Other Prohibited Clauses
Used to prevent health plans from encouraging their members to utilize more cost-effective or higher quality providers.
Example of beneficial activity prevented by these clauses:
Employer to employee: Hospital A is in our network, but we prefer that you visit hospital B, which has higher quality scores and lower copays.
Used to prevent employers from developing benefit plans that encourage their employees to incentivize the use of especially high-quality/low-cost providers by providing employees with lower cost-sharing or out-of-pocket expenses if they use that subset.
Example of anti-tiering clause:
If you visit hospital A, we will waive your deductible and any other out-of-pocket expenses. If you visit any other hospital in our network, your normal $1,000 deductible applies.
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