Tufts Health Plan Insurance

Tufts Health Plan is a nonprofit insurance company that started in 1979 and operates out of Massachusetts. They provide health insurance to a half million residents of Massachusetts and Rhode Island. In 2021, Tufts Health Plan merged with the nonprofit Harvard Pilgrim Health Care and rebranded as Point 23 Health. They provide insurance to people of all ages and take part in community-based programs, such as food assistance initiatives.

Does Tufts Health Plan Cover Rehab?

Most Tufts Health plans cover mental health and substance abuse treatment, as required by the 2010 Affordable Care Act. This federal law requires most long term health insurance plans to cover 10 essential health benefits, which include mental health and addiction treatment.

However, there are exceptions to the law and insurance plans differ. As a result the options for covered treatment vary widely, so you should check with the insurance company about your specific plan.

The type of treatment(s) offered to you are usually based on your doctor’s assessment and recommendations, which help define what is medically necessary in your case. It’s a good idea to work closely with your doctor because you may also need a referral and/or preauthorization before you begin treatment.

What Are Tufts Health Plans?

Tufts Health provides a wide variety of insurance plans. You may get an individual or family plan through your employer or your state’s Insurance Marketplace. Tufts also offers Medicare and Medicaid plans to those who qualify.

An individual or family plan is generally one of two types. With a Preferred Provider Organization plan, (PPO), you can choose your own doctor and treatment facilities, with no referral needed. However you’ll generally pay a higher monthly premium for these plans.

A Health Maintenance Organization, or HMO, plan usually has lower monthly plan fees but they may have higher deductibles and copays. HMOs generally require you to use the provider network for care if you want insurance coverage. Often you will need a referral from your primary doctor to see a specialist, such as a psychiatrist or addiction specialist.

Tufts Health Plan offers Medicare Supplement and Medicare Advantage plans. Medicare supplement plans help you manage the costs of Original Medicare. Medicare Advantage plans (or “Medicare part C”) are a full replacement for Original Medicare and often include extra benefits, like prescription drug coverage and vision and dental care.

Medicare Advantage plans are offered as either a PPO or HMO, similar to the individual and family plans described above.

Tufts Health Plans has Medicaid plans in Massachusetts and Rhode Island. These state sponsored plans help provide coverage for lower income individuals and families. These plans cover addiction treatment along with doctor and specialists’ office visits and some additional benefits, such as eye exams and eyeglasses.

For people who have both Medicare and Medicaid, there are Special Need Plans that are based on age (21-64 or over 65) that include all the benefits of Medicare plus additional benefits such as a case manager if needed.

You can learn more about Tufts Health Plan’s coverage options on their website.

What Outpatient Addiction Treatment Does Tufts Cover?

During outpatient rehab you’ll live at home or in a sober living environment and attend treatment part time.

Outpatient programs include partial hospitalization (PHP), intensive outpatient (IOP), and regular outpatient (OP) programs. In a partial hospitalization program, you would attend treatment during the day and return to your home at night. PHP programs typically run for 4-8 hours a day, three or four days a week, and last for 30-90 days.

Intensive outpatient programs typically offer 9-20 hours of treatment each week, spread over 3 to 5 days per week. A total of 90 days of treatment is typically recommended for IOP programs.

In general outpatient programs, you would visit a clinic or rehab facility one or more times each week. Group counseling and education on addiction and relapse prevention are provided, and individual counseling sessions may be offered when needed.

What Inpatient Addiction Treatment Does Tufts Health Plan Cover?

Most insurance plans focus on medically necessary treatment, highlighting the importance of creating an individualized treatment plan with your doctor.

If the detox process is expected to be difficult you may undergo an inpatient detox process where a licensed healthcare professional oversees and monitors your progress, ensuring your safety. A group of therapists and nurses as well as doctors and clinical staff watch for complications. You may also receive medication to help with detox symptoms.

Inpatient or residential care is one of the most intensive ways to battle an addiction. With these programs you live in the rehab center and take part in targeted treatments to help address triggers and develop coping mechanisms. With inpatient treatment you benefit from peer support and a structured schedule as well as around the clock support and a reduced relapse rate. Inpatient centers often help ease your way back into society with sober living facilities after treatment ends.

Does Tufts Health Plan Cover Methadone & Suboxone (MAT)?

Over the last decade, much research has been done to develop medications that help people fight addiction through both detox and the ongoing treatment process. This is called medication-assisted treatment (MAT) and may involve the use of methadone or suboxone.

Methadone is used to treat opioid addictions. It helps reduce cravings and blocks the effects of opioids.

Suboxone is one of the most common medications used to treat addiction. To avoid misuse suboxone contains naloxone which blocks the euphoria that comes from getting high.

Studies show that MAT greatly reduces the death rate of those living with addiction, and a majority of patients maintain sobriety for two years. Every situation is unique so it’s important to discuss medication with your doctor and consult your specific healthcare plan to make sure medications are covered.

Does Tufts Health Plan Cover Other Mental Healthcare?

The Affordable Care Act requires that most insurance plans offer mental health care. However there are some exceptions so it’s important to always check your plan before you receive care.

Mental illness and substance abuse often go hand in hand and long term care is vital to staying healthy. With the right plan you can use your insurance to obtain an integrated treatment program that works to combat both problems. That may look like attending an integrated program or ensuring that your healthcare providers are communicating regularly.

Does Addiction Treatment Need to Be In Network?

HMO plans don’t cover out of network care. PPOs generally will but the cost is often higher for the patient, including higher copayments and deductibles. If possible you’ll want to find a provider within your network to get the most out of your insurance coverage. If you do opt for an out of network provider research your insurance policy thoroughly and speak with office staff and your doctor to make sure you fully understand how much of the treatment cost you will have to pay.

It may be worth the extra money if an out of network provider has a higher rate of success for treatment or you feel more comfortable with them, but make sure you understand the costs first.

How to Verify Coverage With Tufts Health Plan

To verify that you have coverage for specific treatments you can contact your insurance company directly. A treatment center’s staff may have general guidelines for what policies they take but they can’t guarantee exact numbers like your insurance company will.

You can verify coverage by logging into your online account or contacting the customer service number found on the website or your insurance card. Speak to a representative from the company about what is covered and what’s not before you start a program. Not only does this set you up for uninterrupted treatment, but it also relieves the stress that comes from unexpected bills when you’re trying to get back on your feet.