therapy,
home assessment, and personal care services.
Home delivered meals
Covered – includes preparing, packaging, and delivering meals
to member homes.
Home care services
Covered services provided under a home care plan authorized
by a physician, including full-time, part-time, or intermittent
care by a licensed nurse or home health aide (certified nursing
assistant) for patient care and including, as authorized by a
physician, physical therapy, occupational therapy, respiratory
therapy, and speech therapy. Home care services include
laboratory services and private duty nursing for a patient
whose medical condition requires more skilled nursing than
intermittent visiting nursing care. Home care services include
personal care services, such as assisting the client with
personal hygiene, dressing, feeding, transfer, and ambulatory
needs. Home care services also include homemaking services
that are incidental to the client’s health needs, such as making
the client’s bed, cleaning the client’s living area, such as
bedroom and bathroom, and doing the client’s laundry and
shopping. Homemaking services are only covered when the
member also needs personal care services. Home care
services do not include respite care, relief care, or day care.
Home health services
Home health care is supportive care provided in the home. Care
may be provided by licensed health care professionals who
provide medical treatment needs or by professional caregivers
who provide daily assistance to ensure the activities of daily
living
(ADLs) are met. For patients recovering from surgery or
illness, home care may include rehabilitative therapies.
Rehabilitation services
Physical, occupational, and speech/language therapy provided
in licensed outpatient rehabilitation centers and ordered by an
MCO physician.
21
Covered service/benefit
Coverage
Adult day health
Covered for frail seniors and other adults who need
supervision and health services during the daytime when
medically necessary. Prior authorization is required.
Nursing home care, skilled
nursing facility care
Covered for Rhody Health Partners and Rhody Health
Expansion members for 30 consecutive days. All skilled and
custodial care covered.
Hospice services
Covered when ordered by a network provider. Services are
limited to those services covered by Medicare.
Services for members
with HIV/AIDS or at high
risk for HIV
Medical and non-medical case management services.
Benefits/entitlement counseling and referral activities to help
member obtain public and private programs.
Transplant services
Covered when ordered by a health plan physician.
Gender dysphoria
treatment
Some services may require prior approval.
Benefits from RI Medicaid
Covered service/benefit
Coverage
Dental services
Includes routine dental check-ups and treatment for adults and
children.
Children born before May 1, 2000, receive dental benefits
through UnitedHealthcare Dental & the RIte Smiles program.
Emergency dental services are covered in-plan by Tufts Health
RITogether.
For older children and adults, dental services are provided using
the Medicaid (anchor) card.
Non-emergency medical
transportation
Includes coverage for bus tickets, van, or taxi ride to Medicaid
covered or health plan prior approved medical, dental, or other
health care provider appointments if no other transportation is
available. Must be scheduled in advance.
22
Extended Family Planning Benefits
This benefit is for women who have:
• Qualified for RIte Care
• Were pregnant and are now twelve (12) months postpartum or twelve (12) months
post-loss of pregnancy
• Are subject to losing eligibility for Medicaid
Eligible women may receive for up to twenty-four months of the following schedule of family
planning-related benefits:
Covered service/benefit
Coverage
Copay
Prescription and non-prescription
family planning methods
Covered, including these drugs:
emergency contraceptive pills, specific
oral contraceptives, contraceptive
patches, Depo-Provera, cervical caps,
and diaphragms. Over-the-counter
(OTC) family planning supplies,
including foam, condoms, spermicidal
jelly or cream, and sponges, are
covered with a prescription from your
provider.
$0.00
Outpatient hospital services and
surgery-related services
Tubal ligation (sterilization). IUD
insertion and removal.
$0.00
Outpatient procedures (in the office
or clinic) – office visit
One comprehensive GYN visit and up to
5 additional family-planning method-
related office visits. Tubal ligation
(sterilization). IUD insertion and
removal.
$0.00
Referrals to free clinics for other
medical services; contact the Rhode
Island Department of Health at 401-
222-2320 for a list of clinics and
counseling locations that can
provide these services to you
Referral for other services as needed.
For example, referrals to the state’s
sexually transmitted disease clinic for
treatment or confidential HIV testing
and counseling sites.
None
Gynecological services (well woman
care)
Includes annual GYN exam, one
comprehensive visit, and up to 5 family
planning visits annually.
$0.00
23
Covered service/benefit
Coverage
Copay
Laboratory
Includes pregnancy testing, annual Pap
smear, sexually transmitted disease
testing, anemia testing, dipstick
urinalysis, and urine culture.
None
Covered Medications and Pharmacy
Our plans cover first-time prescriptions and refills. We also cover some over-the-counter (OTC)
drugs with a provider’s prescription.
We use a Preferred Drug List (PDL). To find out if we cover a certain drug, look it up in our PDL.
We update the PDL every month. The PDL applies only to drugs you get at pharmacies and
medications you may receive at your provider’s office. It does not apply to drugs you get at the
hospital.
For the most current PDL and in-network pharmacies, visit
tuftshealthplan.com/member/tufts-health-ritogether/pharmacy/overview-of-pharmacy
. You
can also call us at 866-738-4116 (TTY: 711), Monday through Friday, 8 a.m. to 6 p.m., excluding
holidays.
Generic Drugs
Generic drugs have the same ingredients as brand-name drugs. Brand-name drugs with
generics available require PA.
Prior Approval
Some drugs must meet clinical guidelines before we can cover them. Your provider must ask
us for prior approval (PA) before we cover one of these drugs. We make approval decisions as
fast as your health needs require, up to 24 hours after we get the request.
Prior Approval Denials
If we do not approve a request for PA, you or your designated representative can appeal the
decision. See the Appeals section on page 35 for more information.
If you want more
information about our pharmacy program, visit tuftshealthplan.com/RImember
or call us at
866-738-4116.
Exclusions
We do not cover certain drugs. Examples are drugs used for cosmetic purposes, infertility, or
sexual dysfunction.
24
In addition, we do not cover:
• products that are not approved by the Food and Drug Administration (FDA).
• drugs that are considered investigational or experimental.
• devices, digital therapeutics, or prescription digital therapeutics (PDTs), unless we
indicate otherwise.
• medical supplies*
• contraceptive implants*
*May be covered as a non-pharmacy benefit.
If it is medically necessary for you to use a product that we do not cover, your provider must
request PA.
New-to-Market Drugs
We do not cover new drugs until they are reviewed. If you or your provider want a new drug,
your provider can ask for PA.
Quantity Limits
We limit how much medication you can get at one time. Your provider can ask us for PA if you
need more.
Step Therapy Program
We cover some drugs through our step therapy program. This means you must try a lower cost
drug first. Your provider can ask for PA of the drug they feel is the best one for treating you.
Non-PDL drugs
There are thousands of drugs listed on the Preferred Drug List (PDL). In fact, most drugs are
covered. There are however, select drugs that Tufts Health RITogether does not include on the
PDL. In many cases, these drugs are not on the PDL because there are safe, comparably
effective, and cost-effective alternatives available. Our goal is to keep pharmacy benefits as
affordable as possible. Your provider can ask for PA if they feel that you need one of the non-
PDL (also known as non-formulary) drugs.
90-Day Supply Program
You can fill certain drugs for a 90-day supply. Please refer to the Tufts Health RITogether PDL
to see if a drug can be filled for a 90-day supply.
25
Out-of-Network Services
Covered service/benefit
Coverage
Emergency care
Covered in the United States and its territories. No prior
authorization needed.
Family planning services
Members can see Tufts Health RITogether’s providers or out-of-
network providers for family planning services. No referral is
needed.
All Other Services
Require prior authorization from Tufts Health RITogether. Call
Member Services at 866-738-4116 (TTY: 711) Monday through
Friday, from 8 a.m. to 6 p.m., excluding holidays.
Non-Covered Services
• Experimental procedures or drugs
• Private rooms in hospitals, unless medically necessary
• Cosmetic surgery and drugs related to cosmetic surgery
• Infertility treatment services
• Medications for sexual or erectile dysfunction
• Services outside the United States. and its territories
Experimental and/or Investigational Services
We use a standardized process to consider whether to cover new technology and
experimental and/or investigational drugs, devices, or treatments. The evaluation process
includes:
• Determination of the FDA approval status of the device/product/drug in question
• Review of relevant clinical literature
• Consultation with actively practicing specialty care Providers to determine current
standards of practice
Decisions are formulated into recommendations for changes in policy and forwarded to our
management for review and final implementation decisions.
26
Tufts Health RITogether EXTRAS
Eligible Tufts Health RITogether members can get EXTRAS.
Gift Cards to Use to Buy Kids’ Car Seats
We help your kids ride safely and in style. Members can get a $25 Target gift card to use
toward buying a convertible car seat if they:
• Are 28 or more weeks pregnant
• Are a newborn or up to age 8
These car seats are for kids 5–40 pounds and 19–43 inches tall.
Also, one year later, as long as your child is a member, you can get a $25 Target gift card to use
toward buying a booster car seat. These are for kids 30–100 pounds and 43–57 inches tall.
How to get this EXTRA:
1. Get a copy of the Tufts Health RITogether EXTRAS Reward Form by visiting
tuftshealthplan.com/RITogetherExtras
or calling us at 866-738-4116 (TTY: 711)
2. Mail the completed form to the below address. Keep copies for your records.
Tufts Health Plan
Attn: Claims Department
P.O. Box 524
Canton, MA 02021
Or fax to 857-304-6400
Watch the mail for your gift card. It should arrive in 6 to 8 weeks.
Note: Members can get one Target store gift card to use to buy a car seat every 12 months.
Members can only get two gift cards to use for car seats while they are members. You must be
a Tufts Health RITogether member when you order your car seat gift card and when we process
your EXTRAS Form.
27
Rewards for Healthy Actions
For young members
To help our young members get and stay healthy, we reward their health actions. Here are
rewards for kids:
• aged 3–9 who get a yearly checkup can earn a $25 Shaw’s gift card.
•
aged 10–17 who get a yearly checkup can earn a $10 iTunes or Target store gift card.
• aged 18 and older who get a yearly checkup can earn a $25 Shaw’s gift card.
• who get the recommended childhood shots and screenings by age 2 can earn a $25
Shaw’s gift card. The current shots and screenings include: four DTaP, four Hib, four
PCV, three Hep B, three IPV, three Rota, one Hep A, one MMR, one Varicella, a blood
lead screening and a yearly flu shot. Your child’s PCP will talk to you about the best time
to get these shots and test.
How to get these EXTRAS:
1. Get a copy of the Tufts Health RITogether EXTRAS Reward Form by visiting
tuftshealthplan.com/RITogetherExtras
or calling us 866-738-4116 (TTY: 711)
2. Mail the completed form to the below address. Keep copies for your records.
Tufts Health Plan
Attn: Claims Department
P.O. Box 524
Canton, MA 02021
Or fax to 857-304-6300
Watch the mail for your gift card. It should arrive in six to eight weeks.
Note: You must be a Tufts Health RITogether member at the time of the visit(s) and when we
process your EXTRAS Reward Form.
If you are a new parent
Here are EXTRAS you can earn during and after pregnancy:
•
Get a $25 Shaw’s gift card after taking childbirth, newborn, or
breastfeeding classes.
(New parents are eligible for this reward).
• Get a $25
Shaw’s
gift card after you have two postpartum visits 21–56 days after you
have your baby.
• Get a Target store gift card to use to buy a car seat. See page 26 for more details.
• Get a $25
Shaw’s
gift card for visiting Women, Infants, and Children (WIC) twice during
your pregnancy.
28
Call us at 866-738-4116 (TTY: 711) as soon as you know you are pregnant to learn more about
these benefits.
How to get these $25 gift cards:
1. Get a copy of the Tufts Health RITogether EXTRAS Reward Form by visiting
tuftshealthplan.com/RITogetherExtras
or calling us at 866-738-4116 (TTY: 711)
2. Mail the completed form to the below address. Keep copies for your records.
Tufts Health Plan
Attn: Claims Department
P.O. Box 524
Canton, MA 02021
Or fax to 857-304-6300
Watch your mail for your $25 gift card. It should arrive in 6 to 8 weeks.
Note: You must be a Tufts Health RITogether member at the time of the visit(s) and when we
process your EXTRAS Reward Form. Members can get one $25 gift card during each
pregnancy.
If you have asthma
• Get a $25 Shaw’s gift card for filling out an asthma action plan with your PCP.
• Get information on asthma and a copy of an asthma action plan by calling us at 866-738-
4116 (TTY: 711) or by visiting health.ri.gov/publications/actionplans/Asthma.pdf.
How to get the $25 gift card:
1. Get a copy of the Tufts Health RITogether EXTRAS Reward Form by visiting
tuftshealthplan.com/RITogetherExtras
or calling us at 866-738-4116 (TTY: 711)
2. Fill out an asthma action plan with your PCP
3. Have your PCP sign the asthma action plan
4. Mail the completed form and a copy of the asthma action plan to the below address.
Keep copies for your records.
Tufts Health Plan
Attn: Claims Department
P.O. Box 524
Canton, MA 02021
Or fax to 857-304-6300
Watch the mail for your gift card. It should arrive in six to eight weeks.
29
Note: You must be a Tufts Health RITogether member when you fill out the asthma action plan
and when we process your EXTRAS Reward Form. Members can get one $25 gift card every 12
months.
If you have diabetes
• Get a $25
Shaw’s
gift card for getting an eye exam, two blood sugar (HbA1c) tests, a
protein test and a blood cholesterol test every 12 months.
How to get the $25 gift card:
1.
Get a copy of the Tufts Health RITogether EXTRAS Reward Form by visiting
tuftshealthplan.com/RITogetherExtras
or calling us at
866-738-4116
(TTY: 711)
2. Visit your PCP and get tested
3. Mail the completed form to the below address. Keep copies for your records.
Tufts Health Plan
Attn: Claims Department
P.O. Box 524
Canton, MA 02021
Or fax to 857-304-6300
Watch your mail for your $25 gift card. It should arrive in six to eight weeks.
Note: You must be a Tufts Health RITogether member when you get the five screenings and
when we process your EXTRAS Reward Form. Members can get one $25 gift card every 12
months for getting the screenings.
Fitness Reimbursement
We can help you stay fit. After you have been a member for three months and complete one
of several fitness activities, we will give you up to $50 back. You can earn this benefit every 12
months. Members who are 18 and younger must get a parent’s consent to join a gym or take
part in a fitness activity.
Eligible fitness activities include but are not limited to:
• Gym and health club memberships, including YMCAs and Jewish Community Centers
(JCCs)
• Yoga, Pilates, and fitness classes
• Salsa and other types of dance classes
• Sports leagues, like soccer and basketball
• Martial arts classes, like karate and tai chi
30
Talk with your PCP before you start any diet or exercise programs.
How to get your reimbursement:
1. Get a copy of the Tufts Health RITogether EXTRAS Fitness Reimbursement Form by
visiting tuftshealthplan.com/RITogetherExtras
or calling us at 866-738-4116 (TTY: 711)
2. Mail the completed form and your receipt to the below address. Keep copies for your
records.
Tufts Health Plan
Attn: Member Services Team
P.O. Box 524
Canton, MA 02021
Or fax to 857-304-6300
Watch the mail for your reimbursement of up to $50. It should arrive in six to eight weeks.
Note: You must be a Tufts Health RITogether member when you sign up for your gym
membership or fitness activity and when we process your EXTRAS Fitness Reimbursement
Form. Members can get $50 back once every 12 months.
EXTRAS are subject to change. Some rules may apply. We have the right to stop giving an
EXTRA at any time. See tuftshealthplan.com/RITogetherExtras
for the most current details.
Integrated Care Management
To make sure you get the best possible care, we use an integrated care management model.
This model means that our medical, behavioral health and Community Health Workers work
with you to coordinate the care you need.
Call Member Services at 866-738-4116 (TTY: 711), Monday through Friday, from 8 a.m. to 6
p.m., excluding holidays, to talk to a care manager.
Complex Care Management (CCM) Services
Our complex care management (CCM) program is for members who have long-lasting
conditions. We work with you and your care team to make sure you get the right care, in the
right place, at the right time. We are able to visit you or talk with you on the phone to be sure
your needs are being met.
If you have cancer, a newborn in intensive care, or another long-term and/or multiple health
conditions that are hard to manage, complex care management can help. The CCM team can
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provide you with personalized support, coaching, and education. We can give you or your
caregiver valuable information and help coordinate your care.
Call Member Services at 866-738-4116 (TTY: 711), Monday through Friday, from 8 a.m. to 6
p.m., excluding holidays, to talk to a care manager.
Community Health Services
The Community Health Services program connects you with Community Health Workers
(CHWs). CHWs are certified public health workers who will arrange, coordinate, evaluate, and
advocate for safety net services. Safety net services provide for basic needs such as education,
housing, healthcare, health harming legal issues, transportation, and access to care. For
assistance, call Member Services at 866-738-4116 (TTY: 711), Monday through Friday, from 8
a.m. to 6 p.m., excluding holidays, to find out more about the Community Health Program.
We’re happy to help.
Specific Care Management Services and Programs
Care Management is everything we do to help you manage your health conditions. Call
Member Services at 866-738-4116 (TTY: 711), Monday through Friday, from 8 a.m. to 6 p.m.,
excluding holidays, to find out more about any of these programs:
Disease Management
If you have asthma, diabetes, or chronic obstructive pulmonary disease (COPD), we can help.
We can coordinate with your PCP and talk with you about ways to manage your symptoms.
We can also answer your questions about your medications and connect you to resources in
your community.
Health Needs Assessment
If you are new to Tufts Health RITogether, we will contact you to complete a care needs
screening. This allows us to better understand your health. We may reach out to see if you
would like to work with us. Our care team is supportive and can help you find resources like
counseling or food and housing support.
Maternal and Child Health
If you are pregnant, we can help you have a healthy pregnancy, labor and delivery. If you have
a high-risk pregnancy, we have high-risk pregnancy nurses who can support you. We can also
help get care for you and your newborn after your delivery with programs like the Visiting
Nurse Association (VNA) and Women, Infants and Children (WIC).
Short-Term Care
Coordination
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If you have healthcare needs that need immediate attention, we can help. We can help
support you to get primary care and behavioral health services. We can also help you make or
get transportation your appointments. In addition, we can call you or see you in-person if you
need other support, for example help with food or housing.
Transition of Care (ToC) Program
If you are leaving a 24/7 care facility, we can help make a plan for the care you need to keep
getting better at home. The plan also includes teaching you about your condition and
medications. If you are transitioning to Tufts Health RITogether from another health plan,
please see page 5. We can work to make sure you get the services you need when you need
them.
Plan Details
Member Rights and Responsibilities
As a member of Tufts Health RITogether, you have a RIGHT:
• To receive information about Tufts Health RITogether, its services, providers, and
members’ rights and responsibilities.
• To be treated with respect and dignity and the right to privacy.
• To participate with your providers in decision-making about your health care, including
the right to refuse treatment.
• To privacy of all records and communications as required by law. (Tufts Health
RITogether employees follow a strict confidentiality policy regarding all member
information.)
• To respectful, personal attention without regard to your race, national origin, gender,
gender identity, age, sexual orientation, religious affiliation, or pre-existing conditions.
• To an open discussion of appropriate home and community services or medically
necessary treatment options for your conditions, regardless of cost or benefit coverage.
• To get a second medical opinion for medical and surgical concerns.
• To voice grievances, complaints, or appeals about Tufts Health RITogether or the care
provided by its providers and/or agencies.
• To make recommendations about Tufts Health RITogether’s member Rights and
Responsibilities policies.
• To refuse treatment, and if you do, it will not affect your future treatment.
• To receive information on available treatment options and alternatives.
• To be free from any form of coercion, discipline, or retaliation.
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• To request and receive a copy of your medical records, and request that they be
amended or corrected.
• To be given health care services.
• To exercise your rights and that the exercise of those rights does not negatively affect
the way Tufts Health RITogether and its providers treat you.
You have a RESPONSIBILITY:
• To report changes such as address, income, family size, etc. to the State (HealthSource
RI or the Department of Human Services) within 10 days of the change.
• To choose a PCP and primary care site. Your PCP will coordinate all of your medical care.
You may change your PCP at any time by calling Tufts Health RITogether Member
Services.
• To have all of your medical care provided by or arranged by a provider in the Tufts
Health RITogether network.
• To carry your Tufts Health RITogether member ID and your Rhode Island Medicaid card
with you.
• To provide, to the extent possible, information that
Tufts Health RITogether and its practitioners and providers need to care for you.
• To learn about your health problems and understand the health plan treatment you and
your provider agree on.
• To follow the plans and instructions for care that you have agreed on with your
providers.
• To talk with your PCP about all specialty care. If you need a specialist, your PCP will work
with you to make sure you get quality care.
• To call your PCP first for help if you have an urgent medical condition. If an emergency is
life threatening, call 911 right away or go to the nearest emergency room.
Call Tufts Health RITogether Member Services if you have any questions about your rights and
responsibilities.
Advance Directives
When you can no longer make health care decisions for yourself, there are documents that
will help make your wishes known. These are called living wills and durable power of attorney.
• A living will is a set of instructions. It says what should happen if you become seriously ill
and are unable to communicate.
• Durable power of attorney lets another person make health care decisions for you. You
choose who this person will be. It could be your spouse, a family member, or a friend.
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Advance directives explain the treatment you want if you become seriously ill or injured.
Advance directives can be written or spoken. Ask your primary care provider about these
options. You also can find more information and related forms at the Rhode Island
Department of Health website: www.health.ri.gov/lifestages/death/about/endoflifedecisions/
.
Complaints, Grievances, and Appeals
You have a right to make a complaint, file a grievance, or to file an appeal. If you are unhappy
about the care or services you receive, we want to know about it so we can help fix the
problem.
Can someone else complain or file a grievance or appeal for me?
Yes. Your primary care provider, another provider, friend, family member, or anyone you
want, can ask for you. First you must let us know that you are allowing that person to work
with us. When filing a complaint or grievance, let us know verbally or in writing. When filing an
appeal, let us know in writing. To let us know in writing, submit a Designated Representative
Form that gives the person you want to speak for you permission to help with your complaint,
grievance, or appeal. When filing an appeal, Tufts Health RITogether must get the completed
Designated Representative Form before we can talk to the person you’ve identified. Keep a
copy of your Designated Representative Form. The form is valid for one year from the date you
sign it unless you tell us you no longer want to allow someone to act on your behalf. To get a
Designated Representative Form, call Member Services at 866-738-4116, Monday through
Friday, from 8 a.m. to 6 p.m., excluding holidays.
Complaints
You or your Designated Representative has the right to file a complaint at any time. Please call
your Tufts Health RITogether Member Services at 866-738-4116, Monday through Friday, from
8 a.m. to 6 p.m., excluding holidays. We can address your questions or concerns about
benefits, services, access to appointments, wrong bills you receive, or other issues. If possible,
we will resolve your problem at the time of your call. If that is not possible, we will ask for
more information and get back to you within 30 calendar days after your complaint is filed. At
any time, we may ask you for more information.
You, or your Designated Representative, can also file a complaint or grievance in writing. Send
them to:
Tufts Health RITogether
Attn: Member Appeals and Grievances
1 Wellness Way, Canton, MA 02021
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Grievances
A grievance is a dissatisfaction about any matter other than a service not being covered.
Examples of a grievance include:
• You are not satisfied with the way we responded to your complaint.
• You disagree with us asking for more time to make an authorization decision.
• You have concerns of quality of care or services provided.
• You feel a provider or their employee was rude.
• You feel a provider did not respect your member rights.
You may file a grievance at any time. We will respond to your grievance within 90 calendar
days. Sometimes we need more information or time up to an additional 14 calendar days to
decide. If we need more time, we will contact you to let you know.
You or your Designated Representative can file a grievance in writing or over the phone at any
time. Filing a grievance will not affect your health coverage.
Appeals
An appeal is a request to change a decision made by Tufts Health RITogether for medical care,
services, or drugs that you or your provider believe you should receive. It could also be a
request for services or supplies that are not included in your covered benefits that you or your
provider believe you should receive. You or a Designated Representative can file an appeal in
writing, in person, or by calling Tufts Health RITogether Member Services. Requests to review
services that were denied by us must be made within 60 calendar days of our decision to deny
a service or supply. We will review the care or services that were denied or the coverage
decision that was made.
Send written appeals to:
Tufts Health Plan
Attn: Member Appeals and Grievances
1 Wellness Way, Canton, MA 02021
You can also request an internal appeal by:
• Telephone — call us at 866-738-4116 (TTY: 711), Monday through Friday, from 8 a.m. to
6 p.m., excluding holidays.
• Email — request an internal appeal by email via the “Contact Us” section of our website
at tuftshealthplan.com
; or
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• Secure online Member portal: Log into your secure online portal at
tuftshealthplan.com/memberlogin
to file an Appeal electronically
• Fax — request an internal appeal by faxing us at 857.304.6406.
Qualified Tufts Health RITogether staff decide on appeals that are not about medical issues.
Qualified health care professionals decide on appeals about medical issues within 30 calendar
days of our receiving it. We may ask you for an additional 14 calendar days if we need more to
look into your appeal.
You have a right:
• You have a right to ask for and get copies of all documents related to your appeal. You
may add information about the appeal to your file in writing or in person.
• You have a right to continue to have Medicaid covered services while your appeal is
under review. To have these Medicaid covered services continue, you must call or tell us
within 10 calendar days of the denial. If your appeal is denied, you may have to pay for
the cost of any continued benefits you received. If your appeal is approved and you did
not request that your services be continued while your appeal was being decided, we
will authorize or provide services within 72 hours.
• You have a right to a fast (expedited) appeal if your provider feels a delay in your care or
treatment might be a risk to your life or cause you severe pain. You or your provider
should call Tufts Health RITogether Member Services to request a fast appeal.
Urgent (Fast) Appeals
You can ask us for an urgent or “fast” appeal if waiting up to 30 calendar days for a decision
would cause severe pain or could be a risk to your life without immediate medical attention.
When your provider feels a delay in your care or treatment might be a medical emergency,
you or your provider should call 857.304.6406 (TTY: 711) to request a fast appeal. We will
respond to your fast appeal within 72 hours of receiving it. We may need to extend our review
time for up to 14 days. If we need to extend our time frame, we will notify you within 2
calendar days of our decision to extend the time frame.
If you disagree with our decision to take more time, you may file a Grievance with us. If we
deny your request for a fast appeal, we will decide on your appeal within 30 calendar days of
receiving your appeal.
External Appeals
After you complete the appeal process with Tufts Health RITogether, and you are still not
satisfied, you can request that an independent review organization (IRO) review your appeal
for medical services. Requests for external appeals must be received within four months from
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the date of your appeal decision. Call 857.304.6406 (TTY: 711) for help or for written directions
on how to file an external appeal.
State Fair Hearing
If you are not satisfied with the outcome of Tufts Health RITogether’s appeal decision, you
may request a State Fair Hearing. Your request must be within one hundred and twenty (120)
calendar days from the date of your appeal decision. The State Fair Hearing is facilitated by the
Executive Office of Health and Human Services (EOHHS). You have a right to have Medicaid
covered services continue while you are going through a State Fair Hearing. If the State Fair
Hearing appeal is denied, you may be responsible for the cost of any continued benefits you
received. To request a State Fair Hearing, you can either:
• Call 401-462-2132 (TDD 401-462-3363) after you have finished Tufts Health RITogether’s
internal appeal process, or
• Fax your request to 401-462-0458, or
• Email your request to EOHHS.AppealsOffice@ohhs.ri.gov
, or
• Mail your request to EOHHS Appeals Office, Virks Building, 3 West Road, Cranston, RI
02920.
Complaints About the Appeal Process
You can file a complaint at any time during the appeal process with the Office of the Health
Insurance Commissioner (OHIC) through the consumer helpline:
RI Insurance Resource, Education, and Assistance Consumer Helpline (RIREACH)
300 Jefferson Blvd, Suite 300, Warwick, RI 02888
Telephone: 855-747-3224 (TTY 711)
Website: www.rireach.org
For help with your complaint, grievance, or appeal, you may also call RI Legal Services at 401-
274-2652.
Other Health Plan Information
How to Disenroll from Tufts Health RITogether
You may change your health plan during the state’s annual open enrollment period or within
90 calendar days of joining Tufts Health RITogether. If you wish to disenroll at any other time,
you may do so for any of the following reasons: poor quality of care, poor continuity of care
(such as lack of access to your PCP or necessary specialty services), discrimination, lack of
access to transportation, moving out of state, or for other good reasons. Visit
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www.eohhs.ri.gov
or call Member Services to get a Request to Change Health Plans form. The
completed form must be sent to the Rhode Island Executive Office of Health and Human
Services (EOHHS) for consideration of a plan change.
Coordination of Benefits (COB)
If you or any member of your family have another health plan, that plan is your primary
insurance. Tufts Health RITogether would be your secondary health plan. Call Member
Services if you have other insurance or if that coverage has ended.
CurrentCare®
The more information your providers have about your medical history, the better they can
care for you. You may see more than one provider. You may have had visits to a hospital,
provider’s office, or community clinic. Each of these providers can do a better job caring for
you if they have access to all of your medical records in one place. CurrentCare® is a database
that can give them those records. It is Rhode Island’s electronic health network. If you sign up,
you give permission to your providers to see your health information in the database. This
keeps all of your providers informed and allows them to easily coordinate your health care. If
you want to sign up for CurrentCare, call 888-858-4815 or visit CurrentCareRI.org
. There is no
cost to join.
Rhode Island All-Payer Claims Database
Tufts Health RITogether is required by law to report data about its members’ health care use
and costs. This information will be put in the Rhode Island All-Payer Claims Database. It will be
used by policy makers to make better health care decisions. You have the choice:
1. If you want your family’s data in the records, you do not have to do anything.
2. If you want to have your data left out, please go to www.riapcd-optout.com
. If you cannot
get online, please call Rhode Island’s Health Insurance Consumer Support at 1.855-747-
3224. If you have a question or want to learn more, email
riapcd@ohic.ri.gov.
Fraud, Waste, and Abuse
If you suspect or know that fraud, waste, or abuse is occurring, report it immediately. Fraud
happens when a member or provider does something that is not honest so that he/she or
another person experiences positive results or some type of benefit or incentive. Waste
happens when there is an overutilization of services or other practices that, directly or
indirectly, result in unnecessary costs to the health care system. Abuse happens when
39
appropriate business and medical practices are not followed, and the result is an unnecessary
cost to the Medicaid program. Reporting fraud, waste, and abuse will not affect how you will
be treated by Tufts Health RITogether. You have the choice to remain anonymous when you
make the report. Provide as much information as possible; this will assist those investigating
the report.
Some examples of fraud, waste, or abuse are:
• Sharing, loaning, changing, or selling a health plan or Rhode Island Medicaid ID card so
someone else can get health care services.
• Using someone else’s health plan or Rhode Island Medicaid ID card to get health care
services.
• Using a provider’s prescription pad to alter or forge a provider’s prescription to receive
drugs.
• Receiving benefits in both Rhode Island and another state.
• Lying about how much money you make or where you live to become eligible for
benefits.
• Selling or giving prescriptions to others that were prescribed to you.
• Providers or hospitals that bill you or your health plan for services that were never
provided.
There are many ways to report fraud, waste, and abuse:
• Call Tufts Health RITogether Member Services or write Tufts Health RITogether a letter.
• Call the Tufts Health RITogether Compliance Hot line at 877-824-7123.
• Contact the RI Office of Program Integrity at 401-462-6503.
• RI Department of Human Services Fraud hotline for reports on CCAP, SNAP, RI Works,
and GPA, at 401-415-8300.
• Department of RI Attorney General for reports on Medicaid Fraud, Patient Abuse or
Neglect, or Drug Diversion, at 401-222-2556 or 401-274-4400 ext. 2269.
Parity
Behavioral health and substance use disorder services are considered essential health
benefits. Tufts Health RITogether ensures that financial requirements (such as co-pays and
deductibles) and treatment limitations (such as limits on visits) that apply to mental health or
substance use disorder benefits are no stricter than the limits that insurance plans place on
medical or surgical benefits. If you think that your ability to get behavioral health services is
40
different than getting medical services, call 866-738-4116 (TTY: 711) and tell them you have a
parity complaint.
Privacy Practices
Tufts Health RITogether uses and shares PHI for your treatment to pay for care and to run our
business. We may also use and share your information for other reasons, as allowed and as
required by law
. We must follow the terms of our Notice of Privacy Practices ("Notice") when
using or disclosing your protected health information (“PHI”). We may revise this Notice at any
time. If we do, changes will apply to any of your PHI that we maintain, and we will make a copy
of the Notice available at tuftshealthplan.com
or upon request.
PHI includes health information like medical records that have your name, your member
number, or other information that can identify you. Types of PHI include verbal, written, or
electronic information.
Compliance with State and Federal Laws:
Tufts Health RITogether complies with all applicable federal and state laws, including:
• Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 80.
• The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91.
• The Rehabilitation Act of 1973.
• Title IX of the Education Amendments of 1972 (regarding education programs and
activities).
• Titles II and III of the Americans with Disabilities Act; and section 1557 of the Patient
Protection and Affordable Care Act. (3/29/2021)
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Definitions
Appeal: An appeal is a special kind of complaint you make if you don’t agree with a decision to
deny a request for health care services. You may also file an appeal if you disagree with a
decision to stop or reduce services that you are receiving. For example, you may ask for an
appeal if Tufts Health RITogether does not pay for an item or service you think you should be
able to get. There is a specific process that we must use when you ask for an appeal.
Behavioral Health (mental health and/or substance use disorder) services: Services including
visits, consultations, counseling, screenings, and assessments for mental health and/or
substance use disorder, as well as inpatient, outpatient, detoxification and diversionary
services.
Care Management: How we regularly evaluate, coordinate, and help you with your medical,
Behavioral Health (is mental health and/or substance use), and/or Community Health
Management needs. Through Care Management, we do our best to make sure you can: Access
high-quality, cost-effective, and appropriate care; get information about disease prevention
and wellness; and help you get and stay healthy.
Community Health Worker (CHW): CHWs are certified public health workers who apply their
unique understanding of the experience, language and/or culture of the populations they
serve. CHWs spend a significant portion of time conducting outreach in the communities they
live in and serve. A CHW can meet with you in a convenient place and help you find a health
care provider; identify emergency housing; help find resources and benefits and more.
Complaint: A concern about benefits, services, access to appointments, wrong bills you
receive, or other issues. If possible, we will resolve your problem at the time of your call.
Complex Care Management: A program that provides care for members with hard-to-manage,
unstable, and/or fragile, long-lasting medical and/or Behavioral Health conditions.
Coordination of Benefits (COB): If you have another health plan, that plan is your primary
insurance. Tufts Health RITogether would be your secondary health plan. Call Member
Services if you have other insurance or if that coverage has ended.
Copayment: A payment made by a member for health services in addition to that made by an
insurer.
Designated Representative: A designated representative is someone you choose to act on
your behalf. We are allowed to share your health information with this person.
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Disease Management (DM): How we help you manage certain health conditions like asthma,
chronic obstructive pulmonary disease (COPD), diabetes, and heart failure (HF). We help
develop and stick to a treatment plan and work with PCP and specialist(s).
Durable Medical Equipment (DME): Bought or rented items such as hospital beds, oxygen
equipment, seat lift equipment, wheelchairs, and other medically necessary equipment
ordered by a health care provider to be used in a patient’s home.
Emergency Medical Condition: An illness, injury, symptom or condition so serious that a lay
person would seek care right away to avoid severe harm.
Emergency Medical Transportation: Also known as ambulance services or paramedic services,
these are emergency services which treat illnesses and injuries that require an urgent medical
response and transport to acute care facility.
Emergency Room Care: Care given for a medical emergency when you believe that your health
is in danger.
Emergency Services: An emergency is a potential life-threatening illness or injury. It can cause
serious pain or harm to you if you do not receive treatment right away.
EPSDT: Early, Periodic, Screening, Diagnostic and Treatment
Excluded Services: Items or services that Tufts Health RITogether does not cover.
Grievance: A complaint about the way your health plan is giving care or dissatisfaction about
anything other than a service not being covered. Examples of a grievance include: dissatisfied
with the way your health plan responded to your complaint; your health plan asking for more
time to make an authorization decision; you have concerns about quality of care or services
you got; you feel a provider or their employee was rude, or you feel a provider did not respect
your member rights. A grievance is not the way to deal with a complaint about a treatment
decision or a service that is not covered (see Appeal).
Habilitation Services & Devices: Health care services that help you keep, learn, or improve
skills needed for daily living. Examples include therapy for a child who isn't walking or talking
at the expected age. These services may include physical and occupational therapy, speech
therapy, and other services for people with disabilities in a variety of inpatient and/or
outpatient settings.
Health Insurance: A contract that requires your health insurer to pay some or all your health
care costs in exchange for a premium.
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Home Health Care: Skilled nursing care and home health aide services, physical therapy,
occupational therapy, speech-language therapy, medical social services, durable medical
equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and
other services supplied in the home.
Integrated Care Management: Everything we do to help you get and stay healthy. To make
sure you get the best possible care, we use an integrated care management model. This model
means that, when appropriate, our medical, behavioral health (mental health and/or
substance use) and Community Health Workers work closely with you and each other to
coordinate the care you need.
Medically Necessary: Direct care, services, or supplies that are needed for the diagnosis or
treatment of your medical condition, behavioral health, or prevention of worsening of your
condition. They must meet the standards of good medical practice and aren’t for the
convenience of you or your provider.
Network: A group of doctors, hospitals, pharmacies, and other health care professionals hired
by a health plan to take care of its members.
Non-participating Provider: A health care provider or supplier who is not contracted with your
health plan.
Participating Provider: A health care provider or supplier who is contracted with the Plan and
agrees to accept health plan members. Also known as network or in-network provider.
Physician Services: Services provided by an individual licensed under state law to practice
medicine or osteopathy.
Plan: Managed care entity that manages the delivery of health care services.
Prior Authorization: Health plan approval necessary before you get care. Also called “prior
approval.”
Premium: The amount paid for health insurance every month.
Prescription Drug Coverage: Health insurance or plan that helps pay for prescription drugs and
medications.
Prescription Drugs: Drugs and medications that, by law, require a prescription.
Primary Care Physician/Provider: A doctor (MD or DO), nurse practitioner, or physician
assistant who is trained to give you basic care. Your primary care provider (PCP) is the person
44
you see first for most health problems. He or she makes sure that you get the care that you
need to keep you healthy.
Referral: Request from your PCP to your health plan to approve appointment and/or
treatment to a specialist.
Rehabilitation Services & Devices: Services ordered by your PCP to help you recover from an
illness or injury. These services are given by nurses and physical, occupational, and speech
therapists. Examples include working with a physical therapist to help you walk and with an
occupational therapist to help you get dressed.
Skilled Nursing Care: A level of care that includes services that can only be performed safely
and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).
Specialist: A provider who treats only certain parts of the body, certain health problems, or
certain age groups. For example, some doctors treat only heart problems.
Telemedicine: Telemedicine means the delivery of clinical healthcare services by real time,
audio, video, or other telecommunications technology to assess, diagnose, counsel and
prescribe treatment, and provide care management of your health care. Telemedicine does
not include an email message or facsimile transmission (fax) between a you and your provider
or an automated computer program used to diagnose and/or treat eye or vision conditions.
Transition of Care: The first 180 days that you are a member of RITogether when you can keep
getting care from a provider even if that provider is not in our network.
Transition of Care (ToC) Program: A program to help members when they leave a 24-hour
care facility (like a hospital). We can provide medical, Behavioral Health and coordination of
care or other support members may need to help with their transition of care needs (the care
you need to help you keep getting better at home).
Urgent Care: Care that you get for a sudden illness or injury that needs medical care right
away but is not life threatening. Your primary care provider generally provides urgently
needed care.
If you have questions, please call 866-738-4116 (TTY: 711),
Monday through Friday, from 8 a.m. to 6 p.m., excluding
holidays. Or you can also visit us at TuftsHealthPlan.com.
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