Group Insurance Commission tiering

Effective July 1, 2019

The Group Insurance Commission (GIC) offers a Direct Care and Select Care Commercial product to Fallon Health members. It is an Administrative Services Only product, meaning, the GIC is the Plan Sponsor and Fallon Health is the Administrator. Provider tiering was created in an effort to control costs, improve health care quality and promote cost-efficiency.

Fallon tiers the following specialties for both the Direct Care and Select Care plans:

  • Allergy/immunology   
  • Cardiology
  • Dermatology
  • Endocrinology
  • Gastroenterology   
  • General Surgery 
  • Hematology and Oncology   
  • Nephrology
  • Neurology
  • OB/GYN
  • Orthopedic Surgery  
  • Ophthalmology  
  • Otolaryngology
  • Podiatry  
  • Pulmonary disease
  • Rheumatology
  • Urology  

The tiering works as follows:

  • Tier 1 Direct Care and Select Care:  Plan providers participating in Fallon’s limited network plan who meet excellent cost efficiency standards. Members pay the lowest copayment when seeing a Tier 1 specialist.
  • Tier 2 Direct Care and Select Care: Plan providers participating in Fallon’s limited network plan who meet good cost-efficiency standards.  This tier also includes Select Care providers who do not participate in Fallon’s limited network plan and are not contracted through an academic medical center or specialty hospital.  Members will pay the mid-level copayment when seeing a Tier 2 specialist.
  • Tier 3 Select Care: Plan providers who are contracted through an academic medical center or specialty hospital and do not participate in Fallon’s limited network plan. Members will pay a higher copayment when seeing a Tier 3 specialist.
  • Other Direct Care: Members who seek care at a Fallon Peace of Mind provider will pay a Tier 3 copayment.

Ambulatory surgery tiering

Patients who utilize the services of an ambulatory surgery center for eye and gastroenterology procedures vs. the outpatient department at a hospital will pay a lower copayment of $150 at the ambulatory surgery center. The hospital copayment for the same services is $250.

Download the list of ambulatory surgery centers