Keystone 65 HMO

2014 Frequently Asked Questions

Here are some of the most frequently asked questions concerning Keystone 65 HMOs.

  1. How does Keystone 65 HMO compare with a Medicare supplement?
  2. If I chose a Medical-Only option, can I join a different Medicare Part D drug plan?
  3. Why is it important to choose a primary care physician (PCP) when I enroll in Keystone 65 HMO?
  4. How do I know if the medications I take are covered?
  5. I travel a lot. What if I have an emergency?
  6. What if I need to go outside the network area?
  7. When must I see a capitated provider?
  8. Does Keystone 65 HMO cover dental, vision, and hearing visits?
  9. What resources do you have for managing health conditions like asthma?
  10. Do I have to file claims with Keystone 65 HMO?
  11. What if I have Keystone Health Plan East coverage through my employer?
  12. How can I get more information?
  13. How can I get more information on the services provided under the Keystone 65 HMO plan?
  14. Do I qualify for low-income subsidy?
  15. What is the coverage gap (donut hole) phase of coverage?
  16. What are the prescription drug costs in the coverage gap?
  17. What payments count towards your True out-of-pocket costs, or TrOOP?

1. How does Keystone 65 HMO compare with a Medicare supplement?
A Keystone 65 HMO plan provides more coverage than a typical Medicare supplement plan and Original Medicare combined. There’s emphasis on preventive care — with many services covered at no cost to you. What’s more, with Keystone 65 HMO, you can have the added convenience of choosing a plan that includes both your medical and your Medicare prescription drug coverage.

2. If I chose a Medical-Only option, can I join a different Medicare Part D drug plan?
No. If you are considering a Medicare Advantage plan, and you want drug coverage, you must get it through the plan. You cannot join a stand-alone drug plan if you are enrolled in a Medicare Advantage plan. If you are already in a stand-alone drug plan and you enroll in a Medicare Advantage plan, you will be automatically disenrolled from your stand-alone drug plan.

3. Why is it important to choose a primary care physician (PCP) when I enroll?
Because Keystone 65 HMO is a managed-care plan, all your health care must be provided, referred, or authorized by your PCP. The PCP you select from our extensive network — and it may be the doctor you see now — will coordinate your care. This coordination lessens the likelihood that your medications and treatments conflict. You may choose from more than 3,000 PCPs in the Keystone 65 HMO network.

4. If I choose a Keystone 65 HMO plan with Part D prescription drug (Rx) coverage how do I know if the medications I take are covered?
Review the formulary, which is the list of drugs covered by the plan. We have negotiated special prices with drug companies for the medications on our formulary. The savings are then passed on to you when you fill your prescriptions at a network pharmacy.

5. I travel a lot. What if I have an emergency?
When you travel throughout the United States, you are covered for emergency care, out-of-area urgent care, and renal dialysis. When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider. Our plan also covers emergency and urgently needed care outside of the United States and its territories. Call the plan for details if travelling outside the United States. Please note that non-urgently needed care is not covered outside the United States.

6. What if I need to go outside the network area?
You are required to use Keystone 65 HMO plan providers. All health care, other than emergencies or urgently needed services, must be provided or referred by your primary care physician. The use of non-plan providers, except for emergency care, out-of-area urgent care, and renal dialysis, may result in you having to pay for services rendered. Neither Keystone Health Plan East nor Medicare will pay for these services.

7. When must I see a capitated provider?
An HMO Member must see a capitated provider when your primary care physician is responsible for coordinating and arranging most of your health care services. Your PCP has identified specific providers for the following services: radiology, laboratory, physical therapy and occupational therapy. You should check with your PCP if you need specific information.

8. Does Keystone 65 HMO cover dental, vision, and hearing visits?
Depending on which Keystone 65 HMO plan you choose, you may or may not have dental, vision, and hearing coverage. In 2014, the following Keystone 65 HMO plans include dental, hearing, and vision coverage:

  • Keystone 65 Select Medical-Only HMO with Choice Program
  • Keystone 65 Select Rx HMO with Choice Program
  • Keystone 65 Preferred Medical-Only HMO
  • Keystone 65 Preferred Rx HMO

If you choose one of these plans, you’re covered for routine dental exams and cleanings every six months. You’re also covered for routine vision and hearing services — and can get reimbursements for eyewear and hearing aids.

9. What resources do you have for managing health conditions like asthma?
If you have asthma, diabetes, or other chronic condition, you can get the one-on-one support you need to manage your health through the ConnectionsSM Health Management Program. You’ll have access to a Health Coach any time of day or night, seven days a week at 1-800-ASK-BLUE (press 1, then press 2) or 1-888-525-4481 for the speech- and hearing-impaired.

10. Do I have to file claims with Keystone 65 HMO?
No, there is virtually no paperwork. With our automatic claims filing, you don’t need to worry about paperwork unless you use services outside the Keystone 65 HMO network. In most cases, you simply present your Keystone 65 HMO ID card when you receive medical services.

11. What if I have Keystone Health Plan East coverage through my employer?
If you have coverage through your former (or current) employer, Health and Welfare Fund, or an association group, your benefits may vary. Call us toll-free at 1-877-393-6733 (1-877-219-5457 for the speech- and hearing-impaired), from 8 a.m. to 8 p.m., seven days a week for more information. However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.

12. How can I get more information?
Feel free to call us toll-free at 1-877-393-6733 (1-877-219-5457 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. You can also attend one of our seminars at a location near you (check our calendar for dates), or request a home visit. For accommodation of persons with special needs at sales meetings call 1-877-393-6733 (1-877-219-5457 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. A sales person will be present with information and applications. You can also mail any inquiries to P.O. Box 13713, Philadelphia, PA 19101-3713.

13. How can I get more information on the services provided under the Keystone 65 HMO plan?
Yes. You can request an information packet through the mail or call us toll-free at 1-877-393-6733 (1-877-219-5457 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week.

14. Do I qualify for low-income subsidy?
If you have limited income and resources, you may qualify for low-income subsidy. When you join Keystone 65 Select or Preferred HMO, Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you qualify, your drug costs will also be lower.

15. What is the coverage gap (donut hole) phase of coverage?
Most Medicare Part D plans have a coverage gap. The coverage gap begins after you (or others on your behalf) and your drug plan have spent a certain amount for covered drugs, called the Initial Coverage Limit. Once you reach the Initial Coverage Limit, your cost-sharing for Part D drugs may increase (see below for more information). Please note that not everyone will have increased cost-sharing in the coverage gap. People with Medicare who get Extra Help paying Part D costs will not have increased cost-sharing in the coverage gap for covered Part D drugs.

16. What are the prescription drug costs in the coverage gap?
In 2014, you enter the coverage gap once your total drug spend (combination of deductible, cost-sharing, and plan payments) exceeds the Initial Coverage Limit of $2,850 and ends when your True Out-of-Pocket (TrOOP) costs reach $4,550.

As a Keystone 65 Select Rx HMO Member, once you enter the coverage gap, you are now responsible for paying for 47.5% of the price of brand-name drugs. Although you’ll only pay 47.5% of the cost for the brand-name drug, the entire cost of the drug will count as out-of-pocket spending, which will help you get out of the coverage gap. You’ll also pay only 72% of the cost for covered generic drugs until you reach the end of the coverage gap.

As a Keystone 65 Preferred Rx HMO Member, once you enter the coverage gap, you are now responsible for paying for 47.5% of the price of brand-name drugs. Although you’ll only pay 47.5% of the cost for the brand-name drug, the entire cost of the drug will count as out-of-pocket spending, which will help you get out of the coverage gap. You’ll also pay only 72% of the cost for covered generic drugs until you reach the end of the coverage gap.

17. What payments count towards your True out-of-pocket costs, or TrOOP?
Your yearly TrOOP, which include your deductible (if applicable), coinsurance, and copayments paid for covered Part D drugs, as well as the full cost of brand-name drugs paid for during the coverage gap count towards your TrOOP. Your drug plan premium and non-covered drugs do not count towards your TrOOP.


Website last updated: 9/30/2013
Y0041_HM_14_9866 Approved 11/5/2013

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