Health plan comparison charts

Medical& Dental Coverage Rate Comparison Charts

Children’s Hospital Medical & Dental Plan Rate Comparison Effective 01/01 - 12/31/2004
Plan Name	Coverage	Employee Contribution
		Part Time Employees (20-29.9 weekly)*		Medical Staff and Regular employees (at least 30 hour biweekly)**
		Biweekly	Monthly	Biweekly	Monthly
Tufts Value Option HMO	Individual	55.26	119.72	13.23	28.67
	Dual	110.52	239.45	26.46	57.32
	Family	160.02	346.71	38.39	83.18

Tufts Premium Option HMO	Individual	70.04	152.54	26.38	57.16
	Dual	140.82	305.11	52.76	114.32
	Family	203.98	441.97	76.56	165.88

Tufts Point of Service (POS)	Individual	95.95	207.90	52.25	113.20
	Dual	191.91	415.81	103.46	224.16
	Family	278.08	602.52	150.08	325.17

Neighborhood Health Plan	Individual	75.99	164.64	32.28	69.94
	Dual	167.46	362.84	79.01	171.19
	Family	213.64	462.89	85.63	185.54

Delta Dental Premier	Individual	9.01	19.53	9.01	19.53
	Dual	17.81	38.60	17.81	38.60
	Family	28.48	61.71	28.48	61.71

*Part Time Employees who work 20-29.9 hours weekly

Children's subsidizes individual medical coverage at $170.90/month,
dual coverage at $341.79/month; and family coverage at $496.76/month.

**Medical Staff and regular employees who work at least 30 hours weekly

Children's subsidizes individual medical coverage at $ 265.60/month,
dual coverage at $533.44/month; and family coverage at $774.11/month.

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Tufts Health Plan Value HMO Plan
Group#: 80976
Tufts Value HMO Services		Coverage Level
Deductible
Out of Pocket Yearly Expense Maximum (Excluding prescription drug copayments)		$2,000 /Individual; $4,000/Dual & Family
Inpatient Copayment		$150 per member per admission
Preventive Health Care
Routine Physical Exams		$20 per visit
Well Child Care		$20 per visit
Fitness Benefit		Discount Options
Weight Watchers		Discounts apply
Eye Exams		$20 per visit - one visit per year
Outpatient Medical Care
Office Visit		$20 per visit
Chiropractic Care		$20 per visit - up to 12 visits per calendar yr.
Specialist, Consultations		$20 per visit
Lab		Covered in Full
X-rays, including Mammograms		Covered in Full
Allergy Shots		Covered in Full
Injections and Immunizations		Covered in Full
Radiation Therapy		Covered in Full
Outpatient Surgery (in a physician’ s office)		$20 per visit
Short-term physical, occupational, speech therapy		$20 per visit
Inpatient Hospital Care Inpatient copayment will apply to all inpatient hospital stays including day surgery)
Illness or Injury		Covered in Full after $150 copayment
Physician Care while hospitalized		Covered in Full after $150 copayment
Surgery and Day Surgery		Covered in Full after $150 copayment
Anesthesia		Covered in Full after $150 copayment
Medications		Covered in Full after $150 copayment
Nursing Care		Covered in Full after $150 copayment
X-ray and Lab		Covered in Full after $150 copayment
Intensive Care/Coronary Care		Covered in Full after $150 copayment
Maternity Care
Prenatal Care		Covered in Full after initial $20 copayment
Hospital and Delivery		Covered in Full, Inpatient copayment will apply
Newborn Care in hospital		Covered in Full, Inpatient copayment will apply
Postnatal Care		Covered in Full
Emergency Care
Urgent Office		$20 per visit
Emergency Room		Full coverage after $50 copayment. Waived if admitted. PCP must be notified within 48 hours.
Home Health Care
Home Health Care Services and Intermittent Skilled Nursing Care		Covered in Full
Physician House Calls		Covered in Full
Outpatient Mental Health *
Inpatient Mental Health*
Psychiatric Hospital		Covered in Full, up to 60 days per member per calendar year. Inpatient copayment will apply. Partial hospitalization services are available up to a maximum of 120 days per calendar year in place of inpatient mental health services.
Licensed General Hospital		Covered in Full, Inpatient copayment will apply
Outpatient Substance Abuse**
$20 per visit up to $500 per calendar year.
Detoxification		$20 per visit
Inpatient Substance Abuse**
Rehabilitation		Covered in Full, up to 30 days per member per calendar year. Inpatient copayment will apply Partial hospitalization services are available up to a maximum of 60 days per calendar year in place of inpatient drug and alcohol rehabilitation services.
Detoxification		Covered in Full, Inpatient copayment will apply
Inpatient Skilled Nursing Care and Rehabilitation
Inpatient Skilled Nursing Care and Rehabilitation		Covered in Full, up to 100 days per calendar year
Other Services
Durable Medical Equipment (DME)		20% copayment, not to exceed $5,000 per member per calendar year.
Wigs		Covered in Fulll up to $350 when needed as a result of any cancer or leukemia.
Ambulance		Covered in Full
Oral Health
Surgical Extraction of Teeth (THP Pre-approval Required)		Covered in Full, less applicable copayment
Emergency Dental Care for initial treatment (within 72 hours of injury) necessary to repair oral injuries including x-rays, surgical procedures, extractions and suturing.		Covered in Full, less applicable copayment
Pediatric Preventive Dental		Not covered
Prescription Drugs
Retail - 30 day supply	Generic	Brand/Formulary	Brand/Non-Formulary
	$10	$15	$30
Mail Order - 90 day supply	Generic	Brand/Formulary	Brand/Non-Formulary
	$20	$30	$60

*There is no limit when authorized for the treatment of a
biologically-based mental disorder, rape-related mental or
emotional disorder, or non-biologically based mental,
behavioral or emotional disorders for children through the
age of 18, as described in the Tufts Health Plan Benefit
Handbook.

**Limit does not apply if treatment is in conjunction with
biologically-based mental illness or rape-related mental or
emotional disorders as described in the Tufts Health Plan
Benefit Handbook.

Note:

This grid provides an overview of major services and coverage. All benefits are paid based on medical necessity and under the provisions of the Tufts Health Plan Benefit Handbook.

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Tufts Health Plan Premium HMO Plan
Group #: 80975
Tufts Premium HMO Services		Coverage Level
Deductible
Out of Pocket Yearly Expense Maximum		N/A
Inpatient Copayment		N/A
Preventive Health Care
Routine Physical Exams		$10 per visit
Well Child Care		$10 per visit
Fitness Benefit		Discount Options
Weight Watchers		Discounts apply
Eye Exams		$10 per visit - one visit per year
Outpatient Medical Care
Office Visit		$10 per visit
Chiropractic Care		$10 per visit; Up to 12 visits per calendar year.
Specialist, Consultations		$10 per visit
Lab		Covered in Full
X-rays, including Mammograms		Covered in Full
Allergy Shots		Covered in Full
Injections and Immunizations		Covered in Full
Radiation Therapy		Covered in Full
Outpatient Surgery (in a physician’ s office)		$10 per visit
Short-term physical, occupational, speech therapy		$10 per visit
Inpatient Hospital Care
Physician Care while hospitalized		Covered in Full
Surgery and Day Surgery		Covered in Full
Anesthesia		Covered in Full
Medications		Covered in Full
Nursing Care		Covered in Full
X-ray and Lab		Covered in Full
Intensive Care/Coronary Care		Covered in Full
Maternity Care
Prenatal Care		Covered in Full after initial $10 copayment
Hospital and Delivery		Covered in Full
Newborn Care in hospital		Covered in Full
Postnatal Care		Covered in Full
Emergency Care
Urgent Office		$10 per visit
Emergency Room		Full coverage after $25 copayment. Waived if admitted. PCP must be notified within 48 hours.
Home Health Care
Home Health Care Services and Intermittent Skilled Nursing Care		Covered in Full
Physician House Calls		Covered in Full
Outpatient Mental Health *
Inpatient Mental Health*
Psychiatric Hospital		Covered in Full. 60 days per member per calendar year. Partial hospitalization services are available up to a maximum of 120 days per calendar year in place of inpatient mental health services.
Licensed General Hospital		Covered in Full
Outpatient Substance Abuse**
$10 per visit up to $500 per calendar year.
Detoxification		$10 per visit
Inpatient Substance Abuse**
Rehabilitation		Covered in Full. 30 days / member / calendar year. Partial hospitalization services are available up to a maximum of 60 days per calendar year in place of inpatient drug and alcohol rehabilitation services.
Detoxification		Covered in Full
Inpatient Skilled Nursing Care and Rehabilitation
Inpatient Skilled Nursing Care and Rehabilitation		Covered in Full, up to 100 days per calendar year.
Other Services
Durable Medical Equipment (DME)		20% copayment, maximum not to exceed $5,000 per member per calendar year.
Wigs		Covered in Full up to $350 when needed as a result of any cancer or leukemia.
Ambulance		Covered in Full.
Oral Health
Surgical Extraction of Teeth (THP Pre-approval Required)		Covered in Full, Less applicable copayment
Emergency Dental Care for initial treatment (within 72 hours of injury) necessary to repair oral injuries including x-rays, surgical procedures, extractions and suturing.		Covered in Full, Less applicable copayment
Pediatric Preventive Dental		Not Covered
Prescription Drugs
Retail - 30 day supply	Generic	Brand/Formulary	Brand/Non-Formulary
	$10	$15	$30
Mail Order - 90 day supply	Generic	Brand/Formulary	Brand/Non-Formulary
	$20	$30	$60

**Limit does not apply if treatment is in conjunction with
biologically-based mental illness or rape-related mental or
emotional disorders as described in the Tufts Health Plan
Benefit Handbook.

Note:

This grid provides an overview of major services and coverage. All benefits are paid based on medical necessity and under the provisions of the Tufts Health Plan Benefit Handbook.

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Tufts Health Plan — Point of Service (POS) Option
Group#: 29757
Tufts Point of Service (POS) Option Services		In-Network Coverage Level (Participating Provider & Proper Referral)	Out-of-Network Coverage Level
Deductible		N/A	$250 / Individual, $750/Dual & Family
Out of Pocket Yearly Expense Maximum (including the deductible and coinsurance; excluding prescription drug copayments, coinsurance for DME, mental health, and substance abuse services).		N/A	$1,250/ Individual $2,750/Dual & Family
Inpatient Copayment		N/A	N/A
Preventive Health Care
Routine Physical Exams		$10 per visit	80% after deductible
Well Child Care		$10 per visit	80% after deductible
Fitness Benefit		Discount Options	N/A
Weight Watchers		Discounts apply	N/A
Eye Exams		$10 per visit	80% after deductible
Outpatient Medical Care
Office Visit		$10 per visit	80% after deductible
Chiropractic Care Up to a total of 12 visits (in or out of network combined) per calendar year		$10 per visit	80% after deductible
Specialist, Consultations		$10 per visit	80% after deductible
Lab		Covered in Full	80% after deductible
X-rays, including Mammograms		Covered in Full	80% after deductible
Allergy Shots		Covered in Full	80% after deductible
Injections and Immunizations		Covered in Full	80% after deductible
Radiation Therapy		Covered in Full	80% after deductible
Outpatient Surgery (in physician’ s office)		$10 per visit	80% after deductible
Short-term physical, occupational, speech therapy		$10 per visit	80% after deductible
Inpatient Hospital Care
Illness or Injury		Covered in Full	80% after deductible
Physician Care while hospitalized		Covered in Full	80% after deductible
Surgery and Day Surgery		Covered in Full	80% after deductible
Anesthesia		Covered in Full	80% after deductible
Medications		Covered in Full	80% after deductible
Nursing Care		Covered in Full	80% after deductible
X-ray and Lab		Covered in Full	80% after deductible
Intensive Care/Coronary Care		Covered in Full	80% after deductible
Maternity Care
Prenatal Care		Covered in Full after initial copayment	80% after deductible
Hospital and Delivery		Covered in Full	80% after deductible
Newborn Care in hospital		Covered in Full	80% after deductible
Postnatal Care		Covered in Full	80% after deductible
Emergency Care
Urgent Office		$10 per visit	80% after deductible
Emergency Room		Full coverage after $25 copayment. Waived if admitted. PCP must be notified within 48 hours.	Full coverage after $25 copayment. Waived if admitted. PCP must be notified within 48 hours.
Home Health Care
Home Health Care Services and Intermittent Skilled Nursing Care		Covered in Full	80% after deductible
Physician House Calls		Covered in Full	80% after deductible
Outpatient Mental Health *
Outpatient Care up to a total of 24 visits (in or out of network combined) per calendar year		$10 per visit	80% after deductible
Inpatient Mental Health*
Psychiatric Hospital: Up to a total of 60 days (in or out of network combined) per calendar year. Partial hospitalization services are available up to a maximum of 120 days per calendar year in place of inpatient mental health services.		Covered in Full	80% after deductible
Licensed General Hospital		Covered in Full	80% after deductible
Outpatient Substance Abuse**
Rehabilitation		$10 per visit up to $500 per calendar year.	80% after deductible up to $500 per member per calendar year.
Detoxification		$10 per visit	80% after deductible
Inpatient Substance Abuse**
Rehabilitation: Up to a total of 30 days (in or out of network combined) per calendar year. Partial hospitalization services are available up to a maximum of 60-days per calendar year in place of inpatient mental health services.		Covered in Full.	80% after deductible
Detoxification		Covered in Full	80% after deductible
Inpatient Skilled Nursing Care and Rehabilitation
Inpatient Skilled Nursing Care and Rehabilitation		Covered in Full up to 100 days per calendar year.	80% after deductible up to 100 days per calendar year.
Other Services
Durable Medical Equipment (DME)		20% copayment, not to exceed $5,000 per member per calendar year.	After deductible, covered at 80% not to exceed $5,000 per member per calendar year.
Wigs		Covered in Full up to $350 when needed as a result of any cancer or leukemia.	80% after deductible up to $350 when needed as a result of any cancer or leukemia.
Ambulance		Covered in Full	Covered in Full
Oral Health
Surgical Extraction of Teeth (THP Pre-approval required)		Covered in Full Less applicable copayment	80% after deductible
Emergency Dental Care for initial treatment (within 72 hours of injury) necessary to repair oral injuries including x-rays, surgical procedures, extractions and suturing.		Covered in Full; Less applicable copayment.	80% after deductible
Pediatric Preventive Dental		Not Covered	Not Covered
Prescription Drugs
Retail - 30 day supply
	Generic	$10	$15
	Brand/Formulary	$15	$20
	Brand/Non-Formulary	$30	$35
Mail Order - 90 day supply
	Generic	$20	$20
	Brand/Formulary	$30	$35
	Brand/Non-Formulary	$60	$60

*There is no limit when authorized for the treatment of a biologically-based
mental disorder, rape-related mental or emotional disorder, or non-biologically
based mental, behavioral or emotional disorders for children through the age
of 18, as described in the Tufts Benefit Handbook.

**Limit does not apply if treatment is in conjunction with biologically-based
mental illness or rape-related mental or emotional disorders as described in the Tufts
Benefit Handbook.

Note:

This grid provides an overview of major services and coverage. All benefits are paid based on medical necessity and under the provisions of the Tufts Benefit Handbook.

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Neighborhood Health Plan (NHP)
NHP HMO Services		Coverage Level
Outpatient and Preventative Care
Office Visit for primary/specialty care		$10
Routine check ups		$10
Well baby & pediatric care		$10
Immunizations, Allergy tests & shots		Included in office visit
Eye & Hearing exams		Included in office visit
Outpatient surgery		$50 per occurrence
Inpatient Hospital Care ($250 maximum total co-payments per admission)
Inpatient (semi private room)		$50 per day
Physician care		$50 per day
Surgical services		$50 per day
Lab & X-Ray		$50 per day
Maternity Care
Prenatal & postnatal		$10 per office visit
Delivery & hospital care		$50 per day, $250 maximum
Prescription Drugs
Prescription drugs (including mental disorder drugs) insulin, needles, syringes, and mandated medical formulas. Mail order pharmacy program available for 90-day supply prescriptions		Retail - 30 day supply / Mail Order 90 day supply
		Generic/ Formulary	Brand/ Formulary	Brand/ Non-Formulary
		$10/ $20	$15/ $30	$30/ $90
		No charge for certain prescribed over-the-counter cough and cold medicines with prescription from NHP provider. Check with NHP for coverage details
Emergency services		Full coverage after $50 co-payment. Waived if admitted. NHP doctor must be notified within 48 hours
Mental Health
Inpatient mental health benefits		Full coverage
Outpatient mental health benefits		$10
Other Services
Home health care services (house calls)		Covered in full
Rehabilitative care (such as physical, occupational, and speech therapy)		Full coverage up to 90 days per illness
Participating or cooperating skilled nursing facility		Covered in full up to 100 days per calendar year when medically necessary
Durable medical equipment (DME)		Covered in full
*Note:*	This grid provides an overview of major services and coverage. Some services that are not covered by the plan include but may not be limited to: Acupuncture, chiropractic care, contact lenses/fitting (except cataract), cosmetic surgery (if not medically necessary), dental services, eyeglasses, experimental drugs/procedures, hearing aids, or unauthorized care of non life-threatening situation. All benefits are paid based on medical necessity and under the provisions of the NHP Benefit Handbook.

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