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HMO and Dental Plans Comparison

hmo comparison
dental plans comparison
 

Tufts Health Plan

The Health Maintenance Organization (HMO) 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 1/1/09, the following applies:

  Primary Care Physician Specialist
Outpatient Medical Care    

Most Provider Office Visits

$25 per visit

$35 per visit

Routine Physical Exams

$25 per visit

$35 per visit

Well-Child Care

$25 per visit

$35 per visit

OB/GYN Visits

$25 per visit

$25 per visit

Outpatient Maternity Care (For details refer to rate sheet)

$25 per visit

$25 per visit

Routine Eye Exams (1 visit every 24 months) $25 per visit $25 per visit
Nutritional Counseling (When medically necessary) $25 per visit $35 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 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 rate sheet)

Covered in Full Covered in Full
Diagnostic Lab Tests Covered in Full Covered in Full
Speech & Short-Term Physical/Occupational Therapy $25 per visit $35 per visit
Spinal Manipulation (12 visits per calendar year)

$25 per visit

$35 per visit

Day Surgery

Covered in Full

Covered in Full

     
Inpatient Hospital Care    

All Hospital Services (Acute Care) and Maternity Care

$150 per admission

$150 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

$25 per visit

$35 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

$25 per visit

Inpatient Care (Services provided at a designated facility for up to 60 days per calendar year)

$150 per admission

$150 per admission

 
Substance Abuse

Outpatient Care (Alcohol, Drug and Detoxification) (Up to $500 per calendar year for treatment)

$25 per visit $25 per visit
Inpatient Care (Services provided at a designated facility for up to 30 days per calendar year) $150 per admission

$150 per admission

 

Other Health Services

Durable Medical Equipment

($1,500 calendar year maximum) Covered in Full
Ambulance Service   Covered in Full
Hospice Care   Covered in Full
Home Health Care   Covered in Full

Dental Plan Comparison

  Delta Premier
(5,500 dentists)
Delta Care II
(500 dentists)
  Delta Premier is a great choice for employees who value access, flexibility and freedom of choice. Care is available from approximately 5,500 dentists (over 95 percent of practicing dentists in Massachusetts). Delta Care II is a great choice for employees who value managed care and prevention. Employees choose a "primary care dentist" who directs and coordinates all primary and specialty care. Please note that the provider you choose is not guaranteed to stay in the plan during your enrollment, and therefore you may have to be flexible in choosing other providers.
Type I Services
Diagnostic 100 percent coverage co-payment schedule*
Preventative 100 percent coverage co-payment schedule*
Type II Services
Restorative 80 percent coverage co-payment schedule*
Oral Surgery 80 percent coverage There is a $1,000 per personal annual calendar year maximum
Periodontic 80 percent coverage There is a $1,000 per personal annual calendar year maximum
Endodontics 80 percent coverage There is a $1,000 per personal annual calendar year maximum
Prosthetic Maintenance 80 percent coverage co-payment schedule*
Emergency Dental Care 80 percent coverage co-payment schedule*
Type III Services
Major Restorative 50 percent coverage co-payment schedule*
Prosthodontics 50 percent coverage co-payment schedule*
Calendar Year Deductible (Type II and Type III Services)
  $100 per individual, $300 per family None
Calendar Year Maximum
  $1,000 per person Unlimited except for endodontic, oral surgery, or periodontal services
  Dependents are covered until age 19. Dependents are covered until age 19.
  Full-time students are covered to age 23. Full-time students are covered to age 23
  Fourth Quarter Carry Forward Deductible.  
Orthodontia
  Not covered Benefits based upon 24 months of active treatment.

*All services must be provided by a Delta Care primary care dentist and are subject to the Delta Care Patient co-payment schedule available from Human Resources or on the Delta Dental website at http://www.deltamass.com. Limited out-of-network benefit, subject to a $100 per person deductible applicable to all services.

updated 02/04/09 | 03:05 PM
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