Frequently Asked Questions
Keystone Health Plan East HMO
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.
HMO Basics
What is an HMO?
What is a PCP?
What is a specialist?
What does “in-network” mean?
How many doctors and hospitals are in the network?
How do I find out if my doctor is in the network?
May I change my PCP after I have chosen one?
What is a premium?
What is a copay?
What is a deductible?
What is coinsurance?
What is an out-of-pocket maximum?
What is a preexisting condition exclusion?
What is durable medical equipment?
WHAT’S COVERED?
How do I know what is covered under the plans?
For the deductible plans, which services are subject to the deductible?
Are preexisting conditions covered?
Are routine eye exams covered?
Are emergency services covered?
Do you provide maternity coverage?
Are prescription drugs covered?
Do the plans cover dental?
Are alternative health services covered?
What are the Healthy LifestylesSM programs?
What are the ConnectionsSM Health Management Programs?
What is ibxpress.com?
PRESCRIPTIONS
How does the prescription drug program work?
What is the maximum prescription drug benefit?
What is the difference between generic and brand medications?
What is a formulary?
Does the prescription plan cover non-formulary medications?
Does the prescription plan have a mail-order service?
Do I have to go to a participating pharmacy?
Are birth control pills covered under the Individual HMO plans?
APPLYING
How do I apply?
Can I apply for health coverage for my family?
Can I add my spouse or child at a later date?
Can I add my domestic partner to my health coverage?
Can I add my fiancée to my health coverage?
Can I apply if, I am eligible, for Medicare?
Can I apply for multiple plans?
Can I apply for one plan for myself and another plan for a family member?
How long will it take to process my application?
How can I expedite the processing of my application?
Do I have to supply medical records with my application?
Whom do I contact if I have questions regarding filling out my application?
Once I have accepted coverage, how soon can I expect to receive my membership card and Subscriber Agreement?
PREMIUMS
Do I need to make a premium payment when I submit my application?
Will my actual rate be different than the base rate?
What happens to my initial premium if the coverage I requested is denied?
What happens if my actual rate is more than the base rate?
How long are the rates valid?
When are my premiums due?
How does electronic payment work?
How long will it be before the initial payment comes out of my account?
Application Process
How do I change my address, phone number(s), email address or contact preferences on ibx4you.com?
How do I change my password?
What if I forgot my password?
What if I forgot my username?
What if I forgot my username and password?
What should I do if I receive a message that account access has been disabled?
Can I finish completing my application later?
How do I check the status of my application?
How do I download the Adobe Acrobat Reader software to view documents?
Who do I contact for technical questions about using this site?
HMO Basics
What is an HMO?
An HMO (health maintenance organization) is a health care coverage organization that provides members with access to medical services through a network of doctors and hospitals. One doctor, your primary care physician (PCP), coordinates your overall medical needs.
What is a PCP?
The PCP (primary care physician) is the doctor, internist, or pediatrician who manages your health care and refers you to specialists or health care service providers, such as laboratories and radiology centers. Under certain circumstances, a specialist or an OB/GYN may be selected as a PCP.
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 generally need to obtain a referral from your PCP to receive benefits for care provided by a specialist.
What does “in-network” mean?
Your health care coverage is considered in-network when you use a provider who participates in the Keystone Health Plan East network.
How many doctors and hospitals are in the network?
Keystone Health Plan East’s provider network includes more than 50,000 physicians and 100 hospitals.
How do I find out if my doctor is in the network?
To see if your doctor is in our network, search our provider directory.
May I change my PCP after I have chosen one?
Yes. Once you are a member, it’s easy to change your PCP. Simply login to ibxpress.com, or call 1-800-ASK-BLUE. PCP changes become effective on the first day of the following month.
What is a premium?
A premium is the amount you pay on an incremental basis for health care coverage.
Tip: Signing up for electronic payment is the easiest way to pay your premiums. See “How does electronic payment work?” in the Premiums section for more information.
What is a copay?
A copay is a specified dollar amount you pay for a doctor visit or other specified medical service.
What is a deductible?
A deductible is the total amount, per calendar year, that a member may pay for certain covered medical services before Keystone Health Plan East provides benefits as described in the plan. For services that require a deductible, you will be responsible for paying the provider for services until the deductible has been met. Certain items, such as premium payments, copayments, and expenses not covered by your plan, do not count toward your deductible.
What is coinsurance?
After you’ve met your annual deductible, we share the cost of medical care with you. Coinsurance is the portion that you pay for the cost of a covered service. For example, under a 70/30 coinsurance plan, you are responsible for 30 percent of the cost while Keystone Health Plan East pays the remaining 70 percent, until the out-of-pocket maximum has been reached.
What is an out-of-pocket maximum?
An out-of-pocket maximum is a dollar amount that limits the amount you have to pay out of your own pocket for covered medical services during a calendar year. If you reach the out-of-pocket maximum, we pay 100 percent for covered benefits. The out-of-pocket maximum includes coinsurance, but does not include deductibles or copays.
What is a preexisting condition exclusion?
A preexisting condition exclusion excludes coverage for a certain period of time for services related to any medical condition or illness for which medical advice or treatment was recommended or received within 90 days prior to the effective date of coverage. Refer to the What’s Covered section for more information.
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’S COVERED?
How do I know what is covered under the plans?
To view benefits associated with each plan, visit the Benefits Summary section.
In general, the plans cover:
- doctor’s office visits
- hospital care
- maternity and newborn care
- child wellness exams and immunizations
- outpatient services
- emergency coverage
- skilled nursing facility care
- annual routine gynecological exams
- mammograms
- prescriptions drugs
For the deductible plans, which services are subject to the deductible?
For the deductible plans (e.g., HMO $1500 Deductible, HMO $2500 Deductible, and HMO $5000 Deductible), services subject to a deductible include, but are not limited to, the following services:
- inpatient hospital services
- outpatient surgery
- emergency room
- ambulance
- chemo/radiation/dialysis therapy
- skilled nursing facility
- home health care
- hospice
Routine services, preventive care, and prescription drug benefits have copayment amounts and are not subject to a deductible for the deductible plan options.
Are preexisting conditions covered?
The HMO plans exclude coverage on any preexisting condition during the first 12 months of coverage. A preexisting condition is defined as any condition, illness, or injury for which medical advice or treatment was recommended or received within the 90-day period that precedes your effective date of coverage.
Are routine eye exams covered?
Routine eye exams are covered once every two calendar years using a participating provider. There is also a reimbursement for eyeglasses and contact lenses. Review the Plan Benefits Summary for details.
Are emergency services covered?
Yes. You are covered for medically necessary services for unexpected illnesses or emergency care no matter where you are. Whether you are away at school or traveling for business or pleasure, your coverage extends beyond the local service area so that you have access to health care benefits across the country.
Do you provide maternity coverage?
Yes. Your first OB visit is subject to a copayment. The maternity hospital stay is subject to a copayment for the copay plans or is subject to a deductible and coinsurance for the deductible plans.
Are prescription drugs covered?
Yes. Prescription drug coverage is available with all of the plans. Refer to the Prescriptions section for more information.
Do the plans cover dental?
No. The Individual HMO plans do not cover dental services.
Are alternative health services covered?
You can receive up to a 30 percent discount on alternative health services, including massage therapy and acupuncture through, our Healthy LifestylesSM program.
What are the Healthy LifestylesSM programs?
At no additional cost, you can take advantage of our value-added wellness programs. Our Healthy Lifestyles 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.
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?
ibxpressSM 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;
- find and compare network doctors;
- check the status of a claim;
- request an ID card;
- access health information and tools;
- enroll in a Healthy Lifestyles program;
- find out more about discounted health services and products.
PRESCRIPTIONS
How does the prescription drug program work?
The prescription drug program is administered by FutureScripts®, an independent pharmacy benefits management company. The FutureScripts network includes 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.
For copay plans (i.e., HMO $10 Copay, HMO $15 Copay, or HMO $20 Copay):
Once you have satisfied your annual prescription deductible, you pay the copayment specified for generic formulary, brand formulary, or non-formulary brand.
For deductible plans (i.e., HMO $1500 Deductible, HMO $2500 Deductible, or HMO $5000 Deductible):
There is no annual deductible for prescription drugs. You simply pay the copayment specified for generic formulary, brand formulary, or non-formulary brand.
All Individual HMO plans, both copay and deductible options, are subject to a maximum prescription drug benefit of $2,500 for individuals and $5,000 for families. If you exceed your calendar year maximum, you will pay 100 percent for any prescriptions over the maximum benefit*. You should continue to use a participating pharmacy and show your ID card to receive the negotiated discount rates for your prescription. This rate may be lower than the rate charged to customers who are not members of our Individual HMO plans.
*The maximum prescription drug benefit does not apply to diabetic equipment and supplies, including insulin and oral agents.
What is the maximum prescription drug benefit?
The maximum prescription drug benefit is $2,500 for individuals and $5,000 for families.
The maximum prescription drug benefit is calculated on either:
- FutureScripts negotiated discount price at a participating pharmacy;
- retail charge at a nonparticipating pharmacy.
Once the maximum benefit has been met, members are responsible for 100 percent of either the:
- FutureScripts discount price at a participating pharmacy for covered prescription drugs;
- retail charge at a nonparticipating pharmacy.
However, the maximum prescription drug benefit does not apply to diabetic equipment and supplies, including insulin and oral agents.
You should continue to use a participating pharmacy and show your ID card to receive the negotiated discount rates for your prescription. This rate may be lower than the rate charged to customers who are not members of our Individual HMO plans.
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.
What is a formulary?
The formulary is a list of medications that have been carefully selected for their medical effectiveness, positive results, and value. The formulary includes all generic medications and a defined list of brand medications. The formulary includes at least one drug in all classes of drugs. 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.)
Does the prescription plan have a mail-order service?
Yes. 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.)
Do I have to go to a participating pharmacy?
In order to pay the lowest costs for your prescriptions, you should have them filled at a participating pharmacy or through the mail-order service. If you need a prescription filled outside the network, you will need to pay up front, you will incur higher costs, and you will have to submit a claim form and detailed pharmacy receipt to obtain reimbursement.
Are birth control pills (oral contraceptives) covered under the Individual HMO plans?
Yes. Birth control pills (oral contraceptives) and injectable contraceptives are covered under the prescription drug benefit of each plan. They are subject to a copayment 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.
APPLYING
How do I apply?
You can apply online or you can request an enrollment packet containing a paper application by mail at www.ibx4you.com. 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.
To request an application by mail, you must first register, then select Request a Paper Application by Mail on the How to Apply screen, or call 1-800-263-1410 between 9 a.m. and 9 p.m.
Can I apply for health coverage for my family?
Yes. You can apply for health coverage as a(n):
- individual
- individual and spouse
- individual and child(ren)
- family
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 clause. 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 childern) would be subject to the preexisting condition exclusion period and medical underwriting.
Can I add my domestic partner to my health coverage?
No. Your domestic partner can apply individually for Individual HMO coverage. We do not currently provide combined coverage for domestic partners.
Can I add my fiancée to my health coverage?
No. Your fiancée can apply individually for Individual HMO 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 clause.
Can I apply, if I am eligible, for Medicare?
No. If you are eligible for Medicare, go to www.site65.com for more information on Independence Blue Cross Medicare Advantage and Medicare Supplement plans.
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 HMO 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, Individual HMO $10 Copay, 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. Member’s 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 the processing of my application?
To avoid processing delays, be sure to:
- complete the application as carefully and accurately as possible;
- answer all applicable questions;
- select a primary care physician (PCP) for yourself and each of your covered dependents. Be sure to include the HMO ID number (PCP Office Code) for each physician or medical office;
- 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;
- authorize electronic payment (applies to online and paper applications) or send a check (applies to paper application 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.
Whom do I contact if I have questions regarding filling out my 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 membership card and Subscriber Agreement?
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 your online benefits account.
PREMIUMS
Do I need to make a premium payment when I submit my application?
Independence Blue Cross will provide you with a base rate which is tied to your age, gender, and family status (e.g., single, family). You will need to authorize payment for the initial premium in the amount of this base rate.
Premiums for online applications are paid electronically via the automated clearing house (ACH) process. Premiums for paper applications can be paid via ACH or with a check. If you submit a check, it must be for the first quarterly premium, and the check should be made payable to Keystone Health Plan East.
If you apply with a paper application and select to pay via ACH, you must submit a completed ACH authorization form and voided check (for checking account withdrawals) or deposit slip (for savings account withdrawals) with your application.
Note: Your initial premium will not be processed until coverage is approved by Independence Blue Cross.
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.
Will my actual rate be different than the base rate?
The base rate you are given is determined by the preliminary 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.
What happens to my initial premium if the coverage I requested is denied?
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.
What happens if my actual rate is more than the base rate?
If you authorized electronic payment via ACH, the amount of the actual rate will be withdrawn from your account. If you sent a check for your initial premium in the amount of the base rate, the check will be processed and the difference in premium will be billed and shown on your next premium statement.
For both ACH and check payments, you will be informed of your actual rate with your coverage approval notice.
How long are the rates valid?
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.
When are my premiums due?
Premiums are due on the 1st or 15th of the month, depending on your effective date of coverage. When you apply online, your premiums will always be due monthly and paid electronically through the ACH process. When you apply with a paper application, your premiums will be due quarterly unless you opt for electronic payment, in which case your premiums will be due monthly. Signing up for electronic payment is the easiest way to pay your premiums.
How does electronic payment work?
Electronic payment is a free service offered by Independence Blue Cross that allows you to have your premium automatically deducted monthly from your checking or savings account via the ACH process. Electronic payment is the worry-free way to help ensure you won’t miss a payment and risk losing your health insurance coverage.
You won’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. Plus, electronic payment helps you budget monthly expenses and allows you to spread out your premiums over the course of a year to avoid larger quarterly payments.
All online applicants will pay premiums using electronic payment. If you request a paper application, you will receive an electronic payment enrollment form with your packet.
How long will it be before the initial payment comes out of my account?
Your initial payment will be taken once you are approved and accept the terms of coverage. 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.
Application Process
How do I change my address, phone number(s), email address or contact preferences for my online applicaton?
Go to www.ibx4you.com/apply. 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.
How do I change my password?
Go to www.ibx4you.com/apply. 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 and your new password twice.
What if I forgot my password?
Go to www.ibx4you.com/apply 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 if I forgot my username?
Go to www.ibx4you.com/apply 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 if I forgot 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.
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 9:00 p.m.
Can I finish completing my application 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/apply 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.
How do I check the status of my application?
To see the status of your application, go to www.ibx4you.com/apply and login with your username and password. Once you are in your account, you should be able to see the status of your application.
How do I download the Adobe Acrobat Reader software to view documents?
You can obtain a free download of Adobe Acrobat 6.0 from their website at adobe.com.
Whom do I contact for technical questions about using this site?
Please call 800-263-1410 between 9:00 a.m. and 9:00 p.m. Or, email us your question or comment.
Frequently Asked Questions