How GIC specialist tier structure determines copays (GIC only)
Posted on May 27, 2016
Have you ever wondered how your copay for a provider visit is determined? If you have and you’re a Commonwealth of Massachusetts Group Insurance Commission (GIC) member,* you may find the following information helpful.
Primary care providers
Primary care providers (PCPs) are not tiered. Therefore, for a PCP office visit, a standard $20 copay will apply.
Specialist tier structure
The GIC has selected to use a tier structure for certain Health New England providers based on quality and/or cost efficiency. Providers in the following specialties are considered tiered:
• Cardiology or Cardiovascular Disease
• Endocrinology
• Gastroenterology
• Surgery
• Obstetrics & Gynecology
• Orthopedics
• Otolaryngology (Ear, Nose and Throat)
• Pulmonology
• Rheumatology
There are three specialist tier assignments that determine your copay responsibility:
• Tier 1 (denoted by ***) = Copay of $30
• Tier 2 (denoted by **) = Copay of $60
• Tier 3 (denoted by *) = Copay of $90
You can find tier assignments when you search for a specialist in Health New England’s GIC Provider Directory at healthnewengland.org/gic-provider-search.
Non-tiered specialists
Some specialists do not have a tier assignment. In the case that a specialist is denoted by NT/ID, it means that either the specialist is not tiered by the health plan or there wasn’t enough data to assign a tier.
For any specialist that is not tiered, a $60 copay will apply.
Should you have any questions about specialist tiers or about your plan, contact Health New England Member Services at (413) 787-4004 or toll-free at (800) 310-2835. For TTY/TDD, call (800) 439-2370. Representatives are available to assist you Monday – Friday, 8:00 am – 6:00 pm.
*This information pertains to GIC members who are active employees or retirees without Medicare Parts A & B.
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