adultBasicSM
Adults between 19 and 65 years of age |
| Monthly cost |
$36.00 for low-cost adultBasic
$629.00 for at-cost adultBasic |
| Type of coverage |
Keystone Health Plan East HMO
limited-benefit plan |
| Eligibility based on |
Family size and income, and uninsured 3 months, unless uninsured as a direct result of being unemployed |
| Wait period (if eligible) |
33 mo. wait (as of 11/07) for $36.00 premium
No wait for At Cost $629.00 premium, if eligible |
| Pre-existing condition rule |
No |
| Benefits and Copays |
| Doctor office visits |
$10 copay PCP (except for preventive care) |
| Specialist |
$20 copay |
| Emergency accident and medical care |
$50 copay (waived if admitted) |
| Inpatient hospital services |
10% coinsurance/$1,000 maximum per year for all coinsurance (Two stays per year) |
| Surgery and anesthesia |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Outpatient surgery (short procedure unit & facility) |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Diagnostic services |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Chemotherapy, dialysis and radiation therapy |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Maternity care |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Newborn care |
covered for up to 31 days following birth, 10% coinsurance/$1,000 maximum per year for all coinsurance |
| Dental |
not covered |
| Vision and hearing |
not covered |
| Prescription drugs |
not covered, except for diabetic supplies and insulin and immunosuppressants related to transplants, which are covered at 10% coinsurance/$1,000 maximum per year for all coinsurance |
| Diabetic supplies |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Durable medical equipment |
not covered, except for diabetic supplies and insulin*, which are covered at 10% coinsurance/$1,000 maximum per year for all coinsurance |
| Mental health |
not covered |
| Serious mental illness |
not covered |
| Physical, occupational and speech therapy |
10% coinsurance/$1,000 maximum per year for all coinsurance 15 visits per year, combined |
| Cardiac rehabilitation (36 sessions for a 12-week period) |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Pulmonary rehabilitation (18 sessions per calendar year) |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Respiratory therapy (18 sessions per calendar year) |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Home infusion |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Home health care |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Skilled nursing facility care (60 days per calendar year) |
10% coinsurance/$1,000 maximum per year for all coinsurance |
| Inpatient rehabilitation therapy (45 days per calendar year) |
10% coinsurance/$1,000 maximum per year for all coinsurance |
