Keystone HMO ProactiveCommercial 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 Independence 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 Independence 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
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.
View our list of Keystone HMO network hospitals by state and benefit tier.
Keystone HMO Proactive members pay the lowest cost-sharing for most services when they use a Tier 1 — Preferred provider.
View our list of Keystone HMO network hospitals by state and benefit 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:
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
Learn more about Keystone HMO Proactive plans.
Independence 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.
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.
The pharmacy network for Keystone HMO Proactive plans 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.
The pharmacy network for Keystone HMO Proactive plans 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.
You will be reimbursed in accordance with your applicable payment rates for commercial products.
As you do today, continue to use the Eligibility and Benefits Inquiry transaction on PEAR Practice Management through the Provider Engagement, Analytics & Reporting (PEAR) 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.
The minimum quality standards used for benefit tier placement are unique to provider type. Please refer to the document below for detailed information about minimum quality standards for hospitals and PCPs.
View the Minimum Quality Criteria for Hospitals and PCPs
View the Minimum Quality Criteria for Hospitals and PCPs
Learn more about Keystone HMO Proactive plans in our Find a Plan section.
Contact Us
If you have questions specific to Keystone HMO Proactive or your benefit tier placement, please email us at pnsproviderrequests@ibx.com.
If you have questions specific to Keystone HMO Proactive or your benefit tier placement, please email us at pnsproviderrequests@ibx.com.