Tiering for Specialty Care ProvidersMarch 15, 2022
For Basic, PLUS, and Community Choice members
What is specialist tiering?
Specialist tiering is an important part of the Massachusetts Group Insurance Commission’s (GIC) interest in addressing rising health care costs. UniCare assigns Massachusetts specialty care providers (specialists) to levels or tiers. Similar tiering programs are used in other health plans across the country.
How does specialist tiering affect me?
Specialist tiering is a part of your benefit plan. For example, you pay lower office visit copays when you use Massachusetts specialists assigned to Tier 1 than you do when you see specialists assigned to other tiers. We understand that our members need to choose specialists who are appropriate for them, and our tiering program does not prevent you from doing so. You have the freedom to see any doctor of your choice. You’ll find a chart with specialist office visit copays below.
Will there be any changes to specialist tiering on July 1, 2022?
No. UniCare will continue with group tiering for specialists in the new plan year. This means that all specialists within a practice will have the same tier. This includes doctors, nurse practitioners and physician assistants who practice specialty care. However, if a specialist moves to a different practice during the year, his or her tier may change. You should check your specialist’s tier in our Find Care tool.
How is the tier for each group decided?
Each practice or group is placed in a tier, and all specialists within that practice have the same tier. The tier for each practice will be based on the group’s relationship to a hospital. To determine the tier placement, we use the hospital’s designation provided by the Massachusetts Center for Health Information and Analysis (CHIA).
What are the CHIA designations?
As part of its evaluation of total medical expenses, CHIA has developed a classification system for all hospitals in Massachusetts. Each hospital is designated as being in one of four categories:
- Academic Medical Center *
Note: CHIA’s “Community” designation includes some but not all hospitals designated as Community Choice hospitals under UniCare’s Community Choice plan. If you’re a Community Choice member, it’s important to use Community Choice hospitals for your care to get the highest level of benefits and reduce your out-of-pocket costs.
Why do you use the CHIA designations?
The GIC and other state entities such as the Health Policy Commission have pointed to CHIA’s findings that the average total medical expenses (TMEs) for individuals in a practice group vary greatly across the state depending on the group’s association with a hospital. Those groups operating as part of an Academic Medical Center have the highest TMEs; those related to Community hospitals have the lowest TMEs. Our tiering approach acknowledges the importance of these findings.
What are the tiers for physician practices?
The tiers are shown in the following table:
|Tier 1||Practices and specialty groups related to hospitals in CHIA’s Community* category|
|Tier 2||Practices and specialty groups not in Tier 1 or Tier 3 (including those related to hospitals in CHIA’s Teaching and Specialty categories)|
|Tier 3||Practices and specialty groups related to hospitals in CHIA’s Academic Medical Center category|
* Note: CHIA’s “Community” designation includes some but not all hospitals designated as Community Choice hospitals under UniCare’s Community Choice plan. If you’re a Community Choice member, it’s important to use Community Choice hospitals for your care to get the highest level of benefits and reduce your out-of-pocket costs.
Will there be any changes to UniCare’s office visit copays with specialists?
No. These copays will remain the same on July 1, 2022. The copays for specialty care office visits for each tier are shown in the following table and also on your UniCare ID card. These copays apply to doctors, nurse practitioners, and physician assistants who practice specialty care. Specialist office visit copays effective July 1, 2022.
|Tier 1||Tier 2||Tier 3|
How can I check to see what my specialist’s tier is?
What if my specialist doesn’t appear in UniCare’s Find Care tool?
This means that your specialist is Tier 2.
Does UniCare assign tiers to primary care physicians too?
No. Primary care physicians (PCPs) are not subject to the group tiering process, as described in this document. As shown below, however, members in UniCare’s PLUS and Community Choice plans pay differing primary care copays depending on whether they see PCPs in our Enhanced Personal Health Care program.
- Basic members pay a $20 copay for all non-preventive office visits with PCPs.
- PLUS and Community Choice members pay a $15 copay for non-preventive office visits with PCPs who participate in UniCare’s Enhanced Personal Health Care program, and a $20 copay for non-preventive visits with all other PCPs.
If you have other questions about specialist tiering, please call UniCare Member Services at 833-663-4176 (toll free). You can also email us at email@example.com.