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Tufts Health Plan Comparisons

HMO Value

The Health Maintenance Organization (HMO) Value option allows members to choose a Primary Care Physician (PCP) from an extensive network of doctors which provide or authorize all of your care (except in an emergency or in certain cases of self-referral). Your PCP will be the primary liaison between you and any specialists you might see within the network. Tufts requires that you call your PCP first when seeking medical services, unless it is an emergency. As of 1/1/12, the following applies:

Outpatient Medical Care

Primary Care Physician

Specialist
Most Provider Office Visits $30 per visit $40 per visit
Routine Physical Exams (including most preventative screenings) Covered in Full Covered in Full
Well-Child Care Covered in Full Covered in Full
OB/GYN Visits $30 per visit $30 per visit
Outpatient Maternity Care (For details refer to summary sheet) $30 per visit $30 per visit
Routine Eye Exams (1 visit every 24 months) $30 per visit $30 per visit
Nutritional Counseling (When medically necessary) $30 per visit $40 per visit
Preventive Immunizations Covered in Full Covered in Full
Preventive Pap Smear & Mammograms Covered in Full Covered in Full
Colonoscopy (without surgical intervention) Covered in Full Covered in Full
Colonoscopy (with surgical intervention) $150 per admission $150 per admission
Non-Preventive Immunizations Covered in Full Covered in Full
Non-Routine Pap Smears & Mammograms Covered in Full Covered in Full
Allergy Injections $5 per visit $5 per visit
Diagnostic Procedures Covered in Full Covered in Full
Diagnostic Imaging (For details refer to summary sheet) Covered in Full Covered in Full
Diagnostic Lab Tests Covered in Full Covered in Full
Speech & Short-Term Physical/Occupational Therapy $30 per visit $40 per visit
Spinal Manipulation (12 visits per calendar year) $30 per visit $40 per visit
Day Surgery $150 per admission $150 per admission

Inpatient Hospital Care

    
All Hospital Services (Acute Care) and Maternity Care $250 per admission $250 per admission
Skilled Nursing in Skilled Nursing Facility (Up to 100 days per calendar year) Covered in Full Covered in Full

Emergency Care

    
In Doctor's Office $30 per visit $40 per visit
In Emergency Room $150 per visit $150 per visit

Mental Health

    
Outpatient Care (Up to 24 visits per calendar year) $30 per visit $30 per visit
Inpatient Care (Services provided at a designated facility for up to 60 days per calendar year) $250 per admission $250 per admission

Substance Abuse

    
Outpatient Care (Alcohol, Drug and Detoxification) (Up to $500 per calendar year for treatment) $30 per visit $30 per visit
Inpatient Care (Services provided at a designated facility for up to 30 days per calendar year) $250 per admission $250 per admission

Other Health Services

    
Durable Medical Equipment ($1,500 calendar year maximum) Plan Covers 70% Plan Covers 70%
Ambulance Service Covered in Full Covered in Full
Hospice Care Covered in Full Covered in Full
Home Health Care Covered in Full Covered in Full

 

HMO Advantage

The HMO Advantage plan requires members to pay an upfront annual deductible ($500/employee; $1,000/two-person; $1,000/family) prior to coverage for any diagnostic, inpatient, or outpatient procedure. After deductible is met, member is covered in full with no co-payment. As of 1/1/12, the following applies:

Outpatient Medical Care

Primary Care Physician

Specialist
Most Provider Office Visits $25 per visit $35 per visit
Routine Physical Exams Covered in Full Covered in Full
Well-Child Care $25 per visit $35 per visit
OB/GYN Visits $30 per visit $30 per visit
Outpatient Maternity Care (For details refer to summary sheet) $30 per visit $30 per visit
Routine Eye Exams (1 visit every 24 months) $30 per visit $30 per visit
Nutritional Counseling (When medically necessary) $30 per visit $40 per visit
Preventive Immunizations Covered in Full Covered in Full
Preventive Pap Smear & Mammograms Covered in Full Covered in Full
Non-Preventive Immunizations Covered in Full after deductible Covered in Full after deductible
Colonoscopy (without surgical intervention) Covered in Full Covered in Full after deductible
Colonoscopy (with surgical intervention) Covered in Full after deductible Covered in Full after deductible
Allergy Injections Covered in Full after deductible Covered in Full after deductible
Diagnostic Procedures Covered in Full after deductible Covered in Full after deductible
Diagnostic Imaging (For details refer to summary sheet) Covered in Full after deductible Covered in Full after deductible
Diagnostic Lab Tests Covered in Full after deductible Covered in Full after deductible
Speech & Short-Term Physical/Occupational Therapy (For details refer to summary sheet) Covered in Full after deductible Covered in Full after deductible
Spinal Manipulation (12 visits per calendar year) Covered in Full after deductible Covered in Full after deductible
Day Surgery Covered in Full after deductible Covered in Full after deductible

Inpatient Hospital Care

    
All Hospital Services (Acute Care) and Maternity Care Covered in Full after deductible Covered in Full after deductible
Skilled Nursing in Skilled Nursing Facility (Up to 100 days per calendar year) Covered in Full after deductible Covered in Full after deductible

Emergency Care

    
In Doctor's Office $30 per visit $40 per visit
In Emergency Room $150 per visit $150 per visit

Mental Health

    
Outpatient Care (Up to 24 visits per calendar year) $30 per visit $30 per visit
Inpatient Care (Services provided at a designated facility for up to 60 days per calendar year) Covered in Full after deductible Covered in Full after deductible

Substance Abuse

    
Outpatient Care (Alcohol, Drug and Detoxification) (Up to $500 per calendar year for treatment) $30 per visit $30 per visit
Inpatient Care (Services provided at a designated facility for up to 30 days per calendar year) Covered in Full after deductible Covered in Full after deductible

Other Health Services

    
Durable Medical Equipment ($1,500 calendar year maximum) Plan Covers 70% Plan Covers 70%
Ambulance Service Covered in Full after deductible Covered in Full after deductible
Hospice Care Covered in Full after deductible Covered in Full after deductible
Home Health Care Covered in Full after deductible Covered in Full after deductible

Carelink PPO

Carelink PPO allows members to visit any healthcare provider within the Tufts network and the national CIGNA Open Access Plus network with no prior authorization from their primary care physician. Members have the added benefit of coverage outside of the network. For visit with a non-covered healthcare provider, the member must pay an annual out of pocket deductible ($250/member or $500/family). Once the deductible is met, member is covered at 80% of the Tufts equivalent rate for out-of-network services.

Outpatient Medical Care

Primary Care Physician

Out of Network
Most Provider Office Visits $25 per visit Plan covers 80%
Routine Physical Exams Covered in Full Plan covers 80%
Well-Child Care Covered in Full Plan covers 80%
OB/GYN Visits $25 per visit Plan covers 80%
Outpatient Maternity Care (For details refer to summary sheet) $25 per visit Plan covers 80%
Routine Eye Exams (1 visit every 24 months) $25 per visit Plan covers 80%
Nutritional Counseling (When medically necessary) $25 per visit Plan covers 80%
Preventive Immunizations Covered in Full Plan covers 80%
Preventive Pap Smear & Mammograms Covered in Full Plan covers 80%
Colonoscopy (without surgical intervention) Covered in Full Plan covers 80%
Colonoscopy (with surgical intervention) Covered in Full after deductible Plan covers 80%
Non-Preventive Immunizations Covered in Full after deductible Plan covers 80%
Non-Routine Pap Smears & Mammograms Covered in Full after deductible Plan covers 80%
Allergy Injections Covered in Full after deductible Plan covers 80%
Diagnostic Procedures Covered in Full after deductible Plan covers 80%
Diagnostic Imaging (For details refer to summary sheet) Covered in Full after deductible Plan covers 80%
Diagnostic Lab Tests Covered in Full after deductible Plan covers 80%
Speech & Short-Term Physical/Occupational Therapy (For details refer to summary sheet) Covered in full after deductible Plan covers 80%
Spinal Manipulation (12 visits per calendar year) Covered in full after deductible Plan covers 80%
Day Surgery Covered in Full after deductible Plan covers 80%

Inpatient Hospital Care

    
All Hospital Services (Acute Care) and Maternity Care Covered in Full after deductible Plan covers 80%
Skilled Nursing in Skilled Nursing Facility (Up to 100 days per calendar year) Covered in Full after deductible Plan covers 80%

Emergency Care

    
In Doctor's Office $25 per visit $25 per visit
In Emergency Room $100 per visit $100 per visit

Mental Health

    
Outpatient Care (Up to 24 visits per calendar year) $25 per visit Plan covers 80%
Inpatient Care (Services provided at a designated facility for up to 60 days per calendar year) Covered in Full after deductible Plan covers 80%

Substance Abuse

    
Outpatient Care (Alcohol, Drug and Detoxification) (Up to $500 per calendar year for treatment) $25 per visit Plan covers 80%
Inpatient Care (Services provided at a designated facility for up to 30 days per calendar year) Covered in Full after deductible Plan covers 80%

Other Health Services

    
Durable Medical Equipment ($1,500 calendar year maximum) Plan Covers 70% Plan covers 70%
Ambulance Service Covered in Full after deductible Plan covers 80%
Hospice Care Covered in Full after deductible Plan covers 80%
Home Health Care Covered in Full after deductible Plan covers 80%

Learn more on the Tufts Health Plan website.

 
updated 05/16/12 | 11:27 AM
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