Keystone Health Plan East

 

    

      

Keystone Select II Summary of Benefits

 

 

 

 

  

Benefit

Benefits and Services

Coverage

Doctor Visits

Office visits to your primary care physician

$15 Copayment

 

Home visits by your primary care physician

$25 Copayment

 

Non-routine after hours visits to your primary care physician

$25 Copayment

 

Office visits to referred specialists

$25 Copayment

Preventive Health
Services

Periodic health assessment

$15 Copayment

 

Immunizations (except for travel or employment)

$15 Copayment

 

Routine gynecological care (no referral required)

$25 Copayment

 

Mammography (no referral required)

Covered 100%

 

Well-baby/Well-Child care

$15 Copayment

Maternity

Obstetrical care (including pre- and postnatal care)

Covered with a $25 copayment for first visit. Subsequent visits to your OB/GYN covered 100%. Inpatient admission covered with a $125 copayment per day up to $625 maximum per admission (waived if readmitted within 90 days of discharge for same diagnosis)

 

Newborn care (both doctor and hospital)

Covered 100%


Hospital Services*

Unlimited inpatient stay

$125 copayment per day up to $625 maximum per admission (waived if readmitted within 90 days of discharge for same diagnosis)

 

Surgery

Covered 100%

 

Anesthesia

Covered 100%

 

Drugs and medication

Covered 100%

 

Inpatient doctor care

Covered 100%

 

General nursing care

Covered 100%

 

Administration of blood

Covered 100%

 

Organ transplantation, non-experimental

Covered 100%

Emergency Care

Treatment in hospital emergency room

Covered with a $50 copayment (which is waived if you are admitted to the hospital)

 

Ambulance service

Covered 100% when medically necessary

Specialized Services

Allergy testing and treatment

Covered 100%**

 

Diagnostic, Laboratory and X-ray services

Covered 100%

 

Short-term rehabilitation therapy* (including Occupational, Physical and Speech Therapy)

Covered 100%. Up to 60 consecutive days per condition covered, subject to significant improvement

 

Respiratory Therapy*

Covered 100%

 

Chemotherapy*

Covered 100%

 

Radiation Therapy*

Covered 100%

 

Vision Care, including screening, eye exams and refractions

Covered 100% once every two calendar years**

 

Hearing Screening

Covered 100%**


Specialized Services

Skilled nursing facility services, as specified*1

Covered 100% up to 180 days per calendar year

 

Outpatient Surgery*

$100 copayment (facility)

 

Durable Medical Equipment*

Rental or purchase covered 100% when authorized by Primary Care Physician and pre-approved by KHPE

 

Home Health Care*

Covered 100%

 

Dialysis*

Covered 100%

 

General nursing care

Covered 100%

 

Mental Health Care, as specified

20 outpatient visits per calendar year covered with a $35 copayment per visit. 35 inpatient days per calendar year covered with a $125 copayment per day up to $625 maximum per admission*

 

Serious Mental Illness

60 outpatient days/visits per calendar year covered with a $35 copayment per visit. 30 inpatient days per calendar year covered with a $125 copayment per day up to $625 maximum per admission*

 

Treatment for Substance Abuse

60 outpatient visits per calendar year covered with a $25 copayment per visit. 30 inpatient days per calendar year covered with a $125 copayment per day up to $625 maximum per admission*
(lifetime limits of 120 outpatient visits and 90 inpatient days)

 

Annual copayment maximum

$1,500 per person or
$3,000 per family annually

*  Pre-authorization required

** Office visits subject to copayment

1   Inpatient Hospital copay applies if admitted without prior hospital stay.

Benefits and Services Not Covered                                          

As with all health insurance plans, KHPE’s coverage excludes certain services. Those not covered by KHPE include, but are not limited to, the following:

ü     Services not medically necessary

ü     Services not provided or referred by your primary care physician, except in emergencies

ü     Experimental and investigational services or items

ü     Routine physical exams for non-preventive purposes such as insurance or employment applications, college, or premarital examinations

ü     Service or supplies payable under Workers’ Compensation, Motor Vehicle Insurance, or other legislation of similar purpose

 

ü     The cost of services for which another party has primary responsibility

ü     Care for military service connected disabilities when appropriate government facilities are reasonably accessible

ü     Long-term rehabilitative therapy

ü     Non-medical, rehabilitative services for the treatment of substance abuse in an acute care hospital

ü     Hearing Aids

 

ü     Radial Keratotomy

ü     Custodial or domiciliary care

ü     Weight loss programs except when provided through Healthy LifestylesSM1 programs

ü     Personal or comfort items not medically necessary, such as air conditioners, humidifiers, telephone or similar items

ü     Normal deliveries outside the KHPE service area within 30 days of the estimated delivery date

 

ü     Contraceptive devices and birth control pills, except by additional benefit rider

ü     In-vitro fertilization, embryo transplant, and ovum retrieval

ü     Reversal of voluntary sterilization

ü     Transsexual surgery

ü     Cosmetic surgery except for those services which occurred while a member of KHPE and are performed to restore bodily function or correct deformity resulting from disease, recent trauma or previous therapeutic process

 

ü     Immunization for travel or employment

ü     Prescription drugs and medications, except as required by law or by additional rider

ü     Whole blood or blood plasma

ü     Treatment for temporomandibular joint syndrome (TMJ)

ü     Care of the feet, unless medically necessary

 

ü     Services required by a member who is an organ donor

ü     Dental care including, but not limited to, orthognathic surgery, unless as a result of an accident

ü     Treatment for injuries sustained while committing a felony

 

The plan outlined in this summary represents only a partial listing of benefits. This managed care plan may not cover all your health care expenses. Read your member handbook carefully to determine which health care services are covered. If you need more information, please call 215-241-2240 (if calling within Philadelphia) or 1-800-227-3115 (outside Philadelphia).

 

003578
8/01


WWW.IBX.COM 

Independence Blue Cross and Keystone Health Plan East (KHPE) are independent licensees of the Blue Cross and Blue Shield Association.

Benefits underwritten or administered by KHPE.