Within the Blue Options networkA group of health care providers under contract with a managed care company within a specific geographic area. , 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. and groups of primary care providers (PCPs) are grouped into three benefits tiers. The tiers are based on cost and nationally accepted standards for quality and performance. Where you receive care will determine your Out-of-PocketCopayments, deductibles, or fees paid members for health services or prescriptions. costs for most services.
Keep in mind that these tiers don't apply to emergencyAn 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. care. If you get care at a hospital during an emergency you'll pay the lowest cost share, regardless of the level of the hospital. This also applies if you're admitted to the hospital from the emergency room. Generally, you can lower your out-of-pocket costs by choosing Enhanced Benefits Tier providers each time you get hospital or PCP care.
It's important to consider the tier of your PCP and the facility where your PCP has admitting privileges before you choose a PCP or receive care. For example, if you require hospital care and your Enhanced Benefits Tier PCP refers you to an Enhanced Benefits Tier hospital, you would pay the lowest cost sharing for both your PCP and hospital services. Or, if your Enhanced Benefits Tier PCP refers you to a Basic Benefits Tier hospital for care, you'll pay the lowest copaymentsThe amount that a plan member must pay the provider at the time of service. Also called a copay, this amount varies depending on the specifics of a given health plan contract. for PCP services, but the highest copayments for hospital services, except in an emergency.
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. Providers that don't meet benchmarks for one or both of the domains and hospitals that use nonstandard reimbursement are placed in the Basic Benefits Tier.