Understanding Tiered Products: Are you an in-network PPO provider? | Blue Review (2024)
October 2019
Tiered products – such as Blue Options PPOSM and Blue Choice Options PPOSM– are designed to give the employer and the member the opportunity to help them self-manage their health care spending. With a tiered product, the member’s benefit level of cost-sharing is determined by the network of the independently contracted provider that renders the service. Keep in mind that an employer can customize the benefit levels for each tier.
Tier 1 is the highest benefit level and most cost-effective level for the member, as it is tied to a narrow network of designated providers.
Tier 2 benefits offer members the option to select a provider from the broader network of contracted PPO providers, but at a higher out-of-pocket expense.
Tier 3 benefits, if offered, typically address the use of out-of-network providers as the highest cost option for covered services.
Using the example of the Blue Choice Options PPO tiered product, which currently is offered by the City of Chicago (group numbers 195500, 195501, 195502 and three-character prefix CTY) and Rivers Casino (group number 154061) and any group number with three-character prefix XOX, the tier 1 contracted network is Blue Choice OPT PPOSM (BCO). This network is identified on our Provider Finder® as follows: Blue OptionsSM/Blue Choice OptionsSM (BCO). The tier 2 contracted provider network for Blue Choice Options members includes participating providers in the broader PPO network. Tier 3 benefits, when available, give these members the option to use out-of-network providers, but with the largest responsibility for the cost of care.
All PPO participating providers and Blue Choice PPOSM participating providers are considered to be in-network for Blue Choice Options members.
From the Blue Choice Options member perspective, here’s how it works:
In-network
Tier 1 (BCO)
If the member wants to select a Tier 1 contracted provider and pay the least out-of-pocket costs:
The member will select the network code of BCO when conducting a search on our Provider Finder.
The search will return a list of participating providers in the BCO network.
"Blue Choice OPT" will appear under participating providers’ names.
Tier 2 (PPO)
If the member wants to select a Tier 2 contracted provider, knowing they will incur higher out-of-pocket costs:
The member will select the network code of PPO when conducting a search on our Provider Finder.
The search will return a list of participating providers in the PPO network.
When the member clicks on the provider’s name, applicable networks will be displayed.
Out-of- network
Tier 3 (when available)
The member may select a non-participating provider knowing this option will result in incurring the highest out-of-pocket costs for covered services.
How to Identify Blue Choice Options Members Here are some tips to assist your staff when scheduling appointments for these members:
Ask for the name of the product. The product name, Blue Choice Options, appears on the front of the member’s ID card in the lower left corner. This will help you identify that this is a tiered benefit product. As indicated in the chart above, you are considered an in-network provider for this patient if you are either a contracted Blue Choice PPO or a PPO provider.
Ask for the three-letter network code. This code appears in the lower left on the front of the member’s ID card. The network code for Blue Choice Options is BCO – another indicator that this is a tiered benefit product.
Ask for the statement on the back of the ID card. For Blue Choice Options members this statement will read: This plan is part of the Blue Choice OPT (BCO) network with tiered benefits.
Our growing portfolio of product offerings is part of our initiative to increase access and affordability of health care products for our members and the community we serve. Making it easier for you and your staff to conduct business with us is equally important.
Your out-of-pocket healthcare costs are determined by your doctor's or provider's network tier, as negotiated with the plan's benefit administrator: Tier 1 (specific contracted in-network providers), Tier 2 (contracted local, regional, and nation-wide in-network providers), or Tier 3 (out-of-network providers).
Tier 1: Blue Choice Opt PPO (Highest level of benefits and lowest out-of-pocket costs) Tier 2: PPO Network (Mid-level of benefits and higher out-of-pocket costs) Tier 3: Out-of-network (Lowest level of benefits and highest out-of pocket costs if a member sees an out-of-network doctor) ln a joint effort with Trinity ...
There are a number of important similarities and differences between ACOs, HMOs (Health Maintenance Organizations), and PPOs (Preferred Clinician Organizations): An ACO is generally based on a self-defined network of clinicians, whereas in most HMOs and PPOs, the network is defined by a health plan.
Tier 1 and tier 2 capital are two types of assets held by banks. Tier 1 capital is a bank's core capital, which it uses to function on a daily basis.Tier 2 capital is a bank's supplementary capital, which is held in reserve. Banks must hold certain percentages of different types of capital on hand.
Tier 1 Suppliers: These are direct suppliers of the final product. Tier 2 suppliers: These are suppliers or subcontractors for your tier 1 suppliers. Tier 3 suppliers: These are suppliers or subcontractors for your tier 2 suppliers.
What Are Disadvantages of PPO Plans? PPO plans tend to be more expensive than other managed-care options. They typically have higher monthly premiums and out-of-pocket costs, like deductibles.
HMOs don't offer coverage for care from out-of-network healthcare providers. The only exception is for true medical emergencies. With a PPO, you have the flexibility to visit providers outside of your network. However, visiting an out-of-network provider will include a higher fee and a separate deductible.
It typically allows policyholders to see any doctor or specialist without needing a referral, including those outside the network, though at a higher cost. Freedom to see more doctors: PPO plans allow seeing both in-network and out-of-network providers.
Tier 1 accounts have a lock-in period until the investor turns 60.Tier 2 accounts don't have any lock-in period. Section 80C of the Income Tax Act permits deductions for contributions up to Rs. 1,50,000 annually.
Tier 1 – Aetna® Premier Care Network Plus Multi-Tier providers. Utilizing a provider from this tier results in maximum savings for Aetna members. Tier 2 – Aetna Health broad network providers. Utilizing a provider from this tier results in standard savings for Aetna® members.
Introduction: My name is Stevie Stamm, I am a colorful, sparkling, splendid, vast, open, hilarious, tender person who loves writing and wants to share my knowledge and understanding with you.
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