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Capitation arrangements for Keystone 65 Focus 

December 1, 2015    

As previously communicated, Independence has introduced Keystone 65 Focus Rx HMO (Keystone 65 Focus), a new Medicare Advantage benefit product for 2016. Keystone 65 Focus is a defined-network benefit product with more than 23,000 participating providers in southeastern Pennsylvania. Keystone 65 Focus members will enjoy similar benefits as with broader-network Medicare Advantage HMO benefit products, while taking advantage of lower premiums and out-of-pocket costs resulting from defined network of providers.

The following capitation arrangements apply for the Keystone 65 Focus benefit product:

  • Radiology and physical therapy services. Radiology and physical therapy services will not be capitated. Keystone 65 Focus members must be directed to a participating provider in the Keystone 65 Focus network. These services will be reimbursed on a fee-for-service basis for the Keystone 65 Focus benefit product. Referral requirements still apply.
  • Laboratory services. Laboratory services will remain capitated, and Keystone 65 Focus members must be directed to their primary care physician's (PCP) designated (capitated) laboratory outpatient provider.

Note: For all other Independence Medicare Advantage HMO benefit products, members should continue to be referred to their PCP's capitated sites for radiology, physical therapy, and laboratory services.

Finding providers in the Keystone 65 Focus network

Members who choose Keystone 65 Focus for their health care coverage should only be referred to providers who are participating in the Keystone 65 Focus defined network. You can find Keystone 65 Focus participating providers using the online provider directory.

The sample image shows how a PCP's capitated sites will appear when looking at the online provider directory for Keystone 65 Focus. Please be aware that you will see "N/A" for both Physical Therapy and Radiologist, as a result of capitation not applying to these services for this benefit product.

Keystone 65 Focus Online Provider Directory

Providers will be able to use either the NaviNet® web portal or our online provider directory to identify Keystone 65 Focus-participating physical therapy and facility-based radiology providers. Later this month, we will also publish a list of freestanding radiology sites on our Keystone 65 Focus Rx HMO web page.

Requesting referrals and authorizations for Keystone 65 Focus members

You may currently have Independence Medicare Advantage patients who choose to enroll in Keystone 65 Focus for 2016. Please be aware that, for these patients, their network of participating providers will be narrowing as of January 1, 2016. Therefore, if those patients have referrals or authorizations on file under their current Independence Medicare Advantage plan, you may need to issue a new referral or authorization on or after January 1, 2016, to a Keystone 65 Focus-participating provider.

In addition, if you need to request an authorization for a new Keystone 65 Focus member for services scheduled in early January, please note that you will not be able to do so via NaviNet until after January 1, 2016, when your patient's coverage under Keystone 65 Focus goes into effect. If you must request an authorization prior to January 1, 2016, you will need to do so by calling 1-800-ASK-BLUE and following the prompts for authorizations.

For more information

Refer to the article titled Keystone 65 Focus Rx HMO, our new Medicare Advantage benefit product in the October 2015 edition of Partners in Health UpdateSM for detailed information about Keystone 65 Focus benefits. If you have Medicare patients who are interested in learning more about Keystone 65 Focus, please have them contact Customer Service toll-free at 1-800-645-3965 (TTY/TDD: 711), 8 a.m. to 8 p.m., seven days a week. Keep in mind that providers must remain neutral when assisting patients with enrollment decisions. Any discussions with patients should be an objective assessment of the patient's needs and potential options.

We encourage you to start having conversations with your Independence Medicare Advantage patients about their 2016 plan selection. If you have any questions about Keystone 65 Focus, refer to the frequently asked questions on our Keystone 65 Focus Rx HMO web page. If you still have questions after reviewing this information, please contact your Network Coordinator.

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