You have many things to consider when choosing a doctor or hospital, including what is in-network with your insurance plan. Have you ever wondered why some in-network doctors or hospital visits have higher copays than others? Or what “tiering and steering” means, and how it affects you and your health care choices?
Never Miss a Beat!
Subscribe to Our HealthBeat Newsletter!
Get Healthy Tips Sent to Your Phone!
What Is Tiering?
Tiering is becoming more common among health insurers. The insurance companies organize health care providers into benefit levels, or tiers, based on a variety of factors and other data, including:
- Advanced certifications
- Negotiated rates
- Third-party hospital ratings
- Quality metrics
The insurer then determines how a member’s benefits will apply to the providers in each tier, such as increasing or decreasing the member’s out-of-pocket costs. For example, if you want to make an appointment with Dr. Smith in tier X, the copay may be $10, but if you want to make an appointment with Dr. Jones in tier Y, the copay may be $50. Typically, a tier for which the member’s costs are reduced is referred to as a “higher” level of benefits, while a tier for which the member must pay more is called a “lower” level. The insurer may give a specific name to each tier.
Tiering is a concern for large academic medical centers like UPMC, and for patients who prefer UPMC doctors. As a result of continuously driving medicine forward, UPMC makes investments in new technology, innovative treatment protocols, groundbreaking research, and training future clinicians, which can result in UPMC doctors’ being placed by an insurer in a tier that is more costly to patients.
You might also like…
What Is Steering?
Steering is a health insurer’s use of tiered benefit levels and their associated out-of-pocket costs to members to incentivize members to use particular providers in the network. In the example above, the difference in out-of-pocket costs ($10 versus $50 copay for an office visit) may be important when you’re choosing a provider, especially when you consider the impact with multiple family members over the course of a year. The insurer thus “steers” its members to certain providers and away from others.
If you have a tiered plan, and your preferred providers are typically in a tier that is more expensive to you, you may want to evaluate your options during your next open enrollment period.
Questions about your current policy and coverage, including when you can make changes, are best directed to your employer’s benefits or human resources representative (if you receive health care through your job). You can also call the customer service number on the back of your insurance card.
I Have Highmark Insurance and Prefer UPMC Providers; Will I Pay More to See Them?
UPMC and Highmark have an agreement that provides most Highmark members with in-network access to all UPMC doctors, hospitals, and services in western Pennsylvania.
As part of the new agreement and to ensure that patients are not caught in the middle, Highmark cannot charge its members who have full, in-network access to UPMC more out-of-pocket to go to UPMC providers than to Allegheny Health Network providers.
UPMC also continues to accept most major insurance plans, including Aetna, Cigna, United Healthcare, and UPMC Health Plan.
If you have questions about accessing UPMC, please call our helpline at 1-855-646-8762.
To make an appointment with a UPMC doctor, please call 1-800-533-8762.
A $23 billion health care provider and insurer, Pittsburgh-based UPMC is inventing new models of patient-centered, cost-effective, accountable care. The largest nongovernmental employer in Pennsylvania, UPMC integrates 92,000 employees, 40 hospitals, 700 doctors’ offices and outpatient sites, and a 4 million-member Insurance Services Division, the largest medical insurer in western Pennsylvania. In the most recent fiscal year, UPMC contributed $1.4 billion in benefits to its communities, including more care to the region’s most vulnerable citizens than any other health care institution, and paid more than $800 million in federal, state, and local taxes. Working in close collaboration with the University of Pittsburgh Schools of the Health Sciences, UPMC shares its clinical, managerial, and technological skills worldwide through its innovation and commercialization arm, UPMC Enterprises, and through UPMC International. U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside among the nation’s best hospitals in many specialties and ranks UPMC Children’s Hospital of Pittsburgh on its Honor Roll of America’s Best Children’s Hospitals. For more information, go to UPMC.com.