Understanding Our Network

Tiering with One Standard of Quality

Tufts Health Plan has created a comprehensive network of primary care providers (PCPs), specialists and hospitals. The Your Choice plan gives you access to that network.

Every doctor and every hospital in the Your Choice network has been carefully evaluated based on many criteria. As part of our National Committee for Quality Assurance (NCQA) accreditation and our own quality standards, we are committed to contracting only with high-performing hospitals. Rest assured, every provider and hospital in the Your Choice network meets our standard for quality of care.

One way health care providers differ, though, is in their cost. Not all doctors and hospitals charge the same costs. So we’ve factored in cost-efficiency in our evaluation, and have separated the providers into levels, or tiers. Depending on your plan, you will get care from providers in a 2-Tier system or a 3-Tier system.

Choosing Your Tier

It’s really all about how much you’re willing to pay out-of-pocket for the specific doctor and hospital you want.

If you want the most cost-effective option, choose a doctor or hospital from Tier 1. If the doctor or hospital you really want is in Tier 2 or Tier 3, you have the freedom to choose him or her, but you’ll pay more out-of-pocket costs.

Can I Mix and Match?

To an extent. First, it’s important to know that for any given year, a doctor that’s Tier 1 is always associated with a hospital of the same tier. That’s generally the primary hospital system with which the provider is affiliated. Again, it has to do with cost, not quality.

So let’s say your PCP is Tier 1 and you need knee surgery. Your doctor will most likely refer you to a specialist and hospital that are Tier 1. But let’s say you’re interested in a Tier 2 or Tier 3 specialist. If so, you can choose that doctor, but your out-of-pocket costs will be higher.

Another scenario might be that you have a long relationship with your family doctor, but find out they are Tier 2 or Tier 3. You prefer to continue seeing that doctor, knowing your out-of-pocket costs will be higher. But your spouse doesn’t really mind seeing another doctor, and decides that they want to keep out-of-pocket costs down by seeing a Tier 1 doctor. In this scenario, it’s perfectly okay to mix and match, and give everyone their choice.

Hospitals and Their Tiers

We’ve grouped every hospital in the area into tiers. Like our physicians, a hospital’s tier is not based entirely on quality. Though every hospital meets our high standards, our tiers are also based on cost-efficiency and physician group affiliation.

Emergency Care

In a serious emergency situation, though, you don’t have to think about Tier 1 this or Tier 2 that. You just call 9-1-1 if the situation warrants it, or drive to the nearest emergency room if that’s appropriate. Under the Your Choice plan, the emergency room copay is always equal to the Tier 1 emergency room copay for both the doctor and the hospital.