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Tier 1

The South Dakota State Employee Benefits Program continues to look for ways to save both members and the plan money. Tier 1 is a way for you to save money on certain services performed at approved Tier 1 facilities. We created preferred relationships with specific providers and facilities, to offer you and your family the best cost associated with these services.

Important Tier 1 Information

Understanding Tier 1

Tier 1 is a benefit for you and all covered members of the health plan that will reduce the cost associated with certain cardiac, orthopedic, bariatric, renal care and gastroenterology services.

Bariatric Services
Weight Reduction Surgery Lap-band, Gastric Sleeve
and Roux-en-Y

Cardiac
Balloon Angioplasty
Cardiac Catheterization
Heart Bypass Surgery
Pacemakers

Gastroenterology
Colonoscopy (does not apply to preventive colonoscopies)
Gallbladder
Hernia Repair
Upper GI and/or Endoscopies

Orthopedic
Back & Neck Surgery (including spinal fusion)
Total Knee Replacement
Total Hip Replacement

Renal Care
Dialysis
Kidney Transplants

Tier 1 is based on the service, facility and provider. To receive the highest level of benefit, you must have a Tier 1 service performed at an approved Tier 1 facility by an approved Tier 1 provider.

To view the complete list of Tier 1 services, facilities and providers, click here.

All Tier 1 services require pre-authorization by Health Management Partners (HMP). HMP will assist you with the pre-authorization process. If you have questions, call HMP at 866.330.9886.

Savings

If you have a Tier 1 service performed at an approved Tier 1 facility by an approved provider, you will have a lower out-of-pocket maximum. The out-of-pocket maximum is the most you will pay for services during a fiscal year.

If you have a Tier 1 service at a Non-Tier 1 facility, you will have a higher out-of-pocket maximum. The out-of-pocket maximum is determined by which health plan you are currently enrolled in.

It's Your Choice

You can choose to utilize a Tier 1 facility or Non-Tier 1 facility. If you want to have a Tier 1 service at a Non-Tier 1 facility, you can but you will pay the higher out-of-pocket maximum. DAKOTACARE can also help you understand how the health plan covers Tier 1 services. If you have questions, call DAKOTACARE customer service at 877.573.7347, option 1.

The chart below shows the difference in cost between Tier 1, Non-Tier 1 and Out-of-Network based on your health plan.

FY17 Coverage for Tier 1

$750 Deductible Plan

$1,800 Deductible Plan with HSA

Tier 1*

Non-Tier 1

Tier 1*

Non-Tier 1

  • $750 per person Deductible
  • 25% Coinsurance
  • $3,600 Out-of-Pocket maximum
  • $8,125 Out-of-Pocket maximum per family of three or more
  • $750 per person Deductible
  • 25% Coinsurance
  • $5,350 Out-of-Pocket maximum
  • $10,200 Out-of-Pocket maximum per family of three or more
  • $1,800 per person Deductible
  • $3,600 family Deductible
  • 25% Coinsurance
  • $3,600 Out-of-Pocket maximum single 
  • $8,125 Out-of-Pocket maximum per family
  • $1,800 per person Deductible
  • $3,600 family Deductible
  • 25% Coinsurance
  • $5,350 Out-of-Pocket maximum single 
  • $10,200 Out-of-Pocket maximum per family

 

* To receive the highest level of benefit, you must have a Tier 1 service performed at an approved Tier 1 facility by an approved Tier 1 provider.

 

Tier 1 Services, Facilities, and Providers
Services Facilities and Providers
Cardiac
Heart Bypass Surgery, Cardiac Catheterization, Balloon Angioplasty, Pacemakers

Cardiac
Sanford-Must be a Sanford provider


Rapid City Regional-Must be a DAKOTACARE network provider

Orthopedic
Back & Neck Surgery (including spinal fusion), Total Knee Replacement,
Total Hip Replacement

Orthopedic
Sanford-Must be a Sanford provider


Avera St. Mary’s in Pierre-Must be an Avera provider


Rapid City Regional-Must be a DAKOTACARE network provider


Spearfish Regional (excludes back & neck surgery)-Must be a DAKOTACARE network provider

Black Hills Surgical Hospital-Tier 1 providers include: Robert Ingraham, MD; Stuart rice, MD; Tim Watt, MD; Jonathan Wilson, MD; Clark Duchene, MD; Stephen eckrich, MD; Stuart Fromm, MD; Steven giuseffi, MD; Michael Kadrmas, MD; David lang, MD; Jeff Marrs, MD; Samuel (luke) Mortimer, MD; lew Papendick MD; rand Schleusener, MD; and robert Woodruff, MD; Margaret Chilvers, MD; Jason LaBrie, DO; Emmet McEleney, MD; Aaron Dykstra, MD; Zachary Jager, MD

Bariatric
Weight Reduction Surgery Lap-band, Gastric Sleeve, and Roux-en-Y

Must be enrolled and approved through the Bariatric Management program with Health Management Partners

Bariatric
Sanford-Must be a Sanford provider

Rapid City Regional-Must be a DAKOTACARE network provider

Renal Care
Kidney Transplant and Dialysis
Renal Care
Avera-Must be an Avera provider
Gastroenterology
Colonoscopies (does not apply to preventive colonoscopies), Upper GI and/or Endoscopies, Hernia Repair, Gallbladder

Gastroenterology
Sioux Falls Specialty Hospital (SFSH)-Tier 1 providers include: Mark Milone, Chandar Singaram, Don Wingert, Dave Strand, Bradley Thaemert, Scott Baker, Mike Person, Michael Bauer, Dr. David Knudson

Avera St. Mary’s in Pierre-Must be an Avera provider

Rapid City Regional -Must be a DAKOTACARE network provider

Spearfish Regional-Must be a DAKOTACARE network provider

Black Hills Surgical Hospital-Tier 1 providers include: David Fromm, MD and Lee Trotter, DO

 

 

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