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HMO and Dental Plans Comparison

hmo comparison
dental plans comparison

Tufts health plan Comparison

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 1/1/08, the following applies:

	Tufts HMO	Tufts POS

Outpatient Medical Care
Doctor's Office Visits	$20 per visit	$20 per visit
Routine Physical Exams	$20 per visit	$20 per visit
Well-child Care	$20 per visit	$20 per visit
Specialist Care, Consultations	$20 per visit	$20 per visit
OBGYN Visits	$20 per visit	$20 per visit
Prenatal and Postnatal Care	$20 per visit	$20 per visit
Labratory Tests, Including Pap Smear	Covered in Full	Covered in Full
Diagnostic X-Rays, Including Mammograms	Covered in Full	Covered in Full
Injections and Immunizations	Covered in Full	Covered in Full
Speech Therapy and Short Term Physical/Occupational Therapy	$20 per visit	$20 per visit
Annual Routine Eye Exams	$20 per visit	$20 per visit
Spinal Manipulation (12 visits per calendar year)	$20 per visit	$20 per visit
Allergy Shot	$5 per visit	$5 per visit

Inpatient Hospital Care and Surgery
Day Surgery	Covered in Full	Covered in Full
Acute Care and Maternity Care (for hospital services)	150$ per admission	150$ per admission
Physician's Care while Hospitalized	Covered in Full	Covered in Full
Surgery and Surgeon's services while Hospitalized	Covered in Full	Covered in Full
Newborn Care in Hospital	Covered in Full	Covered in Full
Anesthesia while Hospitalized	Covered in Full	Covered in Full
Medications while Hospitalized	Covered in Full	Covered in Full
Nursing Care while Hospitalized	Covered in Full	Covered in Full
X-ray and Lab Services while Hospitalized	Covered in Full	Covered in Full
Intensive Care/Coronary Care while Hospitalized	Covered in Full	Covered in Full
Radiation Therapy while Hospitalized	Covered in Full	Covered in Full
Skilled Nursing and Skilled Nursing Facility(Up to 100 days per Calendar Year)	Covered in Full	Covered in Full

Wellness Programs
Membership at Network Fitness Facilities	Multiple discount options	Multiple discount options
Weight Watchers Weight Management Program	Discounted Membership	Discounted Membership
Health Education (may require advanced payment)	30% discount per program	30% discount per program

Dental Care
Preventive for children	100% for 2 visits/year for children through 12 years old	Not Applicable

Mental Health - Inpatient
Outpatient Care (up to 24 visits per calendar year)	20$ per visit	20$ per visit
Inpatient Care (services provided through a designated facility program for up to 60 days per calendar year)	$150 per admission	$150 per admission

Substance Abuse
Outpatient Care (Alcohol, Drug and Detoxification) (Tufts Health Plan pays up to $500.00 per calendar year)	$20 per visit	$20 per visit
Inpatient Care (Services provided through a designated facility program for up to 30 days per calendar year)	$150 per admission	$150 per admission

Emergency Care
In Doctor's Office	$20 per visit	$20 per visit
In Emergency Room	$100 per visit	$100 per visit

Other Services
Durable Medical Equipment	Plan pays 80% Member pays 20% ($5000 calendar year maximum)	Plan pays 80% Member pays 20%($5000 calendar year maximum, then at unauthorized level)
Ambulance (when medically necessary)	covered in full	covered in full
Pediatric Dental	covered for children under 12 (contact Tufts for more details)	Not Covered

Deductible and Out-of pocket Maximum
Annual Deductible	not applicable	$400 for individual/$800 for family
Annual Out-of-Pocket Maximum	not applicable	$2000 individual/$4000 family
Annual In-Patient Copayment Maximum	not applicable	$600 individual

Dental Plan Comparison

	Delta Premier (5,500 dentists)	DeltaCare II (500 dentists)
	DeltaPremier 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).	DeltaCare 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 DeltaCare primary care dentist and are subject to the DeltaCare 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 10/19/07 | 06:20 PM

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