| Special CareSM* Single adults and families |
adultBasicSM Adults between 19 and 65 years of age |
|
|---|---|---|
| Monthly Cost | $140.50/one adult; $200.40/one adult & child(ren); $280.95/two adults; $341.00/two adults & child(ren) |
$36.00 for Low Cost; $600.00 At Cost |
| Type of coverage | Traditional Blue Cross & Blue Shield limited benefit plan |
Keystone Health Plan East HMO limited benefit plan |
| Eligibility based on | Family size and income | Family size and income, and uninsured three months, unless uninsured as a direct result of being unemployed |
| Wait period (if eligible) | None | 35 mo. (as of 2/07) for $35.00 premium No wait for At Cost $313.18 premium if eligible |
| *Pre-existing condition rule | Yes Special Care will not pay for expenses related to a condition for which medical advice or treatment was recommended by a physician or received from a physician during the 12 months prior to the effective date of the policy. This “pre-existing” rule does not apply to a person who transfers coverage from another Blue Cross/Blue Shield plan within 30 days or to a person who qualifies for CHIP, Medical Assistance, or Medicare. |
No |
| Copays | 4 doctor office visits/year at $10 copay | $5 PCP/$10 specialist/$25 ER |
| Benefits | ||
| Doctor office visits | 4 visits/year for illness or injury ($10 copay) | unlimited ($5 PCP/$10 specialist) |
| Hospitalization | limited to 21 days per benefit period | unlimited |
| Surgery and anesthesia | covered | covered |
| Emergency accident and medical care | covered | covered ($25 copay, waived if admitted) |
| Diagnostic services | covered up to $1,000 per year | covered |
| Chemotherapy and radiation therapy | covered | covered |
| Maternity care | covered | covered |
| Newborn care | covered for up to 31 days following birth | covered for up to 31 days following birth |
| Dental | not covered | not covered |
| Vision and hearing | not covered | not covered |
| Prescription drugs | not covered | not covered — except for diabetic supplies and insulin and immunosuppressants related to transplants which are covered 100%* |
| Durable medical equipment (DME) | not covered | not covered — except for diabetic supplies and insulin* |
| Mental health | not covered | not covered |
| Serious mental illness | not covered | not covered |
| Substance abuse | not covered | not covered |
*adultBasic excludes prescription drugs except for mandated diabetic supplies and oral agents, including insulin and immunosuppressants, related to transplants. Members will, however, receive a discount on all brand name and generic prescriptions when they present their KHPE adultBasic ID card to a participating pharmacy.
**Please note that if, in addition to you and/or your spouse, you are applying for a child on this application, your child will be screened automatically for the Children’s Health Insurance Program (CHIP) and Medical Assistance.
For more information, call 1-800-464-5437 for adultBasic; 1-866-282-2702 for Special Care.
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