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Reclassification of Tiers for Primary Care Providers and Hospitals for Blue Options (v.4)

Why We Are Updating Our Tiers
Periodic updating of our tiers with the most current available data is an important step in maintaining our tiered-network plans as an affordable choice for the more than 1,000 employers and 100,000 members who have our Blue Options tiered plans. It also encourages providers in our network to continue to improve their cost and quality performance by reflecting these changes over time in the provider's tier.

The analysis of the data and the update to our tiers is based on cost and quality methodologies that use well-accepted performance measurement principles and validated measures articulated by local and national physician leaders and measurement experts. We updated our methodology to determine the hospital's tier and used updated data to reclassify all providers based on their quality and cost results. In cases in which hospitals did not meet our quality standards, they were placed in the next higher tier based on their final cost score.

As we noted in the June IAI, this is our fourth updating of the network tiers, and it reflects changes in the providers' data that occurred since the last update. Future updates will occur on a regular basis.

For 2013, we are updating the hospital and primary care provider group tiering levels within our Blue Options plans. These changes will have a favorable impact on the general pricing of the product. The changes will go into effect for employer groups currently offering a Blue Options plan on the group's first renewal date on or after January 1, 2013 and for all new accounts with an original effective date on or after January 1, 2013. The updated tiering will be identified on member ID cards and in our provider directory as Blue Options v.4.

Below is a summary of the hospital changes. No other hospitals are changing tiers.

Hospital Name Previous Blue Options Tier New Blue Options Tier Reason for Change
Baystate Mary Lane Hospital Enhanced Benefits Tier Standard Benefits Tier1 Quality Score
(not enough data to measure)
Holyoke Medical Center Enhanced Benefits Tier Standard Benefits Tier Quality Score
(did not meet benchmarks for quality)
Lawrence General Hospital Enhanced Benefits Tier Standard Benefits Tier Quality Score
(did not meet benchmarks for quality)
North Adams Regional Hospital Enhanced Benefits Tier Standard Benefits Tier1 Cost Score
(meets benchmark for moderate cost)
Boston Children's at Lexington2 Basic Benefits Tier Standard Benefits Tier Cost Score
(meets benchmark for moderate cost)
Boston Children's at Waltham2 Basic Benefits Tier Standard Benefits Tier Cost Score
(meets benchmark for moderate cost)
Boston Children's North at Peabody2 Basic Benefits Tier Standard Benefits Tier Cost Score
(meets benchmark for moderate cost)

1. To ensure members have access in certain geographic areas, Baystate Mary Lane Hospital and North Adams Regional Hospital have a modified member cost share.
2. Boston Children's Hospital's downtown Boston location will remain in the Basic Benefits Tier/Higher Cost Share.

Here is a summary of the primary care provider changes:

Nurse Practitioner as Primary Care Provider
For those nurse practitioners who are accredited with a specialty of family medicine, internal medicine, or pediatrics and are credentialed as a primary care provider in our network, we now assign tiers to them in the same way as primary care providers. The new tiers for nurse practitioners as primary care providers will be available on our Find a Doctor tool on October 1, 2012.

Changes to Primary Care Provider Tiers
Approximately 24 percent of primary care provider tiers will change, while the tiers of the remaining 76 percent of primary care provider will have the same or lower cost share for their members. In some cases the tier changes have been to a more favorable tier and in some cases to a less favorable tier, based on the updated data. With the updated tiers, the cost that members would pay for care at some primary care providers and hospitals will go up or down—depending on the providers' new tier. Individual letters will be mailed to members whose provider is changing to a higher cost share or to a lower cost share in late October/beginning of November. The new primary care provider tiers for members will go into effect for employer groups currently offering a Blue Options plan on the group's first renewal date on or after January 1, 2013 and for all new accounts with an original effective date on or after January 1, 2013.

The new provider tiers will be available on our Find a Doctor tool on October 1, 2012.

Questions?
If you have any questions, please contact your account executive.

 

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