Tiered Network/Blue Options is a family of health plans that engages members with their health and coverage every time they get care through tiered benefits.

To improve the quality and affordability of health care, we will be implementing several enhancements to our standard plan designs. Learn about the plan changes designed to make health care more affordable.

With the plan, Massachusetts primary care provider (PCPs) and acute-care hospitals are placed into one of three benefits tiers based on how they scored on cost and nationally accepted quality benchmarks.

The tiered network drives value throughout the health plan because each time members seek care from a PCP or hospital, their cost sharing is based on the tier status of the provider they see.

This helps encourage members to consider the cost and quality of their PCP or hospital each time they get care and rewards them for choosing providers on the Enhanced or Standard Benefits Tiers.

Other benefits of the Blue Options family of plans:

• Lower premium costs
• The comprehensive coverage of HMO Blue^® and/or PPO Blue^®
• Access to office visits, prescriptions, emergency room visits, and mental health care for a copayment, similar to other HMO Blue and/or PPO Blue
• A choice of plan platforms and networks, including national and New England

Plan Choice
Within the Blue Options family of plans, we can offer employers access to three types of plans:

• HMO Blue Options v.3—Provides access to our full HMO Blue network in Massachusetts
• Individuals and Small Groups (employers with 50 or less employees)
• Large Groups
• HMO Blue New England Options v.3—Expands access to six-state New England region
• Individuals and Small Groups (employers with 50 or less employees)
• Large Groups
• Preferred Blue PPO Options v.3—Provides access to care with no referrals throughout our nationwide network.
• Individuals and Small Groups (employers with 50 or less employees)
• Large Group

How Tiers Work Within Massachusetts
Each time members seek care from a PCP or hospital, their cost sharing is based on which of the three tiers* the provider is assigned to. This helps encourage members to consider the cost and quality of their PCP or hospital each time they get care and rewards them for choosing providers in enhanced or standard benefits tiers.

• Enhanced Benefits Tier—Lowest member cost sharing—Includes Massachusetts PCPs and hospitals that met our quality benchmark and our benchmark for lowest cost.
• Standard Benefits Tier—Mid-level member cost sharing—Includes Massachusetts PCPs and hospitals that met our quality benchmark and our benchmark for moderate cost. Also includes providers without sufficient data for measurement on one or both benchmarks. In limited circumstances, the Standard Benefits Tier includes certain providers whose scores would put them in the Basic Benefits Tier to provide geographic access for members.
• Basic Benefits Tier—Highest member cost sharing—Includes Massachusetts PCPs and hospitals that scored below our quality benchmark and/or our benchmark for moderate cost.

*Note: For the cost benchmark, hospitals were measured on their individual facility's performance and PCPs were measured according to the costs their group's HMO patients incurred. Physician groups can be composed of an individual provider, or a number of providers who practice together. Tier placement is based on benchmarks where measurable data is available; those without sufficient data were defaulted to the Standard Benefits Tier. Specialty hospitals were measured on cost alone for their overall tier rating. Hospitals with nonstandard reimbursement were placed in the Basic Benefits Tier.

Outside Massachusetts
Depending on the plan design selected, tiering will work differently.

• HMO Blue New England Options—A network provider who is listed as a general practitioner, internist, family practitioner, pediatrician, obstetrician/gynecologist, nurse practitioner, rural health center, or general hospital is considered an Enhanced Benefits Tier provider. Other providers in our New England network carry the higher, specialist copayment.
• Preferred Blue PPO Options/Blue Precision—Employers have the option to access the tiered network in Massachusetts or on a national basis*. Members can check our national network to see if there are tiered providers in the locality where they are receiving care. In states where a tiered network is available, member's cost sharing would follow that tiering. In local PPO service areas where different levels of preferred providers are not available, providers would carry the lower Enhanced Benefits Tier cost sharing.

Provider Search
To see individual provider tiers, or how they've performed against our cost and quality benchmarks used for tiering just use our Find a Doctor tool. Be sure to select the plan design labeled "v.3."

You can also download a copy of our Blue Options hospital tiering list to see how individual hospitals are tiered.

For more information on the Blue Options plans, contact your account executive or broker.

* National tiering is available to self-insured employers only.