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Upcoming Medicare Advantage HMO and PPO benefits changes 

November 1, 2012    


Effective January 1, 2013, there will be several changes to our current Medicare Advantage HMO and PPO plans
in addition to the introduction of our $0 premium medical-only plan, Keystone 65 Select HMO. The following tables
highlight some of these changes. Please note that this is a list of our significant benefits changes, not a comprehensive
list of all benefits changes.

Keystone 65 Preferred HMO benefits changes


BenefitKeystone 65 Preferred HMO
Current (2012)Changes for 2013
Depression screeningNot coveredNo copayment
Emergency care$50 copayment for emergency care;
emergency care is offered in the United States.
$65 copayment for emergency care;
worldwide coverage for emergency
and urgently needed care (not waived if admitted).
Inpatient hospital care$190 copayment per day for days
1 – 8; $0 copayment for additional
days per stay; $1,520 maximum
per stay.
$215 copayment per day for days
1 – 7; $0 copayment for additional
days per stay; $1,505 maximum
per stay.
Obesity screening and therapy to
promote sustained weight loss
Not coveredNo copayment
Outpatient Hospital$350 copayment for Outpatient
Hospital (per date of service); $100
copayment for Ambulatory Surgical
Centers (per date of service).
$350 copayment for Outpatient
Hospital (per date of service); $100
copayment for Ambulatory Surgical
Centers (per date of service).
Primary care physician$10 copayment per visit$5 copayment per visit
Screening and counseling to reduce
alcohol misuse
Not coveredNo copayment
Services to treat kidney disease and
conditions
$25 copayment per visit for
outpatient dialysis
20% per visit for outpatient dialysis
Urgently needed care$10 – $40 copayment for urgently
needed care.

The copayment amount depends on
the provider type:
  • $10: PCP
  • $40: Specialist
$5 . $40 copayment for urgently
needed care.

The copayment amount depends on
the provider type:
  • $5: PCP
  • $20: Network Urgent Care Center
  • $40: Specialist
Urgently needed care is covered
worldwide. For urgently needed care
received outside of the United States,
the emergency room copayment will
apply.

Personal Choice 65SM PPO benefits changes


BenefitPersonal Choice 65SM PPO
Current (2012)Changes for 2013
Annual physical examNot coveredNo copayment
Cardiovascular disease risk reduction visit (therapy for cardiovascular disease)Not coveredNo copayment
Out-of-network: 30% coinsurance
Cervical and vaginal cancer screeningPap tests and pelvic exams are
covered once every 12 months
Pap tests and pelvic exams are
covered once every 24 months
Depression screeningNot coveredNo copayment
Out-of-network: 30% coinsurance
Dialysis$25 copayment per dialysis visit20% coinsurance per dialysis visit
Emergency care$50 copayment$65 copayment (not waived if
admitted)
Obesity screening and therapy to promote sustained weight lossNot coveredNo copayment
Out-of-network: 30% coinsurance
Primary care physician$10 copayment per office visit$5 copayment per office visit
Screening and counseling to reduce alcohol misuseNot coveredNo copayment
Out-of-network: 30% coinsurance
Urgently needed care$10 - $40 copayment$5 - $40 copayment

Optional supplemental benefits package available to Keystone 65 Select HMO members

Our Keystone 65 Select HMO members will have the option to purchase the Choice Care program, an optional supplemental benefits package, for an additional $10 a month. The optional supplemental benefits package will cover vision, dental, and hearing. See the table below for details about the supplemental benefits package.

Covered ServicesMember pays
Dental services — Preventive dental
One exam and cleaning every six months$15 copayment per visit
Hearing services
Non-Medicare-covered routine hearing exams, including fitting and evaluation for two hearing aids, covered every three years$45 copayment for non-Medicare-covered hearing exams
and evaluation
Medicare-covered hearing exams$45 copayment for Medicare-covered hearing exams and
evaluations
Hearing aids, covered every three yearsCovered up to $500 for two hearing aids
Vision care
Non-Medicare-covered routine eye exams, every two years$0 copayment for routine eye exams, once every two years
Eyewear not covered by Medicare, every two yearsCovered up to $100 for eyewear
Note: Vision, dental, hearing, and SilverSneakers are still included in the benefits packages for Keystone 65 Preferred HMO and Personal Choice 65 PPO members.

Please contact your Network Coordinator if you have any questions about these 2013 benefits changes for Medicare Advantage HMO and PPO members.

SilverSneakers is a registered mark of Healthways, Inc.





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