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Tufts Health Plan Insurance Coverage for Drug and Alcohol Treatment

Tufts Health Plan is a nonprofit insurance organization that has been serving clients for more than 40 years. The company was founded in 1979 by Dr. Morton Madoff and originally provided health insurance to employers only. The original name of the company was “Tufts Associated Health Maintenance Organization. By the end of its first year of offering health insurance plans, Tufts already had 3,000 members.

Over the years, Tufts Health Plan has grown and expanded into new markets. Today, Tufts Health Plan serves individuals, employers, people purchasing insurance through the Massachusetts Health Insurance Exchange, people on Medicare and people on Medicaid. In August of 2019, Tufts Health Plan announced its merger with Harvard Pilgrim Healthcare.

At this time, Tufts Health Plan is headquartered in Watertown, Massachusetts.

What Providers Will Accept Tufts Health Plan?

Tufts Health Plan offers an extensive provider network with participants in Massachusetts, New Hampshire and Rhode Island. The network includes more than 29,000 doctors and specialists, as well as 91 different hospitals. For subscribers dealing with substance use disorders, an expansive network of behavioral health services is also available. However, not all Tufts Health Plan policies include the entire network. Subscribers can verify the physicians and facilities in their specific network by reviewing their plan documents.

Understanding Your Tufts Health Plan Coverage

Tufts Health Plan offers several different policies to employers and individual subscribers. The specific type of policy chosen will determine your access to treatment, as well as the amount you will pay for the services you receive. Below is an overview of some of the different types of policies available from Tufts Health Plan.

Tufts Health Plan PPO Policies

Tufts Health Plan offers Preferred Provider Organization (PPO) policies that offer flexibility for subscribers. With these plans, subscribers can visit any doctor or specialist of their choice without a referral, as long as the doctor chosen is within the PPO network. For people seeking rehab services, PPO policies typically offer more freedom.

Tufts Health Plan HMO Policies

When you have a Tufts Health Plan HMO (health management organization) policy, all of your care must be coordinated by an in-network primary care provider. For the purposes of addiction treatment HMO plans can be more restrictive. However, in most cases, you can still get the care you need.

Tufts Health Plan Advantage Policies

Tufts Health Plan Advantage policies may be structured as HMO or PPO plans. However, with an Advantage plan, premiums are typically lower because of higher deductibles and coinsurance expenses. If you are planning to enroll in an addiction treatment program, your costs may be higher with an Advantage policy.

Tufts Health Plan Advantage Saver Policies

Tufts Health Plan Advantage Saver Policies are high deductible policies that have the lowest premiums of all policies available from Tufts Health Plan. They typically include a Health Savings Account. If you have this type of plan, you can expect your out-of-pocket expenses for addiction treatment to be higher.

Tufts Health Plan Tiered Plans

Tiered plans from Tufts Health Plans offer subscribers access to the entire Tufts provider network. However, providers within the network are grouped into tiers based on the quality and cost of care they provide. With this type of plan, the cost of your addiction treatment program will depend on the tier in which your provider is located.

Tufts Health Plan Select Network HMO

Tufts Health Plan’s Select Network HMO offers a network of select providers, including 55 hospitals and more than 21,000 doctors. This plan is less expensive for members than other HMO options available from Tufts, but choice of provider is more limited.

Tufts Health Plan CareLink

Tufts Health Plan CareLink is available as an employer-based policy designed for employers who have a large number of employees living outside the standard Tufts Health Plan service area. This plan includes a national network of providers available to employees in any location.

Will My Addiction Treatment Be Covered by Tufts Health Plan?

Tufts Health Plan will cover the cost of addiction treatment, as long as you meet all of your policy’s requirements. Tufts covers outpatient treatment for addiction, as well as intermediate and inpatient care. The exact requirements to have addiction treatment vary but may include:

  • Getting preauthorization
  • Choosing a treatment facility from within your network
  • Getting a referral from your primary care provider
  • Meeting your deductible

The exact amount you can expect to pay out-of-pocket for treatment will also vary based on different factors. For example, the cost of treatment will be affected by the facility you choose, the length of your program and the provisions of your insurance plan. For this reason, it is important to verify your coverage and expenses before beginning treatment.

Does Tufts Health Plan Require Preauthorization or Precertification?

Preauthorization and precertification are procedures that are sometimes necessary to make sure addiction treatment or other services will be covered. Tufts Health Plan may require preauthorization or precertification for addiction treatment services. In many cases, Tufts Health Plan will not cover addiction treatment unless it has been deemed medically necessary.

If you are not sure whether preauthorization or precertification will be necessary for your treatment, contact Tufts Health Plan to discuss the matter before you enroll in a program. Otherwise, you may find yourself facing unexpected expenses.

Estimating the Cost of Rehab

Your Tufts Health Plan policy is likely to cover at least some of the cost of your rehab, as long as you follow all of the necessary procedures and choose an appropriate provider. However, many patients want to know exactly how much they will be expected to pay out-of-pocket so they can prepare accordingly. Unfortunately, estimating the cost of your treatment can be difficult with so many different factors involved.

To simplify the estimation process, try out our addiction treatment coverage tool!

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