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 and easy to understand benefits of HMO Blue^® and/or PPO Blue^® plans
• Access to office visits, prescriptions, emergency room visits, and mental health care for a copayment, similar to other HMO Blue and/or PPO Blue

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  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.
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  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.

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

  • For care in 2012
  • For care in 2011
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  Additional Information and Resources

• You have access to the tools and information that can make selling the Blue Options plans easy.

  • Blue Options Brochure—Introduces the value of the Blue Options plans to your clients.
  • Blue Options Fact Sheet—A quick overview explaining the benefits of Blue Options plans.
  • Tiered Services Cost Comparison Fact Sheet—See how the costs of services on different tiers stack up and how the Blue Options plans help drive members to high-value providers
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  Member Information and Resources

• Your clients have access to a wide range of support tools to make educating and engaging their employees easy.

  You can also access the tools by following the links below:

  • Member Communications Tools—Review all the resources available to help you explain the value of Blue Options to members at the BlueIQ Communications Center.
  • Member Education Web site—our specially designed web site (www.bluecrossma.com/blueoptions) makes it easy for new and current members to use their plan efficiently.

   

  FAQ - Get answers to questions about:

  The plan

  Its benefits

  How the deductible works

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

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

This web site gives general information about our tiered network plan designs. There are currently three tiered provider networks called HMO Blue Options v.3, HMO Blue New England Options v.3, and Preferred Blue PPO Options v.3. In our tiered plans, members pay different levels of cost share (copayments, coinsurance, and/or deductibles) depending on the benefits tier of the provider furnishing the services. A provider's benefits tier may change. Overall changes to the benefits tiers of providers will happen no more than once each calendar year. For help in finding the benefits tier of a provider, visit the online provider search tool and search for the appropriate network.