Below are frequently asked questions about Keystone Health Plan East HMO. Click on a topic below to view a list of related questions. If you have additional questions, please email us your specific questions.
What are medically underwritten plans?
With medically underwritten plans, your health history and current health will be reviewed to determine whether you qualify for enrollment. If approved, some health conditions may require you to pay a higher premium. If you do not qualify for a medically underwritten plan, you may want to consider one of our guaranteed enrollment plans.
What are guaranteed enrollment plans?
With a guaranteed enrollment plan, you get coverage as long as you meet eligibility requirements, such as residency and annual income, and pay your monthly bill. Your health history is not reviewed prior to accepting your application.
What is an HMO?
HMO stands for health maintenance organization. If you pick an HMO plan, you’ll need to select a family doctor who can help you with general health concerns, or refer you to a network specialist for care.
What is a PPO?
PPO stands for preferred provider organization. With a PPO plan, there’s no need to select a primary care physician (aka PCP or family doctor). You can visit any doctor or specialist in the network, without a referral, and you have the freedom to choose doctors outside the network if you’re willing to pay more for their services.
What’s the difference between medically underwritten HMO and PPO plans?
With our HMO plans from Keystone Health Plan East, you select a primary care physician to coordinate all of your health care needs and provide you with referrals to network specialists when needed. In comparison, our Personal Choice® PPO plans give you the flexibility to receive care from doctors both in and out of network. There’s no need to pick a primary care physician and you never need a referral. Our PPO plans also provide in-network coverage coast-to-coast when you use BlueCard® PPO participating providers. While our PPO plans offer you the freedom to access care directly, they do not provide coverage for maternity and vision care, which are included in our HMO options.
What is a premium?
This is the amount you pay for your health insurance coverage. This is separate from costs you pay when you use your benefits to get care, such as copays, deductibles, and coinsurance.
What is a copay?
It’s a set dollar amount you pay for a covered health service. If you have a $10 copay for a doctor’s visit, you simply pay $10 and we cover the rest.
What is a deductible?
This is a fixed dollar amount that you must pay before your insurance kicks in. If you use a participating provider, your costs are based on our discounted rate.
What is coinsurance?
Some plans require you to pay a percentage of your medical costs. If you use a participating provider, your costs are based on our discounted rate.
What does out-of-pocket maximum mean?
This is the maximum amount that you will have to pay under your plan. Once you hit your out-of-pocket maximum, we’ll cover services requiring a deductible or coinsurance 100% for the remainder of the benefit period.
Which services are subject to the deductible?
For deductible plans, the in-network deductible applies only to services you’re less likely to use, such as hospital and emergency care. You still have copays or 100% coverage for doctor visits, screenings, and immunizations.
For HSA plans, the deductible applies to all services except preventive care. Refer to the benefits summary for details on which services apply to the deductible.
What is a primary care physician (PCP)?
This is just another term for your family doctor. HMO plans require you to pick a PCP to coordinate your health care and refer you to a specialist if needed.
Can I change my primary care physician (PCP) after I have chosen one?
Yes. Once you are a member, it’s easy to change your PCP. Simply login to ibxpress.com to make the change, or call 1-800-275-2583. PCP changes become effective on the first day of the following month.
What is a specialist?
A specialist provides medical care for certain conditions in addition to the treatment provided by your primary care physician (PCP). For example, you may need to see an allergist for allergies or an orthopedic surgeon for a knee injury. Under an HMO plan, you need to obtain a referral from your PCP to receive benefits for care provided by a specialist. Under our PPO plans, you never need a referral to see a specialist.
What is a referral?
If you have an HMO plan, your family doctor (or PCP) will need to write you a referral before you see other network providers, such as a dermatologist. No need to pick up a piece of paper, our referrals are done electronically.
What does precertification mean?
This may also be called preapproval or prior authorization. Basically, you may need additional approval from your health plan before you receive certain tests, procedures, or medications. It’s a way to make sure the services you’re getting are safe and effective.
What is a preexisting condition?
It’s a health condition you received medical care for before applying for insurance. All of our medically underwritten plans have exclusions for pre-existing conditions for the first 12 months of coverage, except for applicants under 19 and dependent children under 19. Under our HMO plans, we will look at any conditions that you received services for in the 90 days preceding your enrollment. For our PPO plans, the look back period is 12 months.
Can the preexisting condition exclusion period be waived or reduced?
Yes. There are two ways in which you can qualify for a preexisting condition exclusion waiver or reduction, through a Blue-to-Blue transfer or creditable coverage.
Blue-to-Blue transfer – If you’ve had active health coverage with a Blue Cross® or Blue Shield® plan for up to 12 months without a break in coverage prior to your requested effective date, you can receive credit for each month of prior coverage up to the entire exclusion period of 12 months.
Creditable Coverage – If you had active coverage with another insurance carrier for at least 18 months without a break in coverage of more than 63 days prior to your current application, you can receive credit for the entire exclusion period of 12 months.
What is durable medical equipment?
Durable medical equipment includes, but is not limited to, the following: hospital beds, crutches, canes, wheelchairs, walkers, peripheral circulatory aids, cervical collars, traction equipment, physiotherapy equipment, oxygen equipment, and ostomy supplies. You should always check with both your provider and Independence Blue Cross to determine whether an item is considered to be durable medical equipment.
What does in network mean?
Your health care coverage is considered in network when you use a provider who participates in our network of more than 55,000 doctors and 100 hospitals. For HMO plans, it’s the Keystone Health Plan East network. For PPO plans, it’s the Personal Choice® network and you have the option to visit doctors out of network at a higher cost. To see if a provider or hospital is considered in-network, visit our provider directory.
What does out of network mean?
Your health care coverage is considered out of network when you visit a doctor or hospital that does not participate in our network. With an HMO plan, you only have coverage for in-network providers, while PPO plans allow you the freedom to see both in- and out-of-network providers.
What services do all plans cover?
Both Keystone HMO and Personal Choice PPO plans cover the following services:
office visits
preventive care
prescription drugs
hospital stays
emergency/urgent care
X-rays
Laboratory services
Keystone HMO plans also offer routine eye care and maternity coverage, while Personal Choice PPO plans do not. For more details about what services are covered, refer to each plan’s benefits summary.
Are emergency services covered?
Yes. You are covered for medically necessary services for unexpected illnesses or emergency care no matter where you are.
Is mental health covered?
Mental health services are not covered through the individual plans. However, the prescription drug benefit does cover any prescriptions related to mental illness.
Do the plans provide wellness programs?
At no additional cost, you can take advantage of our value-added wellness programs. Our Healthy LifestylesSM programs provide incentives, reimbursements, and support to help you take control of your health and lead a healthier life. For example, you can get up to $150 back on the cost of your fitness center fees through the Healthy Lifestyles program. After becoming a member, you can learn more about the advantages of Healthy Lifestyles through ibxpress.com.
Are alternative health services available?
You can receive a discount on alternative health services, including massage therapy and acupuncture through, our Healthy LifestylesSM program.
What are the ConnectionsSM Health Management Programs?
Like our Healthy Lifestyles programs, the Connections Health Management Programs are value-added programs available to you free of charge. Connections provides:
24/7 access to a Health Coach for support when it comes to everyday or more serious health concerns;
information and support when you are facing medical decisions or treatment options;
help when you are living with chronic conditions such as diabetes or asthma.
What is ibxpress.com?
ibxpress is the fast, simple, and secure way to manage your health benefits when it’s convenient for you. Visit ibxpress.com to review your benefits, change your PCP, check the status of a claim and request an ID card. Plus, we’ve partnered with WebMD® to provide you with personalized tools and information to help you make health decisions that are right for you. Included with these tools are:
Are prescription drugs covered?
Yes, prescription drugs are covered for all of the individual plans. Please refer to your benefits summary for details.
How does my prescription drug benefit work?
The prescription drug program is administered by FutureScripts®, an independent pharmacy benefits management company. The FutureScripts network includes more than 60,000 retail pharmacies, including most national and regional chain pharmacies and many neighborhood pharmacies.
Each time you go to a participating pharmacy to fill a prescription, simply present your ID card.
Copay plans –If your plan has an annual prescription deductible, you must first pay the full cost of prescriptions up to that amount. Then, you pay either the copay or coinsurance specified for generic formulary, brand formulary, or non-formulary brand. If your plan has a maximum copay amount, that means that IBC will cover any expenses beyond that amount for a particiular prescription. Personal Choice PPO 30 does not include a deductible so you simply pay a copay when using in-network pharmacies. If you use an out-of-network pharmacy, then you will be required to pay 50% coinsurance instead of a copay.
Deductible plans –These plans do not have a deductible for prescription drugs. You simply pay the copay or coinsurance specified for generic formulary, brand formulary, or non-formulary brand. If your plan has a maximum copay amount, that means that IBC will cover any expenses beyond that amount for a particiular prescription. When using out-of-network pharmacies, you must pay 50% coinsurance instead of copays.
HSA plans – These plans have a prescription deductible that is integrated with the medical deductible. This means that you pay for prescriptions in full until your medical deductible has been reached. Once the deductible has been met, you are either covered 100% (PC PPO 5000 HSA) or you pay the copay (PC PPO 3000 HSA) specified for generic formulary, brand formulary, or non-formulary brand drugs from in-network pharmacies. When using out-of-network pharmacies, you will need to pay 50% coinsurance.
Is there a maximum prescription drug benefit?
No. In accordance with health care reform provisions effective October 1, 2010, all of our plans have unlimited prescription drug benefits.
What is the difference between generic and brand medications?
A generic drug is an equivalent version of a brand drug with the same active chemical ingredients and equivalency in strength. A brand drug has a patented marketing name.
Do my benefits include mail-order service?
Yes, as long as you use a participating pharmacy in-network. You can receive a 90-day supply of maintenance medications for two applicable copayments (generic/brand/non-formulary) through the mail-order service. (Typically, this represents a savings of one copayment.) To get started with mail-order service, login to ibxpress.com.
Are birth control pills covered under my plan?
Yes. Birth control pills (oral contraceptives) and injectable contraceptives are covered under the prescription drug benefit of each plan. They are subject to applicable cost-sharing depending on the plan and whether a drug is considered generic formulary, brand formulary, or non-formulary brand. Using our mail-order service for prescription drugs makes it convenient to refill prescriptions and may provide a savings of one copayment for a 90-day supply of birth control pills.
What is a formulary?
The formulary is a list of medications that have been selected for their medical effectiveness, positive results, and value. The formulary includes all generic medications and a defined list of brand medications. You maximize your benefits when you purchase formulary medications.
Does the prescription plan cover non-formulary medications?
Yes. You have access to non-formulary medications; however, you pay less when you select formulary medications. (You maximize cost savings when selecting a generic drug.)
How do I apply?
You can apply online or you can request an application kit
be mailed to you. Applying online is simple and secure. In addition, online applications are processed faster and you can check the status of your application at any time.
Can I add my spouse or child at a later date?
Yes. You can apply to add a spouse or child at a later date, and such a request will be subject to medical underwriting and the preexisting condition exclusion, except for applicants under 19 and dependent children under 19. Requests to add stepchildren at a later date will also be subject to medical underwriting and the preexisting condition exclusion. If you apply to add your natural or legally adopted child(ren) more than 31 days after they become a dependent due to birth or placement for adoption, that child (or those children) would be subject to the preexisting condition exclusion period, expect for applicants under 19, and medical underwriting. Learn the ways in which you may qualify for a preexisting condition exclusion waiver or reduction.
Can I add my domestic partner to my health plan?
No. Your domestic partner can apply individually for coverage. We do not currently provide combined coverage for domestic partners.
Can I add my fiancée to my health plan?
No. Your fiancée can apply individually for coverage. Once you are married, you can request that your spouse be added to your existing coverage. However, your spouse will be subject to medical underwriting and the preexisting condition exclusion. Learn the ways in which you may qualify for a preexisting condition exclusion waiver or reduction.
Can I apply for multiple plans?
No. You must select one plan when you apply for an individual health plan. Please note that you may always downgrade to a lower premium option within the Individual plans. However, if you choose to upgrade to a higher premium option, it will be subject to medical underwriting. If you do not know which plan you want to select, you may want to begin with the highest premium option because you can always downgrade your coverage.
Can I apply for one plan for myself and another plan for a family member?
You cannot apply for one plan yourself and another plan for dependents. Members of your family 18 and older must complete a separate application to apply for a different plan.
How long will it take to process my application?
The underwriting process may take several weeks. It is important to note that we may not be able to meet your requested effective date. Therefore, you should continue your existing health coverage until you have been given a final determination on whether your request for coverage has been approved.
How can I expedite processing of my application?
Applying online will reduce the processing time of your application. To avoid processing delays, be sure to:
complete the application as carefully and accurately as possible;
provide full medical history details, including dates, for all questions answered “yes” in the Health Related and Health History sections of the application;
sign and date the Declarations and Conditions of Enrollment page (an E-signature is used for online applications);
sign and date the Authorization for Release of Medical Information page;
include payment, whether you select “Bill Me” (online applications only), electronic payment through ACH (applies to online and paper applications), or send a check (paper applications only) for the initial premium.
Do I have to supply medical records with my application?
No. You do not have to supply medical records with your application. However, you may need to supply medical records during the underwriting review process, in which case you will be contacted by Independence Blue Cross.
Who should I contact if I have questions about how to fill out an application?
Please call 1-800-263-1410 between 9 a.m. and 9 p.m. or email us your question or comment.
Once I have accepted coverage, how soon can I expect to receive my member ID card and contract?
Your membership card and Subscriber Agreement are generally sent three to five business days after you are enrolled. You will receive them separately in the mail. In the meantime, you may register on ibxpress.com and print a temporary ID card from our member website, ibxpress.com.
What are my payment options?
If you apply online, you have the option to pay monthly using electronic payments, or you can select the Bill Me option to pay by check at a later date. If submitting a paper application, you can either include a check for the first month’s premium or complete the Electronic Payments form to authorize monthly electronic payments. Since the rate you are quoted is a preliminary rate, it’s possible that you may be accepted at a higher rate based on medical underwriting. If so, your first invoice or automatic withdrawal will reflect the higher amount.
Important: Receipt of your initial payment does not constitute enrollment in this program. Your coverage does not begin until your application has been approved and you have been assigned an Effective Date of Coverage. Your initial premium will not be processed unless you have been approved for coverage by Independence Blue Cross.
Will my actual rate be different from my rate quote?
The preliminary rate you are given is determined by the information (age, gender, and family status) you provide when you request a quote. This base rate may be adjusted once your completed application is reviewed by medical underwriting.
If I am denied coverage, do I get my initial premium payment back?
Yes. If your coverage is denied and you authorized electronic payment via ACH, the initial premium transaction will not be processed. If you submitted a check with your paper application, your original check will be returned with the notice that coverage was denied.
How long are the rates valid?
Rates are guaranteed for the first six months of coverage, regardless of any rate or age band increases for the individual medically underwritten products. After the first six months, rates are subject to change at any time with the prior approval of the Pennsylvania Insurance Department. You will receive advance notification of any future rate changes.
What does 6-month rate guarantee mean?
This means that your rates are guaranteed for the first six months of coverage, regardless of any rate or age band increases for the individual medically underwritten products. After the first six months, rates are subject to change at any time with the prior approval of the Pennsylvania Insurance Department. You will receive advance notification of any future rate changes.
How do electronic payments through ACH work?
With electronic payments, you authorize your monthly payment to be automatically withdrawn from your account. It’s a worry-free way to help ensure you won’t miss a payment and risk losing your health insurance coverage. You don’t have to write and send in checks. With electronic payment, your premium is taken care of even when you’re away on business or vacation.
When will the initial payment come out of my account?
Your initial payment will be processed once you are approved. Since the underwriting process may take several weeks, please note that we may not be able to meet your requested effective coverage date. Therefore, it is critical that you keep your existing health coverage until you have been given a final determination on whether your request has been approved.
Who do I contact for technical questions about using ibx4you.com?
Please call 800-263-1410 between 9:00 a.m. and 9:00 p.m. Or, email us your question or comments.
Can I save my application and finish later?
Once you start your application online, you may save it at any point and return within 30 days to complete it. Just go to www.ibx4you.com/login and login with your username and password to finish your application. After 30 days, you will need to start a new application. To save your application, click the Save button on the Account Information screen.
Want to check the status of your application?
To see the status of your application, go to www.ibx4you.com/login and login with your username and password. Once you are in your account, you should be able to see the status of your application.
What do I do if I forgot my username?
Go to www.ibx4you.com/login and click on the Forgot Your Username? link. Enter your email address and click the Continue button. Provide the answer to the security question, which you answered during registration. Click Submit. Your username will be sent to the email address provided.
What do I do if I forgot my password?
Go to www.ibx4you.com/login and click on the Forgot Your Password? link. Enter your username and click the Continue button. Provide the answer to the security question, which you provided during registration. Click Submit. Your Password will be reset to a temporary password. The temporary password will be sent to the email address on file for your account. When you login for the first time using the temporary password, you will be prompted to choose a new password.
What do I do if I forgot both my username and password?
Follow the instructions under, “What if I forgot my username?” above. Once you receive your username via email, login again and follow the instructions under “What if I forgot my password?” above.
How can I change my password?
Go to www.ibx4you.com/login. After you login with your username and password, click the Account Info link, then click the Change Password button found on the Account Information screen. Type in your current password once and your new password twice.
How can I change my address, phone number, email address, or contact preferences?
Go to www.ibx4you.com/login. After you login with your username and password, click the Account Info link, then click the Modify button found on the Account Information screen. Make your changes, then click Update to save your changes or Cancel to discard the changes.
What should I do if I receive a message that account access has been disabled?
To safeguard your privacy and maintain the security of online transactions, account access is disabled when a user attempts to log in three times using an unrecognized username or password. To reset account access, call 1-800-263-1410 between 9:00 a.m. and 5:00 p.m.
How do I download the Adobe Acrobat Reader software to view documents?
You can obtain a free download of Adobe Acrobat Reader from their website at adobe.com.
