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

*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 — 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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