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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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