FLASH: Simplete Provider Tiers Affect Out-Of-Pocket Costs

Simplete plans are tiered health plans that offer Medicare and commercial members flexibility with out-of-pocket costs and provider choices. Members will typically have lower out-of-pocket costs at the time of service when they see Tier 1 providers. 

Please make sure you’re charging the correct copay amount based on which tier you’re on for a member’s Simplete plan.

Providers within the same practice might be on two different tiers. For example, a physician might be a Tier 1 provider, but a physician assistant working under them might be a Tier 2 provider. Always make sure you’re charging the correct copay amount for the specific provider the member sees. 

To check which tier a provider is on:

• Log in to Your Health Alliance for providers.
• Go to the Attach to Member tab to look up the member’s plan details.
• Choose “View Member Details,” then “Provider Directory.”
• Search for the provider and see which tier is listed.

We recommend doing this ahead of time so you’re prepared to charge the correct amount when the member arrives.

If you need helping finding tier information, please call Customer Service at 1-800-851-3379, option 3. Members can also find provider tier information on YourHealthAlliance.org.

Here’s an overview of the Simplete plan structures.

Medicare Simplete Plans

• Simplete 1: One tier of in-network coverage and providers.
• Simplete 2: Two tiers of in-network coverage and providers.
• Simplete 3 (POS): Three tiers of coverage and providers, including out-of-network benefits.

Simplete Memorial, Small Group Plans

• HMO Two Tier: Two in-network levels of coverage and providers, but no out-of-network coverage besides ER and urgent care.
• POS Three Tier: Two in-network levels of coverage and providers, plus one out-of-network level of coverage.

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