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Frequently Asked Questions

Frequently Asked Questions About Keystone HMO Proactive Plans With a Tiered Network

What Is a Tiered Network?

Keystone HMO Proactive works just like a typical HMO in that you can visit any doctors and hospitals in the network, and you select a primary care physician (PCP) who refers you to specialists. With a tiered network, you can save on your out-of-pocket costs when you visit certain health care providers.

All Keystone Health Plan East HMO providers have been grouped into three tiers based on cost and, in some cases, quality measures. While all of the doctors and hospitals in our network must meet high quality standards, some are able to offer more cost-effective care. If they cost less, then you’ll pay less. It’s that simple. You can check what tier a doctor is in by searching for them in our Find a Doctor tool and selecting “Keystone HMO Proactive” in the plan drop-down menu.

  • 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.

What Is the Difference Between a Tiered Network and a Limited Network?

With an HMO tiered network plan, the network is divided into three groups that we call tiers. All three tiers have high-quality doctors and hospitals. But don’t think that high quality has to equal high cost. These tiers help you choose providers that offer you the best value on care. Our HMO tiered network plans are called Keystone HMO Proactive and give you access to the full HMO network of more than 46,000 doctors and 160 hospitals, unlike a limited network that gives you access to a smaller portion of a network.

Are There Certain Services That Are Covered at the Same Cost Regardless of Tier Level?

Yes. Many covered services will cost you the same amount no matter the tier level of the provider or facility you choose. These are:

  • Preventive care
  • Emergency room
  • Emergency ambulance
  • Urgent care
  • Prescription drugs
  • Pediatric dental and vision
  • Behavioral health
  • Transplants
  • Spinal manipulation
  • Outpatient lab/pathology1
  • Routine radiology/diagnostic1
  • MRI/MRA, CT/CTA scan, PET scan1
  • Physical/occupational therapies1

What Happens If I Am Admitted to a Tier 2 – Enhanced or Tier 3 – Standard Hospital Through Their Emergency Room?

Emergency room fees are the same no matter which tier of hospital you choose. However, if you are admitted to the hospital from the ER, your out-of-pocket costs for the inpatient hospital stay will be determined by the hospital’s tier.

What Is Unique About the Keystone HMO Proactive Plans?

The Keystone HMO Proactive plans still include the full Keystone Health Plan East HMO network of providers. However, with our Proactive plans, doctors, hospitals, and other types of providers in the Keystone Health Plan East HMO network have been assigned to one of three benefit tiers. For most services, you can save money when you visit providers in lower tiers.

There are some services, such as preventive care and emergency room, physical therapy, occupational therapy, and mental health, which have the same cost-sharing regardless of the provider’s assigned tier.

Why Should I Choose a Keystone HMO Proactive Plan With a Tiered Network?

Keystone HMO Proactive plans are ideal if you’re looking for a more affordable plan. They tend to have lower monthly premiums, plus they give you an opportunity to save even more on your cost-sharing by visiting providers in Tier 1 – Preferred. When you choose a Keystone HMO Proactive plan, you don’t have to stick with just one tier. You can choose Tier 1 – Preferred providers for some services and providers from Tier 2 – Enhanced or Tier 3 – Standard for other services. The choice is yours each time you receive care. You can check the tiers of your current doctors and providers using our Find a Doctor tool.

Are All Providers From the Keystone Health Plan East HMO Network Assigned a Tier?

Yes, all doctors, hospitals, and other health care providers from the Keystone Health Plan East HMO network are assigned a tier; however, there are some services that have the same cost-sharing across all tiers. Examples include preventive care, emergency room, physical therapy, occupational therapy, and mental health. Refer to the summary of benefits for more details.

Will My Cost-Sharing Always Vary Based on the Provider and Tier I Choose?

No. There are some services that have the same cost-sharing across all tiers. Examples include preventive care, emergency room, physical therapy, occupational therapy, and mental health. Only certain provider types will have cost-sharing that varies based on the tier assignment. Refer to the summary of benefits for more details.

How Did Independence Blue Cross Determine Which Tier Providers Are Assigned to?

We assign our HMO network providers to one of three tiers on an annual basis. These tier assignments are based on relative cost, quality (if available) and the tier of the facilities in which your PCP typically refers Independence Blue Cross patients for hospital and outpatient surgical services. While all of the doctors in our network must meet high quality standards, many offer the same services at a lower cost.

What Percentage of Providers Are in Tier 1 – Preferred?

More than 50 percent of doctors and hospitals are in Tier 1 – Preferred, so you have plenty of choices on where you receive care. And you don’t have to stay within one tier. For example, you can choose to see Tier 2 – Enhanced providers for some services and Tier 3 – Standard providers for other services.

How Often Will Providers Change Tiers?

Independence Blue Cross re-evaluates its tier assignments annually, and tier assignments are effective January 1.

How Can I Find Out Which Tiers My Doctors and Hospitals Are In?

You can see all of the Keystone Health Plan East HMO network hospitals arranged by tier and county by viewing the Tiered Network Hospital List. You can also see which tiers your doctors and hospitals are assigned by using our Find a Doctor tool.

If My Doctor Refers Me to a Specialist in Tier 2 – Enhanced or Tier 3 – Standard, Is There Anything I Can Do?

Yes. You can speak with your doctor about why he or she chose the specialist. You can explain to your doctor that you have a tiered network plan and that you prefer to see a Tier 1 – Preferred specialist if possible.

Do I Need to Worry About Tiers in the Event of an Emergency?

No. If you have an emergency, you should visit the nearest hospital. Emergency room services, in addition to a few other services, have the same cost-sharing across all tiers. Please note that if you are admitted to an in-network hospital from the emergency room, the cost-sharing for inpatient hospital care will apply based on the tier of the in-network hospital. If you are admitted to an out-of-network hospital following an emergency room admission, the Tier 3 – Standard level of benefits (highest cost-sharing) will apply.

Can a Doctor Be Assigned to More Than One Tier?

Yes, since tiers are assigned by office location, rather than by individual doctor. For example, Dr. Smith’s office in the city may be assigned to Tier 1 – Preferred while the office in the suburbs may be assigned Tier 2 – Enhanced. What you pay when you see Dr. Smith will be based on the tier of the office you visit for your appointment. This tier assignment will be displayed in our Find a Doctor tool.

What Is the Difference Between Keystone HMO Silver Proactive and Keystone HMO Silver Proactive Value?

While the plans are very similar, the Keystone HMO Silver Proactive Value plan has a $1,500 deductible in Tier 1, while the basic Keystone HMO Silver Proactive plan has no deductible in Tier 1. However, it’s important to note that there are a variety of services, such as visiting your primary care physician (PCP), seeing a specialist, or going to the emergency room that are not subject to the Tier 1 deductible in the Keystone HMO Silver Proactive Value plan. Inpatient stays and outpatient services will be subject to the deductible and the applicable member cost-sharing in the Keystone HMO Silver Proactive Value plan.

Please note that as of 2017 Keystone HMO Silver Proactive Value is not available for purchase through the Federal Health Insurance Marketplace.

Who Can I Contact For Keystone HMO Proactive Inquiries?

You can contact a customer service representative for Keystone HMO Proactive related-inquiries by calling 1-844-BLUE-4ME (1-844-258-3463, TTY: 711).

1 When you receive services at a designated site referred by your primary care doctor