Understanding Tiered Products:
Are you an in-network provider?
Posted January 12, 2015
Our November 2014 Blue Review included an article titled, New Products Offer More Choices and Potential Savings for Our Members. This article focused on two new PPO products – Blue OptionsSM and Blue Choice OptionsSM – which became effective Jan. 1, 2015. These tiered products 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. Here is the basic benefit structure of a tiered product:
- 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 tiered product, which currently is offered by the City of Chicago (group numbers 195500, 195501, 195502 and alpha prefix CTY) and Rivers Casino (group number 154061 and alpha prefix XOX) members, the tier 1 contracted provider network is Blue Choice OPT PPO (BCO)SM. This network is identified on our Provider Finder® as follows: Blue Options or Blue Choice Options (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: Tier 2 (PPO) If the member wants to select a Tier 2 contracted provider knowing they will incur higher out-of-pocket costs: 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.
From the Blue Choice Options member perspective, here’s how it works:
If the member wants to select a Tier 1 contracted provider and pay the least out-of-pocket costs:
If the member wants to select a Tier 2 contracted provider knowing they will incur higher out-of-pocket costs:
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
It has come to our attention that members may be mistakenly denied services by contracted PPO providers. We understand and recognize that this is a new product for you and our members. Here are some tips to assist your staff when scheduling appointments for these members:
- Ask the name of the product. The product name, Blue Choice Options, appears on the front of the 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 is in red in the lower left on the front of the 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 uses the Blue Choice OPT (BCO) network with tiered benefits.
Our growing portfolio of product offerings is part of BCBSIL’s efforts to meet its goal of increasing access and affordability of health care products to our members and the community that we serve. Making it easier for you and your staff to conduct business with us is equally important. We appreciate your patience, cooperation and support as we all work to adapt to new product options.