Tier assignments for Harvard Pilgrim Health Care’s ChoiceNet HMO and PPO plans take effect on Jan. 1, 2025. Last month Harvard Pilgrim mailed letters notifying physician groups and hospitals of their tier assignments for these products.
ChoiceNet HMO and PPO are tiered network plans for which member cost sharing falls into one of three tiers, as determined by the provider’s tier assignment. Point32Health determines 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, Point32Health utilizes 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 measures are unavailable, tiers are based solely on health status adjusted total medical expenses or relative prices, or both.
Please note that participation in Harvard Pilgrim’s limited Focus Network – MA HMO is determined by ChoiceNet hospital tier assignments. (Tier 3 hospitals are not included.) Some hospitals and affiliated physicians may no longer participate in Focus Network – MA HMO and some may newly participate in Focus Network – MA HMO as of Jan. 1, 2025 due to their ChoiceNet tier assignments.
Harvard Pilgrim’s Provider Directory currently displays ChoiceNet tiers for providers for the current plan year. As of Oct. 1, 2024, members will also be able to view ChoiceNet provider tiers for the upcoming 2025 plan year.
For more information about the methodology used to determine provider tiers, please see the Fast Facts for Hospital Administrators and Professional Providers in the Tiered Network Product Resources section of Harvard Pilgrim’s provider website.