Effective January 1, 2012, there will be several changes to our current
Medicare Advantage HMO and PPO plans in addition to the introduction of our new
limited network HMO 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
Keystone 65 Preferred HMO
Benefit
Current
Changes for 2012
Smoking and tobacco use cessation
Not covered
No copayment
Diabetes screening
Not covered
No copayment
Inpatient hospital care
$175 copayment per day,
days 1-8; $1,400 maximum
per stay
$190 copayment per day,
days 1-8; $1,520 maximum
per stay
Skilled nursing facility care
$20 copayment per day for
days 1-20 $100 copayment per day for days 21-100
$30 copayment per day for
days 1-20 $110 copayment per day for days 21-100
Physician services, including doctor?s office visit
$15 copayment for each primary care physician office visit
$10 copayment for each primary care physician office visit.
Outpatient hospital services
$150 copayment in ambulatory
surgical center
$300 copayment in outpatient
hospital facility
$100 copayment in ambulatory
surgical center
$350 copayment in outpatient hospital facility
Urgently needed care
$15 - $40 copayment
$10 - $40 copayment
Radiation therapy
$25 copayment
$40 copayment
Complex radiology
$80 copayment for complex
radiology, which includes MRI/
MRA, CTA/CT scans, PET scans, and nuclear cardiology studies
$100 copayment for complex
radiology, which includes MRI/
MRA, CTA/CT scans, PET scans, and nuclear cardiology studies
Personal Choice 65SM PPO benefits changes
In-network
Out-of-network
Benefit
Current
Changes
for 2012
Current
Changes
for 2012
Smoking and tobacco use cessation
Not covered
No copayment
Not covered
No copayment
Diabetes screening
Not covered
No copayment
Not covered
No copayment
Primary care visit
$20 copayment
$10 copayment
Member
responsible for 30% of charges after $500 deductible is met
Member
responsible for
30% of charges
after $500
deductible is met
Outpatient hospital services
$125 copayment
in ambulatory
surgical center
$250 copayment
in outpatient
hospital facility
$100 copayment
in ambulatory
surgical center
$350 copayment
in outpatient
hospital facility
Member responsible for
30% of charges
after $500 deductible is met
Member
responsible for
30% of charges
after $500
deductible is met
Ambulance services
$100 copayment
$75 copayment
$100 copayment
$75 copayment
Urgently needed care
$20 - $40
copayment
$10 - $40
copayment
$20 - $40
copayment
$10 - $40
copayment
Optional supplemental benefits package available to Keystone 65 Select HMO
members
Our new Keystone 65 Select HMO members will have the option to purchase the
Choice Program, an optional
supplemental benefits package, for an additional $10 a month. The optional
supplemental benefits package will cover
vision, dental, and hearing, as these benefits are no longer included for
Keystone 65 Select HMO members. See the
table below for details about the supplemental benefits package.
Covered services
Member pays
Dental services ? Preventive dental
One exam and cleaning every six months
$15 copayment
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 years
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 years
$100 for eyewear
Note: Vision, dental, and hearing 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
2012 benefits changes for Medicare
Advantage HMO and PPO members.