Blue Options gives you great benefits, including coverage for preventive care, prescriptions, and
medical emergenciesAn accident or sudden illness that an ordinary layperson believes needs to be treated right away or it could result in loss of life, serious medical complications, or permanent disability. Important: If you believe that you are having a life-threatening medical emergency, call 911 or your local emergency number and seek medical help immediately. .
But, unlike other plans, Blue Options lets you control your costs every time you get care. You can choose from more than 17,000 doctors and hospital in three benefits tiers. Your cost is based on the tier of primary care provider (PCP) or hospital you choose. And if you need help using your Blue Options plan, we're right there to guide you.
Understand Doctor and Hospital Tiers
PCPs and hospitalsAn institution whose primary function is to provide diagnostic and therapeutic inpatient services, for a variety of surgical and non-surgical medical conditions. In addition, most hospitals provide outpatient services, including emergency care. in the Blue Options networkA group of health care providers under contract with a managed care company within a specific geographic area. are grouped into three benefit levels—or tiers. The tiers are based on cost and nationally accepted standards for quality. The cost you pay for care Out-of-Pocket is based on the benefits tiers of your doctors and hospitals.
|Benefits Tier||Quality||Your Cost|
|Enhanced||Includes Massachusetts hospitals and PCPs that meet the standards for quality and low cost relative to our benchmark.||$ — lowest cost|
|Standard1||Includes Massachusetts hospitals and PCPs that meet the standards for quality and are moderate cost relative to our benchmark and hospitals that do not meet the standards for quality but are low or moderate cost relative to our benchmark.||$$ — moderate cost|
|Basic||Includes Massachusetts hospitals that are high cost relative to our benchmark and PCPs that do not meet the standards for quality and/or are high cost relative to our benchmark.||$$$ — highest cost|
1. In limited circumstances, to increase your local access, the Standard Benefits Tier includes certain providers whose scores would put them in the Basic Benefits Tier.
Note: PCPs were measured based on their HMO patients as part of their provider group, and hospitals were measured based on their individual facility performance. Provider groups can be composed of an individual provider, or a number of providers who practice together. Tier placement is based on cost and quality benchmarks where measurable data is available. Providers without sufficient data for either cost or quality are placed in the Standard Benefits Tier. PCPs that do not meet benchmarks for one or both of the domains and hospitals that do not meet benchmarks for cost or that use nonstandard reimbursement are placed in the Basic Benefits Tier.
This web site gives general information about our tiered network plan designs. There are currently three tiered provider networks called HMO Blue Options v.4, HMO Blue New England Options v.4, and Preferred Blue PPO Options v.4. 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.
Your plan has a new benefit for certain members with a serious health condition, such as cancer or cystic fibrosis. With this benefit, which is due to a change in Massachusetts' law, members who qualify can receive care at certain higher-cost facilities and pay a lower cost share for up to one year. This benefit only applies in the following situations. Choose the one that applies to you.
- You purchase health coverage directly from Blue Cross Blue Shield of Massachusetts
- You get coverage through employer groups with fewer than 50 employees