Keystone HMO Gold Proactive
33871PA0040005
Gold
HMO
Keystone HMO Gold Proactive is a Gold HMO plan by Independence Blue Cross.
Locations
Keystone HMO Gold Proactive is offered in the following counties.
Plan Overview
This is a plan overview for 2022 version of Keystone HMO Gold Proactive 33871PA0040005.
| Insurer: | Independence Blue Cross |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 33871PA0040005 |
Cost-Sharing Overview
Keystone HMO Gold Proactive offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Keystone HMO Gold Proactive includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | 8550 | 8550 per person | $17100 per group |
| Deductible: | 0 | 0 per person | $0 per group |
| Coinsurance: | 0 per person | $0 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Keystone HMO Gold Proactive will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | ||
| Out-of-Network Deductible: |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | 0 |
| Copayment: | 800 |
| Coinsurance: | 0 |
| Limit: | 20 |
| Deductible: | 0 |
| Copayment: | 2400 |
| Coinsurance: | 0 |
| Limit: | 20 |
| Deductible: | 0 |
| Copayment: | 900 |
| Coinsurance: | 40 |
| Limit: | 0 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Keystone HMO Gold Proactive?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Keystone HMO Gold Proactive offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Diabetes, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol |
| Notice Pregnancy: | Yes |
| Referral Specialist: | Yes |
| Specialist Requiring Referral: | Referrals are required for all services except: Emergency Services, OB/GYN, Mammograms, Inpatient Hospital Services, Dialysis services performed in a Participating Facility or by a Participating Professional Provider, Nutrition Counseling and Diabetic Education Program |
| Plan Exclusions: | Acupuncture, Bariatric Surgery, Cosmetic Surgery, Dental Care (Adult), Hearing Aids, Long-term Care, Private Duty Nursing, Routine eye care (Adult), Routine foot care, Weight Loss programs, Non-emergency care when traveling outside the U.S., Most coverage provided outside the U.S. |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Keystone HMO Gold Proactive covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | |
| Out of Service Area Coverage: | No |
| Out of Service Area Coverage Description: | |
| National Network: | No |
Additional Benefits and Cost-Sharing
Keystone HMO Gold Proactive includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Bariatric Surgery Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Abortion for Which Public Funding is Prohibited Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Emergency Transportation/Ambulance Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Mental/Behavioral Health Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Eye Glasses for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 1 Item(s) per Year |
| Mental/Behavioral Health Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Diabetes Education Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Non-Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This benefit has a dollar maximum per prescription. See plan brochure. |
| X-rays and Diagnostic Imaging Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Substance Abuse Disorder Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Inherited Metabolic Disorder – PKU Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Additional EHB Benefit |
| Orthodontia – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Dental Check-Up for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 1 Exam(s) per 6 Months |
| Generic Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has low cost generics, mandatory generics and a Preferred Pharmacy Network. See plan brochure. |
| Dialysis Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
| Rehabilitative Speech Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 30 Visit(s) per Benefit Period |
| Transplant Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Basic Dental Care – Child Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Routine Eye Exam (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Telemedicine Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Additional EHB Benefit |
| Treatment for Temporomandibular Joint Disorders Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Imaging (CT/PET Scans, MRIs) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 30 Visit(s) per Benefit Period |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. This plan may have lower cost share for Telemedicine visits through participating in-network providers. |
| Specialty Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This benefit has a dollar maximum per prescription. See plan brochure. |
| Major Dental Care – Child Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Major Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Allergy Testing Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Chemotherapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
| Outpatient Rehabilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 30 Visit(s) per Benefit Period Rehabilitation services include physical therapy (PT), occupational therapy (OT), and speech therapy. PT/OT (30 visits combined); Speech Therapy (30 visits).Substantially Equal |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. See plan brochure. |
| Radiation Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
| Hospice Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Respite Care: If the Member were to receive Hospice Care primarily in the home, the Member’s primary caregiver may need to be relieved, maximum of seven days every six months. In such a case, the Health Benefit Plan will provide coverage for the Member to receive the same kind of care. |
| Urgent Care Centers or Facilities Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Primary Care Visit to Treat an Injury or Illness Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. This plan may have lower cost share for Telemedicine visits through participating in-network providers. See plan brochure. |
| Routine Eye Exam for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 1 Exam(s) per Year |
| Outpatient Surgery Physician/Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
| Hearing Aids Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Laboratory Outpatient and Professional Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Reconstructive Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
| Accidental Dental Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Prosthetic Devices Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Nutritional Counseling Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 6 Visit(s) per Benefit Period |
| Acupuncture Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Skilled Nursing Facility Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 120 Days per Benefit Period |
| Home Health Care Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 60 Visit(s) per Benefit Period This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
| Weight Loss Programs Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Basic Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Emergency Room Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Cosmetic Surgery Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Substance Abuse Disorder Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Prenatal and Postnatal Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Your cost is for first OB visit only. Note: This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
| Inpatient Physician and Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. See plan brochure. |
| Specialist Visit Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | The Member’s Primary Care Physician (PCP) provides a Referral, when one is required, to a Participating Professional Provider when their condition requires a Specialist’s Services. Note: This plan has 3 in-network tiers. Your cost share will vary depending on the tier. This plan may have lower cost share for Telemedicine visits through participating in-network providers. See plan brochure. |
| Routine Dental Services (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Habilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 30 Visit(s) per Benefit Period Habilitation services include physical therapy (PT), occupational therapy (OT), and speech therapy. PT/OT (30 visits combined); Speech Therapy (30 visits). Visit limits do not apply to services that are prescribed for Mental/Serious Mental Illness Health Care, and Treatment of Alcohol or Drug Abuse and Dependency.Substantially Equal |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. See plan brochure. |
| Private-Duty Nursing Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Long-Term/Custodial Nursing Home Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Dental Anesthesia Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Additional EHB Benefit |
| Orthodontia – Child Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Orthodontic treatment must be Medically Necessary.Substantially Equal |
| Diabetes Care Management Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This benefit pertains to Diabetes Education.Additional EHB Benefit |
| Delivery and All Inpatient Services for Maternity Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
| Routine Foot Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Preventive Care/Screening/Immunization Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Age and frequency schedules may apply. |
| Well Baby Visits and Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Age and frequency schedules may apply. |
| Chiropractic Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 20 Visit(s) per Benefit Period |
| Infertility Treatment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Artificial Insemination is covered: Facility services provided by a Participating Facility Provider and services performed by a Referred Specialist for the promotion of fertilization of a female recipient’s own ova (eggs). Note: This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
| Durable Medical Equipment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Infusion Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | This plan has 3 in-network tiers. Your cost share will vary depending on the tier. |
Free Preventive Services
There is no copayment or coinsurance for any of the following Keystone HMO Gold Proactive preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Ready to sign up for Keystone HMO Gold Proactive?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904