Referrals Required-by Payor

Below is a list of payors and products NEPHO participates in denoting whether or not referrals are required.
Plan Referral Grid

Allways Health Partners

CommercialHealth ConnectorYes

Plan Type Product Type or Name PHO Contract?
Commercial PPO Yes
Commercial HMO Yes
Commercial Tiered Choice Yes

Blue Cross Blue Shield of Massachusetts (BCBSMA)

Plan Type Product Type
or Name
PHO
Contract?
Referral
Required?
Commercial HMO Yes Yes
Commercial POS Yes Yes
Commercial PPO Yes Yes
Medicare Advantage HMO Yes** Yes-messenger model for non TMP PCPs
Medicare Advantage PPO Yes** Yes-messenger model

Boston Medical Center (BMC) Healthnet

Plan Type Product Type
or Name
PHO
Contract?
Referral
Required?
MassHealth MassHealth Yes Yes-messenger model
MassHealth CarePlus Yes Yes-messenger model
QHP ConnectorCare Yes Yes-messenger model
QHP Silver Yes Yes-messenger model
QHP Bronze (Select Network) No No
QHP Gold (Select Network) No No
QHP Platinum (Select Network) No No
Dual Eligibles (65 and older) SCO No No

CIGNA

Plan Type Product Type or Name PHO Contract?
Commercial Collaborative Accountable Care Yes

Commonwealth Care Alliance (CCA)

Plan Type Product Type  PHO
Contract?
Referral
Required?
Dual Eligible (65+) SCO Yes** No
Dual Eligible (>65) One Care No

**Physician participation is optional

Fallon

Plan Type Product Type
or Name
PHO
Contract?
Referrals
Required?
Commercial Direct Yes Yes
Commercial Select Yes Yes
Commercial PPO Yes No
Commercial Tiered Choice Yes Yes
Commercial Steward Comm No
MassHealth Medicaid No
Dual Eligible (>65) Total Care No
Dual Eligible (65+) Navicare SCO No
Medicare Adv HMO No
Medicare Adv PPO No
QHP Comm Care No
PACE Summit No

Harvard Pilgrim Health Care (HPHC)

Plan Type Product Type
or Name
PHO
Contract?
Referrals
Required?
Commercial HMO Yes Yes
Commercial POS Yes Yes
Commercial PPO/HPI Yes No
Commercial GIC  Primary Choice HMO Yes Yes
Commercial GIC Independence Plan POS Yes Yes
Commercial National (Passport,
Access America)
Yes Yes
Commercial HMO with Focus
Network
Yes*** Yes
Commercial BMC/BI/Lahey/Partners Employee Tiered Plans Yes*** Yes
Commercial BMC Select No
Commercial ElevateHealth NH No
Medicare Suppl. Supplement (Indiv) Yes No
Medicare Suppl. Enhance (Employer) Yes No
Medicare Advantage Medicare Stride Yes Yes

*Some PCPs are excluded
***All NEPHO PCPs included as well as Specialists who are Primary with NEPHO

Tufts Health Plan (THP)

Plan Type Product Type
or Name
PHO
Contract?
Referrals
Required?
Commercial HMO Yes Yes
Commercial POS Yes Yes
Commercial PPO/EPO Yes Yes
Commercial GIC Navigator Yes Yes
Commercial GIC Spirit Yes Yes
Commercial Select Network Yes Yes- PHO PCPs and PHO Primary SCP only
Commercial Uniform Service
Family Health Plan
Yes Yes
Commercial Steward Employee Choice Plan No

***All NEPHO PCPs included as well as Specialists who are Primary with NEPHO

Tufts Health Public Plans (THPP)

Plan Type Product Type
or Name
PHO
Contract?
Referrals
Required?
MassHealth Tufts Health Together Yes No
QHP Direct ConnectorCare Yes No
QHP Direct Platinum Yes No
QHP Direct Gold Yes No
QHP Direct Silver Yes No
QHP Direct Bronze Yes No
Dual Eligible (>65) One Care/Unify No

Tufts Medicare Preferred (TMP)

Plan Type Product Type  PHO
Contract?
Referral
Required?
Medicare Advantage Tufts Medicare Preferred
(TMP)
Yes exclusive plan for limited # of PCPs Yes
Dual Eligible (65+) Tufts Senior Care Options (SCO) Yes Yes

*Some PCPs are excluded

UniCare

Plan Type Product Type  PHO
Contract?
Referral
Required?
Commercial PPO Yes No
Commercial Indemnity Yes No