2019 Keystone HMO Silver Proactive Select Plan Details - HealthPocket

Keystone HMO Silver Proactive Select

$370.52/mo

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Zip Code19120
Applicant3/26/1984 Male
Coverage Start3/27/2019
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameKeystone HMO Silver Proactive Select
Plan IDhhs-33871PA0120008
Plan Year2019
Insurance ProviderIndependence Blue Cross
Metal LevelSilver
Plan TypeHMO
Deductible$0
Out-of-Pocket Maximum$7,850
Personal Score

Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$40 Copay
Specialist Visit$80 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$0 per group
Out-of-Pocket Maximum - Family$15700 per group

Prescription drug coverage

Generic Drugs$20 Copay
Preferred Brand Drugs50.00% Coinsurance
Non-Preferred Brand Drugs50.00% Coinsurance
Specialty Drugs50.00% Coinsurance

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$550 Copay
Inpatient Hospital Services (e.g., Hospital Stay)$500 Copay per Day
Inpatient Physician and Surgical ServicesNo Charge
Emergency Transportation or Ambulance Service$200 Copay

Maternity

Prenatal and Postnatal Care$80 Copay
Delivery and all inpatient services for maternity care$500 Copay

Mental Health

Mental/Behavioral Health Outpatient Services$80 Copay
Mental/Behavioral Health Inpatient Services$500 Copay per Day
Substance use disorder outpatient services$80 Copay
Substance use disorder inpatient services$500 Copay per Day

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 $204
Marketplace Extra 1
$0.00Select
from $230
Marketplace Solutions 1
$0.00Select
from $238
Marketplace Direct 1
$0.00Select
from $245
Healthy Benefits Value HMO 0.50
$0.00Select
from $245
BlueCross Value 0.50, a Multi-State Plan
$0.00Select
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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
  • What Is the Silver Plan?

    ObamaCare’s Silver Plan is a type of Metal Plan on the Health Insurance Marketplace. Silver Plans qualify for both Tax Credits and Cost Sharing subsidies.Silver Plans have lower out-of-pocket costs than Bronze Plans but higher out- of-pocket costs than both Gold and Platinum Plans. All Silver Plans share the same minimum health benefits, but the way they charge out-of-pocket costs can differ significantly.

  • How are Silver Plans different than other Obamacare health plans?

    The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Silver Plan pays 70% of covered medical costs for a typical enrollee. Silver Plans are also the only metal plans which offer cost-sharing reduction (CSR) versions to consumers that require financial assistance for out-of-pocket costs.

  • How much does a Silver Plan cost?

    The monthly premium for a Silver Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and the region in which you live. You can use HealthPocket’s comparison tool to compare Silver Plan premiums in your area.

  • When Can I Enroll in a Silver Plan?

    The Open Enrollment period for the 2018 Affordable Care Act health plans begins November 1, 2017 and ends December 15, 2017. See our Open Enrollment article for more information.

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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.