Keystone Health Plan East HMO plans are available to individuals and families who live in Southeastern Pennsylvania. We help you compare the most affordable Independence Blue Cross policies on and off the Exchange and easily apply for coverage. If you reside in the counties of Bucks, Montgomery, Chester, Philadelphia or Delaware, you can purchase private or small business benefits through our website. Services also extend to New Jersey and Delaware.
Pa Keystone HMO plans allow you to organize your medical treatment through a primary care provider (pcp). With almost 21,000 network physicians available, it’s easy to find a doctor, specialist, hospital, or other medical facility that’s located within minutes of your work or residence. Currently there are six available options which include one Platinum, two Gold, two Silver and a Bronze.
HMO Vs. PPO
These six plans are offered through the Pa Marketplace and are eligible for the federal subsidy, which began in 2014. You choose a primary care physician that is typically your first contact if you need treatment. If specialized or emergency aid is needed, you are referred to other providers within the network. Deep discounts are usually provided when you stay “in-network.” ER expenses are an exception, since often you need immediate aid and can’t choose the facility.
Treatment outside of the network often results in higher deductibles and/or out-of-pocket expenses. When scheduling surgeries or procedures, it’s important to verify that all of your treatment will be performed by in-network providers. Typically, verification can be completed online or by directly asking the physician or facility.
Note: If you are over age 65 and/or eligible for Medicare, you can compare the best Medigap plans in Pennsylvania since you would not need an “under-65” policy. “Advantage” options are also available, which usually eliminate most of the premium. Part D (prescription) benefits are also available.
Naturally, the higher the deductible (Bronze) or copay you select, the lower the premium will be. And there are plenty of available providers to find in the area. Skipping almost all paperwork when a claim is filed is a very popular feature. You also can change from a current pcp to another at any time. There are are no fees or charges and the process is very quick.
There are also numerous PPO plans that are also available. Typically, out-of-pocket costs are higher, although you do not need to have a pcp to coordinate and oversee your treatment. There is a wider selection of physicians, specialists and hospitals to utilize, although once again, if you stray away from the provider list, you pay much more. Also, PPO coverage generally costs more than HMO coverage.
The available policies for individuals and families are Platinum, Gold, Gold Proactive, Silver, Silver Proactive, and Bronze. The Platinum plan is the most expensive option while the Bronze, which features higher out-of-pocket expenses, is the least expensive plan.
Each of these six plans (discussed in detail below) contains 10 “Essential Health Benefits” (required by law). Specifically, these benefits are: preventive and wellness, pediatric treatment (including dental), hospitalization, mental illness and substance abuse, lab services, ER care, rehabilitation and habilitation, prescriptions, and maternity. Of course, there are many other coverages in addition to these 10 benefits.
“Proactive” plans are divided into three “tiers” (preferred, enhanced and standard) that allow you to choose cost-saving providers. The preferred tier physicians and facilities cost the least while the standard tier providers cost the most. Often, you can choose the level of pricing, although all providers must meet strict Keystone standards.
This concept allows consumers the opportunity to save money on most treatment, but still receive treatment from providers that have to meet the highest possible quality standards. And you can mix and match different services with different tiers.
Although preventive services, mental illness, emergency room treatment and most therapies have identical tiers, other services will have multiple tiers. Upon request, we will provide an online link that allows you to view and compare different options in your area. About half of all doctors are in the preferred tier and any adjustments are made once per year.
It’s important to note that physicians with multiple locations can have more than one assigned tier. For example, a specific location may have lower expenses, and thus charge a lower price than another office location in a “high-rent” district.
Six HMO Plans
More specific details about each of the six available HMO plans are listed below:
Platinum – No deductible or coinsurance highlights this “Cadillac” plan. The maximum out-of-pocket cost is $3,000 for an individual and $6,000 for a family. Office visit/specialist copays are $15 and $30 respectively, and brand-name drugs are only subject to a $30 copay. If you are hospitalized, the admission fee is $400 per day (not to exceed $2,000). The ER charge is $250.
Gold – The out-of-pocket expenses are significantly higher than the Platinum plan ($6,100 and $12,200) as are the copays ($25 and $60) for primary care physicians and specialists. The hospital admission copay is bumped up to $750 and prescription copays are also higher.
Gold Proactive – There are no deductibles although the maximum out-of-pocket expense is $6,350 per person and $12,700 per family. Since it is a tiered plan, office visit (PCP) copays are $15, $30 or $45, depending upon the tier of physicians you choose. Specialist copays are $40, $60 and $80, once again, depending upon the tier you select.
Your in-hospital daily stay maximum is only $350 in the preferred tier, but $1,100 in the standard tier. Maternity, outpatient expenses, and outpatient surgeries all have major variances between tiers. Also, retail clinics will receive the preferred tier pricing with the exception of Walgreens Healthcare Clinics, which are always billed in the standard tier. A comparison of all three Gold plans (2 HMO and 1 PPO) are found below:
Silver – The Silver plan, unlike the Gold and Platinum options, does have a deductible ($2,000 individual and $4,000 family). There is also 30% coinsurance and $35/$70 office visit copay combinations. The generic drug copay is $10, so in many situations, paying for the prescription yourself results in minor savings. Retail brand and non-formulary drugs, however, have a 50% coinsurance although your cost is limited to $250.
Silver Proactive – There is no deductible in the “preferred” tier, which provides a huge incentive to utilize that specific network. Otherwise, a $3,000 deductible applies. Copays are $20 and $45 for office visits and a $400 maternity and/or hospital inpatient per day charge applies (maximum five copays). Once again, if you use the enhanced or standard tiers, a deductible applies and the per-day expense substantially increases.
Bronze – $6,000 individual ($12,000 family) deductible with 0% coinsurance make this plan one of the cheapest Exchange policies available. Office visit copays are $40 and $80 respectively with a low $40 copay to retail clinics. 30 occupational or physical therapy visits are allowed with a $60 copay.
Keystone HMO Plans Provide Comprehensive Benefits
More than 50,000 national and local locations can be used to fill or renew your generic and non-generic RX needs. Both mail-order and direct pick-up are available. “FutureScripts,” an independent company affiliated with IBX, administers the prescription program for all members. A unique ID card is provided to streamline the process when you visit any location.
“FutureScripts” is included on the HMO Bronze, HMO Silver Proactive and HMO Gold Proactive plans. Important To Note: Walgreens and RiteAid are considered “outside of network” with FutureScripts and you will incur higher out-of-pocket expenses if you use these pharmacies. However, $4 generic drugs are offered on all policies except the Platinum option.
There is no maximum annual or lifetime benefit, so you can not “run out” of prescription coverage. However, copays, deductibles and out-of-pocket expenses will vary, depending on the plan you choose. Naturally, the Platinum and Gold plans (both HMO and PPO) will have more inclusive coverage than Bronze Metal plans, including copays rather than deductibles. Birth control (oral and injectable contraceptives) are considered “preventive” and are covered.
Yes…Some medications are free, since they are considered “preventive medications,” and no copay or deductible applies. Many pharmacies will provide these drugs in person, and through mail order. The following classes of drugs qualify:
Vitamin D supplements to Seniors over the age of 65.
Tobacco interventions for current smokers.
Folic acid supplements for females that are either pregnant or contemplating having a baby.
Iron supplements for children at risk.
Breast cancer chemotherapy preventive medications.
Fluoride supplements for children (Specific age limits apply).
Prior to 2014, many individual plans either excluded maternity benefits, limited coverage, added a waiting period (often as much as 270 days) or charged thousands of dollars extra to add it as a rider. For all Marketplace tier policies (including Keystone Health Plan East), these exclusions and extra charges have been eliminated. In fact, during Open Enrollment, if you are pregnant, you can secure coverage in 15 days.
In addition to complete (100%) preventive benefits before and after delivery, prenatal visits (including preconception) are covered. Your gynecological history including birth control, obstetric history, current medications and existing allergies will be initially discussed. Vaccinations, lifestyle information and genetic screening may also be covered, if relevant to your situation. First, second and third trimester visits will be part of the benefit package.
Additional benefits available (if needed) include alcohol addiction screening, tobacco counseling and cessation programs, iron deficiency screening, infection screening and gestational diabetes prevention and screening. A glucose-screening test is quite routine during pregnancy, since it is one of the most common medical issues for expectant mothers.
Breastfeeding support and counseling (and supplies) is typically partially or fully covered. Lactation support and rental of breast pumps is also a covered benefit, subject to some restrictions and limitations. We also utilize this pregnancy resource that provides in-depth information on a week-by-week and trimester basis.
Enrolling is much easier than the initial (2014) rollout of ACA plans. Often the process took between 45 minutes and two hours. That was too long! The total application time should now take between 15 and 20 minutes. We have simplified the entire procedure through a combination of updated software and the streamlined ACA application. If you aren’t eligible for the federal subsidy, the process will actually be quicker!
Many policies have changed from last year, including shrinking provider networks, additional preventive benefits, and tier designations. To ensure you apply for the most suitable policy and maximize your subsidy (if applicable), we always recommend calling or emailing us before you enroll. A quick 10-minute review could potentially save you thousands of dollars,
Included in your membership are programs that promote wellness and help you manage your treatment in the most effective and least costly manner, especially if you have chronic conditions. Coaches and nurses are available 24/7 and assistance with critical medical decisions are provided. “Lifestyles” programs are also provided that include valuable discounts for many products and memberships.
January 27 2015 – “Blue Insider” is now available to policyholders. It became effective yesterday and will offer a multitude of events, attractions, and products at a substantial discount (up to 60%). By utilizing their exclusive “Working Advantage” portal, members can save money on the following items:
Movies, zoos, theatrical events, concerts, sporting events, restaurants, and parks. Also, many consumer products will be discounted including books, electronics, food establishments, and clothing.
February 9 2015 – Through January 15th, more than 175,000 persons had enrolled in Exchange plans in the five-county Keystone service area. More than 400,000 persons have purchased policies in the entire state as of February 1. Silver and Bronze-tier plans continue ti be the most popular policies and most applicants receive some type of federal funding to help lower the premium.