Getting Care

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Within the Blue Options network , hospitals 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-Pocket costs for most services.

Keep in mind that these tiers don't apply to emergency 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.

  • Enhanced Benefits Tier—Includes Massachusetts PCPs and hospitals that met our quality benchmark and our benchmark for lowest cost.

  • Standard Benefits Tier—Includes Massachusetts PCPs and hospitals that met our quality benchmark and our benchmark for moderate cost. 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.

  • Basic Benefits Tier—Includes Massachusetts PCPs and hospitals that scored below our quality benchmark and/or our benchmark for moderate cost.

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 copayments 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.