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Benefits
Primary
and Preventive Health Services | Outpatient
Services | Inpatient
Services
Outpatient Services
Unless otherwise specified in this benefits handbook,
the following benefits are provided on an outpatient basis
when:
- Medically necessary;
- Provided or referred by your primary care physician;
and
- Preapproved by Keystone, where specified.
Allergy Testing and Treatment
Allergy tests, testing materials and treatment.
Ambulance Services (Preapproval, unless
an emergency service and medical intervention and/or stabilization
is medically necessary during transport)
Ambulance services on land, air or sea for medical intervention
and/or stabilization of the member’s condition by a licensed
medical professional during transit from the site where
an emergency medical condition occurs to the facility
of treatment. Other ambulance services will be covered
only when ordered or referred by your primary care physician
and preapproved by Keystone. The vehicle used must be
one that is specially designed and equipped for use only
to transport sick or injured persons.
Anesthesia
(Preapproval for outpatient epidural injection)
Anesthesia services performed in connection with covered
services.
Autologous Blood Drawing/Storage/Transfusion
Services provided in conjunction with a planned episode
of care that requires transfusion, including but not limited
to, surgical procedures. Benefits are provided for storage
of autologous blood until the date of scheduled care.
Cardiac Rehabilitation Therapy (Preapproval)
Chemotherapy (Preapproval for administration
in a facility)
Diabetic Self-Management
and Education
Benefits are provided for self-management training and education
relating to diet when prescribed by a primary care physician
or referred specialist. Covered services may be provided
by a participating provider who is a licensed health care
professional approved by Keystone. Covered services may
also be provided by a participating community-based program
which is approved by Keystone in accordance with criteria
based on the certification programs for diabetic self-management
training and education programs developed by the American
Diabetes Association and the Pennsylvania Department of
Health, or at a participating hospital on an outpatient
basis as follows:
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A. |
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Visits medically necessary upon the
diagnosis of diabetes; |
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B. |
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Visits under circumstances whereby
your primary care physician identifies or diagnoses
a significant change in your symptoms or conditions
that necessitates changes in your self-management;
and |
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C. |
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Where a new medication or therapeutic
process relating to your treatment and/or management
of diabetes has been identified as medically necessary
by your primary care physician. |
Diabetic Supplies
(Preapproval)
Benefits are provided for equipment and supplies when obtained
through a participating durable medical equipment provider
for use when you are not an inpatient. Covered supplies
include blood glucose monitors, monitor supplies, injection
aids, syringes, insulin infusion devices, and pharmacological
agents for controlling blood sugar.
Diagnostic Laboratory and X-Ray Services
X-ray and laboratory tests, procedures, and materials.
Covered routine diagnostic outpatient services must be
performed by your primary care physician’s designated
provider.
Dialysis
Dialysis treatment when provided in the outpatient facility
of a hospital, a free-standing renal dialysis facility.
When you become eligible for Medicare coverage of dialysis,
Keystone dialysis benefits will be coordinated with such
Medicare coverage.
Genetic Testing and Counseling
Benefits are provided for genetic testing and counseling.
Covered services are those testing and counseling services
provided to members at risk by pedigree for a specific
hereditary disease. The services must be for the purpose
of diagnosis and where the results will be used to make
a therapeutic decision.
Gynecological Care
Benefits are provided for female members for covered services
provided by any Keystone participating obstetrical/gynecological
specialist without a referral. Covered services include:
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A. |
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Routine maternity care; |
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B. |
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Routine gynecological care including
Papanicolaou (Pap) smears; and |
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C. |
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Other gynecological care. |
A referral is required for specialty care provided by a
gynecological oncologist.
Home Health Care
(Preapproval)
Care provided by a home health care provider in the member’s
home, if within the service area.
Home Visits
Physician visits to your home, if within the service area.
Hospice Care (Preapproval)
Palliative and supportive services provided to a terminally
ill member through a hospice program by a hospice provider
given on an outpatient basis or in the member’s home in
accordance with a plan of treatment preapproved by Keystone.
Immunizations (Shots)
Adult immunizations (except those required for travel
or work). Coverage will be provided for those immunizations,
including the immunizing agents, which, as determined
by the Pennsylvania Department of Health, conform with
the standards of the Advisory Committee on Immunization
Practices of the Center for Disease Control, U.S. Department
of Health and Human Services.
Infusion Therapy
(Preapproval)
Treatment includes but is not limited to, infusion or inhalation
parenteral and enteral nutrition, antibiotic therapy, pain
management and hydration therapy.
Injections
(Preapproval, when required)
Injectable medication for the immediate treatment of an
injury or acute illness when administered in the physician’s
office.
Insulin and Oral Agents
Insulin and oral agent benefits will be available when dispensed
by a Prescription Order for use when you are not an inpatient.
Following is a description of your insulin and oral agent
benefits, subject to the Limitations shown below:
- Prescribing Physician:
Insulin and oral agents are covered when prescribed
by your primary care physician or referred specialist.
Generically equivalent pharmaceuticals will be dispensed
whenever applicable.
- A pharmacy need not dispense a Prescription Order
which, in the Pharmacist’s professional judgment, should
not be filled, without first consulting with the prescribing
physician.
- The quantity of a Prescription Drug, for purposes
of cost-sharing, dispensed from a pharmacy pursuant
to a Prescription Order or Refill is limited to thirty
(30) days.
- Prescription Refills will not be provided beyond six
(6) months from the most recent dispensing date.
- Prescription Refills will be dispensed only if 75%
of the previously dispensed quantity has been consumed
based on the dosage prescribed.
Mammogram Screening
Screening and diagnostic mammograms are available without
a referral. Benefits for mammography services are payable
only if performed by a participating provider who is properly
certified by the Department of Health in accordance with
the Mammography Quality Standards Act of 1992, and as later
amended.
Maternity Care
Benefits are provided for female members for covered services
provided by a primary care physician or participating obstetrician/gynecologist
without a referral.
Medical Foods (Preapproval)
Benefits are provided for nutritional products which are
specifically formulated for the therapeutic treatment of
phenylketonuria, branch-chain ketonuria, galactosemia, and
homocystinuria. These foods may be taken by mouth and may
not be a person’s sole source of nutrition. This treatment
must be ordered by your primary care physician or referred
specialist.
Newborn Care
Care of a newborn child, born to an enrolled female adultBasic
member, is covered for a period of up to 31 days following
birth. Such care shall include routine nursery care, prematurity
services, preventive health care services, as well as coverage
for injury or sickness, including the necessary care and
treatment of medically diagnosed congenital defects and
birth abnormalities. To ensure continuity of care for the
newborn, the mother of the newborn should fill out an application
for Medicaid or CHIP as soon as the baby is born. The social
services department at the hospital or the Caring Foundation
can assist the mother of the newborn with this process.
Obstetrical Care
Benefits are provided for female members for obstetrical
care, including prenatal and postnatal care, complications
of pregnancy and childbirth.
Covered services are provided by a primary care physician
or participating obstetrician/gynecologist without a referral.
Office Visits
Covered services provided in the physician’s office.
Oral Surgery (Preapproval
in a facility)
Limited oral surgical procedures in an outpatient setting
and required in connection with the following:
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A. |
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The removal or exposure of teeth
which are partially or totally covered by bone; |
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B. |
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Accidental injury to the jaw or structures
contiguous to the jaw or injury related to sound
natural teeth; |
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C. |
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The correction of a non-dental physiological
condition which has resulted in a severe functional
impairment; or |
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D. |
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Treatment for tumors and cysts requiring
pathological examination of the jaws, cheeks, lips,
tongue, roof and floor of the mouth. |
Orthotics (Preapproval)
Benefits are provided for the initial purchase and fitting
(per medical episode) of orthotic devices, except foot orthotics,
unless the covered member requires foot orthotics as a result
of diabetes.
Foot orthotics ordered and covered as a result of diabetes,
must be obtained through a participating durable medical
equipment provider.
Podiatric Care
Covered services include: capsular or surgical treatment
of bunions; ingrown toenail surgery; and other non-routine
medically necessary foot care. In addition, for patients
with peripheral vascular and/or peripheral neuropathic diseases,
including but not limited to diabetes, routine foot care
services are covered. All such care must be performed by
your primary care physician’s designated provider.
Preventive Care
Preventive health care, including, but not limited to, periodic
health assessments, well-child care (covered for up to 31
days following birth), and periodic gynecological examinations,
according to schedules approved by Keystone, when provided
by your primary care physician or a participating gynecologist.
Prosthetic Devices
(Preapproval)
Benefits will be provided for the initial purchase and fitting
(per medical episode) of prosthetic devices and supplies
(except dental prosthetics), which replace all or part of
an absent body organ and its adjoining tissues or replace
all or part of the function of a permanently useless or
malfunctioning body organ.
Pulmonary Rehabilitation
Services (Preapproval)
Benefits are limited to treatment received within a 60 consecutive
day period.
Radiation Therapy
Reconstructive Surgery
(Preapproval)
Covered services available when medically necessary following
a covered surgical procedure.
Rehabilitation Therapy
Services (Preapproval)
Covered services for all covered therapies other than speech
therapy must be performed by your primary care physician’s
designated provider. Covered services for acute conditions
are subject to the determination that significant improvement
can be expected within 60 days per episode. Services are
provided for 60 days per episode for each of the following
therapies:
- Occupational;
- Physical;
- Hand; and
- Speech.
Covered services include:
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A. |
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All therapeutic exercise, testing
and soft tissue mobilization; |
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B. |
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All physical modalities utilizing
heat, cold, light, air, electricity, sound, all
forms of water therapy, massage, mobilization and
mechanical stimulation; |
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C. |
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Checking out the fitting of splints,
braces, prostheses and other orthotic devices (orthotic
devices are not covered unless stated otherwise);
and |
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D. |
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Reconditioning, including work reconditioning. |
Respiratory Therapy
(Preapproval)
Respiratory therapy services when provided by a licensed
respiratory therapist.
Specialist Services
Covered services provided by referred specialists. Referrals
to non-participating specialists are approved by Keystone
when no appropriate participating specialist is available
within a reasonable geographic distance when the referral
is judged to be medically necessary by Keystone. The referral
is valid for an enrolled member for 90 days from the date
of issue. Self-referrals are excluded, except for emergency
and routine gynecological and obstetrical care. Additional
covered services recommended by the referred specialist
will require another written referral from your primary
care physician.
Spinal Manipulation Services
(Preapproval)
Covered services may be provided by your primary care physician
or referred specialist (except for a chiropractor) licensed
to perform such services. Covered spinal manipulation services
are provided in order to treat an acute condition related
to an acute medical episode and are subject to the determination
that significant improvement can be expected. Services are
covered when received in a 60 day period per medical episode.
Surgery (Preapproval)
Surgical services required for treatment of disease or injury.
Termination of Pregnancy
(Preapproval)
Covered only when necessary to prevent the death of the
woman, or in the case of rape or incest. Elective abortions
are not covered.
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