Effective January 1, 2015, there will be several changes to
our current Medicare Advantage HMO and PPO plans including the introduction of
a new $0 premium plan – Keystone 65 Basic HMO with Rx. Keystone 65 Basic
HMO includes a $450 deductible that applies to certain services, including
durable medical equipment, inpatient hospital, inpatient mental health,
outpatient surgery, and prosthetics. The plan will be available to Medicare
beneficiaries in Bucks and Philadelphia counties.
Medicare Advantage HMO and PPO members should have already received their
2015 Annual Notice of Changes/Evidence of Coverage. They will have
until December 7, 2014, to make any changes to their health care plans.
The Member Help Team, Independence?s Medicare Customer Service program, will
continue to ensure that our Medicare Advantage HMO and PPO members receive
special care and attention. This dedicated service team works closely with
other areas within Independence — as well as with billing agencies,
pharmacies, and physician offices — to respond to member concerns quickly
and resolve their issues the first time around. Members can access the Member
Help Team by calling the Customer Service number on the back of their ID
card.
The following tables highlight some of the Medicare Advantage HMO and PPO
benefits changes for 2015. Please note that this is a list of our significant
benefits changes, not a comprehensive list of all benefits changes.
Contact your Network Coordinator if you have any questions.
Medicare Advantage HMO and PPO monthly plan premiums
Plan type
Keystone 65 Basic HMO
Keystone 65 Select HMO
Keystone 65 Preferred HMO
Personal Choice 65SM PPO
Medical only
Not available
Philadelphia/Bucks: $0
Chester/Delaware/ Montgomery: $25
Philadelphia/Bucks: $135
Chester/Delaware/ Montgomery: $194
Philadelphia/Bucks: $155
Medical with Choice Program (hearing, dental, vision)
Not available
Philadelphia/Bucks: $7
Chester/Delaware/ Montgomery: $32
Not available
Not available
Medical with Rx
Philadelphia/Bucks: $0
Philadelphia/Bucks: $25
Chester/Delaware/ Montgomery: $64
Philadelphia/Bucks: $190
Chester/Delaware/ Montgomery: $263
Philadelphia/Bucks: $240
Chester/Delaware/ Montgomery: $113
Medical with Rx and Choice Program
Philadelphia/Bucks: $7
Philadelphia/Bucks: $32
Chester/Delaware/ Montgomery: $71
Not available
Not available
Medicare Advantage HMO and PPO benefits highlights
Service category
Keystone 65 Basic HMO
Keystone 65 Select HMO
Keystone 65 Preferred HMO
Personal Choice 65SM PPO
Primary care physician visits
$20 copay per visit
$20 copay per visit
$10 copay per visit
$15 copay per visit
Specialist visits
$50 copay per visit
$45 copay per visit
$40 copay per visit
$40 copay per visit
Emergency room (U.S. and worldwide)
$65 copay per visit (not waived if admitted)
$65 copay per visit (not waived if admitted)
$65 copay per visit (not waived if admitted)
$65 copay per visit (not waived if admitted)
Urgent care center
$30 copay (not waived if admitted to the hospital)
$30 copay (not waived if admitted to the hospital)
$20 copay (not waived if admitted to the hospital)
$20 copay (not waived if admitted to the hospital)
Outpatient surgery
$150 copay per visit for ambulatory surgical centers, after the deductible is
met;
$300 copay per visit for outpatient hospital facility, after the deductible is
met
$150 copay per visit for ambulatory surgical centers;
$400 copay per visit for outpatient hospital facility
$125 copay per visit for ambulatory surgical centers;
$400 copay per visit for outpatient hospital facility
$150 copay per visit for ambulatory surgical centers;
$400 copay per visit for outpatient hospital facility
Inpatient hospital
$270 per day for days 1 ? 7 ($1,890 per stay maximum) per admission, after the
deductible is met
$270 per day for days 1 ? 7 ($1,890 per stay maximum) per admission
$240 per day for days 1 ? 7 ($1,680 per stay maximum)
$900 per admission;
unlimited days per admission
Dental, vision, hearing (non-Medicare covered)
Benefits available for additional $7 per month in plan premiums through the
Choice Program
Benefits available for additional $7 per month in plan premiums through the
Choice Program
Dental: $20 copay for exams and cleanings once every 6
months
Vision: $40 copay once every two years; covered up to $100
every 2 years for eyewear
Hearing: $40 copay once every 3 years; covered up to $500 for
hearing aids (two aids) every 3 years
Not covered
Using in-network retail clinics
Medicare Advantage HMO and PPO members who go to a network retail clinic for
preventive and urgent care will pay the same copayment amount as for a primary
care physician office visit. A retail clinic is a type of walk-in clinic
located in a supermarket, pharmacy, or retail store where members can receive
preventive care or treatment for uncomplicated minor illnesses in a
non-emergency setting. Retailers include Walgreens (Healthcare Clinics), CVS
(MinuteClinic®), and Walmart.
Since the types of services vary by location, members are encouraged to call
ahead to see if the retail clinic they want to use has the services they need
(e.g., some retail clinics do not offer urgent care or flu shots).
Note: Not all retail clinics are a part of our network. To see if a
retail clinic is part of the Independence network, members can use the Find a Provider tool. They can also call
the Member Help Team for more information using the number on the back of their
member ID card.
MinuteClinic, L.L.C. is a Delaware corporation,
accredited by The Joint Commission as a retail health provider licenses to
operate retail-based health clinics.