Your Choice 2-Tier FAQs

Frequently Asked Questions About Your Choice Plans

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These Frequently Asked Questions address the Your Choice plan in a general manner. If you have a specific question about the plan, please call us. We’re here to help.

What is the Your Choice Tiered Provider Network Option?

This option groups hospitals and affiliated providers into tiers, or levels, based on comprehensive cost and quality information and a methodology that incorporates:

  • Overall provider efficiency and care management
  • Provider quality
  • An integrated approach to member health care

We assign levels to our contracted providers and hospitals based on a combination of nationally accepted quality measures and measures of cost efficiency – contracted rates for each service and total medical expense (TME), which reflect efficiency in managing a member’s total care.

  • Level 1 represents the most cost-efficient, quality providers in the Tufts Health Plan Your Choice network, and offers you the lowest cost share. It includes access to a broad range of physician groups, community hospitals, and several tertiary hospitals.
  • Level 2 represents quality providers in the Tufts Health Plan Your Choice network that are not as cost-efficient as Level 1 and result in higher member cost sharing (for the two-tiered option, Level 2 will combine with Level 1 providers, offering members the lowest cost share).
  • Level 3 represents providers in the Tufts Health Plan Your Choice network that either do not meet the quality threshold and/or do not meet the threshold for cost efficiency and result in the highest member cost sharing (with the two-tiered option, Level 3 will become Level 2 – the highest cost sharing level).

Will Primary Care Providers (PCPs) and specialists be tiered?

Yes, all PCPs will be tiered. There will be a PCP level and a specialist level copayment per tier. This means there will be a total of 6 copayments on each plan:

Tier PCP Copayment Specialist Copayment
Tier 1 $ $
Tier 2 $$ $$
Tier 3 $$$ $$$

Will all providers affiliated with a hospital have the same tier as the hospital?

The intent is to group provider groups and their primary hospital affiliation in the same tier to reflect the referral patterns that the physicians would most often make. Providers are tiered by their primary provider unit (PU) or Independent Practice Association (IPA), which means they could be affiliated with more than one PU/IPA and also more than one hospital. As a result, there will be some providers who work at a hospital that has a different tier.

Why are all hospitals and physician groups affiliated with Partners (PCHI) on Tier 3?

  • Tufts Health Plan’s overall tiering methodology supports tiering at a contracted provider organization/system level. Therefore all physicians and hospitals affiliated with Partners (primary affiliation) were evaluated as a group for cost efficiency and quality measures.
  • We believe this approach more accurately reflects the total cost of care and will reduce the incidence of cross-tier referrals, since most of the Partners physicians will refer you to other Partners providers.

Why is Tier 2 larger than it was last year – the first year of the plan?

  • A small amount of movement is anticipated each year and accounts for part of the increase in the number of Tier 2 providers. But this year, we changed the “default” tier for out-of-state hospitals from Tier 1 (2012) to Tier 2 (2013).
  • The central philosophy behind the Your Choice Plan is to encourage you to use Tufts Health Plan contracted providers on the lowest cost tiers. Putting all out-of-state and non-Tufts Health Plan contracted hospitals into Tier 2 encourages you to choose Tufts Health Plan-contracted Tier 1 providers.
  • The breakdown for contracted hospitals in the Tufts Health Plan Your Choice network is as follows:
    • Tier 1 represents ~53%
    • Tier 2 represents ~32%
    • Tier 3 represents ~15%
  • The breakdown for contracted PCPs and specialists in the Tufts Health Plan Your Choice network is as follows:
    • Tier 1 represents ~ 46%
    • Tier 2 represents ~27%
    • Tier 3 represents ~27%

Why does Tufts Health Plan tier specialists?

  • Tiering specialists is consistent with our philosophy of tiering at an integrated system/contract-entity level
  • Plan design provides incentives and encourages members to seek more cost-efficient, quality specialty care
  • Specialty care accounts for a large percentage of medical expenses

How does Tufts Health Plan classify a doctor who has admitting privileges at multiple hospitals with different tier placements?

In most cases, Tufts Health Plan has tiered providers at the organizational or contracting level. We have tiered hospitals and physicians in a group practice affiliated with a particular hospital into the same level to account for referral patterns, since most of the time, physicians refer within their provider organization. For example, if a physician is part of an IPA affiliated with Hospital A, then all of the physicians in that IPA will be on the same level as Hospital A. Those doctors with multiple admitting privileges will be tiered based on the physician’s primary IPA affiliation.

How often will providers be re-tiered?

  • Tier placements are updated on an annual basis beginning January 2013, based on the most recently available and completed quality, unit cost and TME information.
  • Tufts Health Plan reserves the right to re-assess placements for providers that experience significant changes in quality, unit cost or total medical expenses that have a material impact on their position relative to the network average and which are not captured in the base year data as permitted by applicable state law and regulations.
  • Note: Tufts Health Plan may alter the methodology and/or source data to comply with any and all applicable regulations and legislative changes.

What happens if a doctor is in one tier and they admit a member to a hospital in another tier?

If a member is admitted to hospital A, Tier 1, and has surgery with a physician who is Tier 2, the member will be responsible for a mixture of Tier 1 and Tier 2 cost-share. In most instances, the hospital and the physician rendering services at the hospital will be in the same tier. If the plan design has only copayments for tiered services, the copayment will be assigned based on the tier of the hospital.

How can I change my Primary Care Provider (PCP)?

If you would like to change your PCP, the easiest thing to do (if you haven’t already) is create an online account at mytuftshealthplan.com. Just click “Get Started Now” and follow the instructions. Once you’ve set up your account and have chosen a new PCP, click “Change Primary Care Provider” on the Home page. If you need any help, feel free to call a Member Representative at the number on your member ID card.

If I’m admitted through the emergency room (ER) and as a result do not have a choice of hospital for the inpatient stay, what will be the cost share?

If you are admitted through the ER, the inpatient services will be processed at Tier 1 cost share. Since choice is a key element of the Your Choice plan, and in this situation you did not have a choice regarding the hospital, you will only be responsible for a Tier 1 cost share, regardless of the tier of the hospital.

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