What is the Health Insurance Marketplace?

Mandated by the Health Care Law, the Health Insurance Marketplaces are a new way for certain consumers to buy health insurance. They offer a choice of different health plans for those who buy their own individual and/or small group coverage, certify health plans that participate, and provide information to help consumers better understand their health coverage options. IBC participates in the federally facilitated Health Insurance Marketplace for Pennsylvania by offering various commercial Products.

Keystone HMO Proactive Commercial Tiered Network Product

Keystone HMO Proactive — our lower-cost, tiered provider network product — is available to individuals and small groups. Keystone HMO Proactive has benefit designs with different member cost-sharing by tier and offers members lower out-of-pocket costs (e.g., copayment) for most services when they select or are referred to a provider in the Preferred benefit tier.

Our HMO network providers have been categorized into one of three benefit tiers for Keystone HMO Proactive:

  • Tier 1 – Preferred: Members pay the lowest cost-sharing for most services.
  • Tier 2 – Enhanced: Members pay a higher cost-sharing for most services compared to Tier 1 – Preferred.
  • Tier 3 – Standard: Members pay the highest cost-sharing for most services.

Benefit tier placement

  • Primary care physicians (PCP): Criteria include relative cost (i.e., contracted fee schedule), minimum quality standards, if applicable, and the tier of the facilities in which a PCP typically refers IBC patients for hospital and outpatient surgical services.
  • Specialists: Criteria include relative cost (i.e., contracted fee schedule) and the tier of the facilities in which a specialist typically refers IBC patients for hospital and outpatient surgical services.
  • Hospitals: Criteria include cost and minimum quality standards
  • Ancillary providers: Benefit tier placement is based on relative cost (i.e., contracted fee schedule) as compared to other network providers in an ancillary provider’s specialty

Frequently Asked Questions

If I need to refer a Keystone HMO Proactive member to another physician, how do I know what tier the physician is assigned to?

Are all providers from the Keystone HMO network assigned a tier?

How often will IBC update provider benefit tiers?

How does the prescription drug benefit work for my patients enrolled in Keystone HMO Proactive?

How do tiered network products impact my reimbursement rates?

How do I know what copayment amount to collect from a Keystone HMO Proactive member?

What are the minimum quality standards used for benefit tier placement?

Where can I find more information about Keystone HMO Proactive?

If I need to refer a Keystone HMO Proactive member to another provider, how do I know what tier the provider is assigned to?
When referring a Keystone HMO Proactive member to another provider, such as a specialist or facility, use the Find a Doctor tool to find a provider’s tier placement. Be sure to select Keystone HMO Proactive in the Select a Plan drop-down menu.

Keystone HMO Proactive members pay the lowest cost-sharing for most services when they use a Tier 1 – Preferred provider.

You can also use the PDF below, which lists Keystone HMO network hospitals and outpatient surgery centers by state and benefit tier.

Note: This document is current as of the revision date listed. For the most up-to-date information, use the Find a Doctor tool.

Hospital and Outpatient Surgery Center Benefit Tier Placements

Are all providers from the Keystone HMO network assigned a tier?
Yes, all physicians, hospitals, and ancillary providers from the Keystone Health Plan East HMO network are assigned a tier; however, certain services have the same cost-sharing for all benefit tier levels and therefore are not affected by the provider tier.

Services that have the same cost-sharing across all tiers include, but are not limited to, the following:

  • transplants
  • laboratory
  • preventive care
  • ambulance
  • urgent care
  • physical, occupational, and speech therapy
  • mental health
  • chiropractics
Note: Provider specialties that exclusively provide services that do not have tiered benefit differentials have been defaulted to Tier 3 – Standard Benefit Level.

Visit ibx4you.com for more information about cost-sharing for Keystone HMO Proactive members.

How often will IBC update provider benefit tiers?
IBC will re-evaluate the benefit tier placements annually and will provide network providers with advance written notice of any changes to their benefit tier placement that will become effective on January 1 of the following year. Over the course of the year, there may be some cases wherein the providers’ benefit tier is updated for the better. For example, a providers’ tier can be updated from Tier 2 to Tier 1 but not from Tier 1 to Tier 2 during the course of the year.

How does the prescription drug benefit work for my patients enrolled in Keystone HMO Proactive?
Keystone HMO Proactive plans use the FutureScripts® Preferred Pharmacy Network. The FutureScripts® Preferred Pharmacy Network allows us to achieve greater cost savings, and ultimately a lower premium for the member.

This pharmacy network is new to Independence as of 2014 and is a smaller version of our full FutureScripts® pharmacy network. Specifically, the Preferred Pharmacy Network excludes Walgreens and Rite Aid. If a member elects to get a prescription filled at Walgreens or Rite Aid, it will be considered an out-of-network claim and the member will be responsible for the total cost of the prescription drug(s) at the pharmacy. Some members can submit a paper claim for partial reimbursement.

With this preferred network, members will continue to have access to more than 50,000 pharmacies, such as CVS, Wal-Mart, and Target, in addition to independent pharmacies.

How do tiered network products impact my reimbursement rates?
You will be reimbursed in accordance with your applicable payment rates for commercial products.

How do I know what copayment amount to collect from a Keystone HMO Proactive member?
As you do today, continue to use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal to verify your patients’ copayment amount for their office visit. This transaction will display the appropriate cost-sharing amounts for all three tiers. Therefore you will need to know your benefit tier placement to determine the appropriate amount of cost-sharing to collect from the Keystone HMO Proactive member.

What are the minimum quality standards used for benefit tier placement?
The minimum quality standards used for benefit tier placement are unique to provider type. Please refer to the PDF below for detailed information about minimum quality standards for hospitals and PCPs.

2014 Minimum Quality Criteria for Hospitals and PCPs

Where can I find more information about Keystone HMO Proactive?
Go to www.ibx4you.com to learn more about Keystone HMO Proactive.

Contact Us

If you have questions specific to Keystone HMO Proactive or your benefit tier placement, please email us at provinquiry@ibx.com.