New tier assignments for Harvard Pilgrim’s ChoiceNet and Hospital Prefer plans take effect on January 1, 2016, and last month Harvard Pilgrim mailed letters notifying physician groups and hospitals whose tier changed of their new tier assignments for these products.
The ChoiceNet HMO and PPO plans are tiered network versions of the Best Buy HMO and PPO plans. Physician tiering applies only to ChoiceNet; the Hospital Prefer plan offers a simplified network design that tiers hospitals only.
For both plans, member cost sharing falls into one of three tiers, as determined by the provider’s tier assignment. Harvard Pilgrim determined network tier assignments based on quality and cost performance, as measured by health status adjusted total medical expenses and relative prices. To develop the quality score used to determine tier placement, Harvard Pilgrim utilized measures endorsed in the Standard Quality Measurement Set (SQMS), introduced by the Massachusetts Statewide Quality Advisory Committee to provide a standardized quality measurement system. If applicable quality measured were unavailable, tiers were based solely on health status adjusted total medical expenses or relative prices, or both.
The Provider Directory will be updated by October 1, 2015 to reflect the 2016 tier assignments.
For more information, including links to product administration information, a description of the tiering methodology, fast facts, and provider tier appeal guidelines and review form, please see the Tiered Network Plans page.