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Cost-sharing for Keystone HMO Proactive members 

January 9, 2014    

As previously communicated, IBC has begun offering new health plans both on and off the Health Insurance Marketplace. Coverage for these commercial products began January 1, 2014, including our lower-cost tiered provider network product called Keystone HMO Proactive.

Our HMO network providers have been categorized into one of three benefit tiers for Keystone HMO Proactive:

  • Tier 1 – Preferred: Members pay the lowest cost-sharing for most services.
  • Tier 2 – Enhanced: Members pay a higher cost-sharing for most services compared to Tier 1 – Preferred.
  • Tier 3 – Standard: Members pay the highest cost-sharing for most services.

Note: Certain services have the same cost-sharing for all benefit tier levels, including preventive care, emergency room, ambulance, urgent care, pharmacy, behavioral health, transplants, outpatient laboratory, imaging, and physical/occupational/speech therapy.

Cost-sharing for Keystone HMO Proactive members

Cost-sharing (deductible, coinsurance, and/or copayments) for Keystone HMO Proactive members varies based on the member’s benefit plan (i.e., Silver or Gold) and the provider’s benefit tier placement.

If a Keystone HMO Proactive member presents to you for service, use the NaviNet web portal to view a summary of the member’s benefits. Through the Eligibility and Benefits Inquiry transaction, NaviNet will display the appropriate cost-sharing amounts for all three tiers. Therefore, you will need to know your benefit tier placement to determine the appropriate amount of cost-sharing to collect from the Keystone HMO Proactive member.

To find your benefit tier placement, search for your practice/facility by selecting Reference Tools from the Plan Transactions menu, and then Provider Directory. Be sure to select Keystone HMO Proactive in the Select a Plan drop-down menu as shown below.

For more information about Keystone HMO Proactive, visit our website.

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.

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