2019 Keystone HMO Bronze Plan Details - HealthPocket

Keystone HMO Bronze

$271.42/mo

Apply For This Plan

Zip Code19120
Applicant4/22/1984 Male
Coverage Start4/23/2019
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameKeystone HMO Bronze
Plan IDhhs-33871PA0120004
Plan Year2019
Insurance ProviderIndependence Blue Cross
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$7,400
Out-of-Pocket Maximum$7,900
Personal Score

Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$50 Copay
Specialist Visit$100 Copay
Laboratory Outpatient and Professional ServicesNo Charge
X-rays and Diagnostic Imaging$120 Copay
Diagnostic Imaging such as MRIs, CT, and PET scans$250 Copay
Deductible - Family$14800 per group
Out-of-Pocket Maximum - Family$15800 per group

Prescription drug coverage

Generic Drugs$15 Copay after deductible
Preferred Brand Drugs50.00% Coinsurance after deductible
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.ibx.com/providerfinder
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Yes - Referrals are required for all services except: Emergency Services, OB/GYN, Mammograms, Inpatient Hospital Services, Dialysis services performed in a Participating Facility or by a Participating Professional Provider, Nutrition Counseling and Diabetic Education Program
Does this plan cover services outside plan service area?Not Covered
Does this plan cover services outside the country?Not Covered

Hospital services

Emergency Room Services$500 Copay with deductible
Inpatient Hospital Services (e.g., Hospital Stay)$700 Copay per Day with deductible
Inpatient Physician and Surgical Services50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service50.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$100 Copay
Delivery and all inpatient services for maternity care$700 Copay with deductible

Mental Health

Mental/Behavioral Health Outpatient Services$100 Copay
Mental/Behavioral Health Inpatient Services$700 Copay per Day with deductible
Substance use disorder outpatient services$100 Copay
Substance use disorder inpatient services$700 Copay per Day with deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Acupuncture
Infertility Treatment
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Durable Medical Equipment
Hospice Services
Dental Anesthesia
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Telemedicine
More Limited BenefitsSkilled Nursing Facility
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Chiropractic Care
Nutritional Counseling
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsBariatric Surgery
Cosmetic Surgery
Hearing Aids
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
Treatment for Temporomandibular Joint Disorders
PremiumPlan NameDeductible
from $338
Bronze PPO 7350/0/60
$7,350.00Select
from $369
Ambetter Balanced Care 5 (2019)
$7,350.00Select
from $392
Bronze HMO 7350/0/60
$7,350.00Select
from $414
Bronze PPO 7350/0/60
$7,350.00Select
from $437
Shared Cost Blue PPO Bronze 7500
$7,500.00Select
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  • Phone Number
    (215) 324-2180
  • Office Locations
    448 E Wyoming Ave
    Philadelphia, PA 19120
448 E Wyoming Ave Philadelphia PA, 19120

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)