2022 Medicare Advantage Plan Benefit Details for the Keystone First VIP Choice (HMO D-SNP)

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

— Plan Health Benefits —
Base Plan
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: $480.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $3
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: $0 copay
• Specialist: $0 copay
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0 copay (authorization required)
• Lab services: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $0 copay (authorization required)
• Outpatient x-rays: $0 copay (authorization required)
Emergency care/Urgent care
• Emergency: $0 copay
• Urgent care: $0 copay
Inpatient hospital coverage
• $0 copay (authorization required)
Outpatient hospital coverage
• $0 copay (authorization required)
Skilled Nursing Facility
• $0 copay (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $0 copay
Rehabilitation services
• Occupational therapy visit: $0 copay (authorization required)
• Physical therapy and speech and language therapy visit: $0 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $0 copay (authorization required)
• Outpatient group therapy visit with a psychiatrist: $0 copay
• Outpatient individual therapy visit with a psychiatrist: $0 copay
• Outpatient group therapy visit: $0 copay
• Outpatient individual therapy visit: $0 copay
Opioid treatment program services
• In-network: 0% coinsurance
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): $0 copay (authorization required)
• Prosthetics (e.g., braces, artificial limbs): $0 copay (authorization required)
• Diabetes supplies: $0 copay (authorization required)
Dialysis
• 0% coinsurance
Hearing
• Hearing exam: $0 copay
• Fitting/evaluation: $0 copay (limits apply)
• Hearing aids: $0 copay (limits apply)
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: $0 copay (limits apply)
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: $0 copay (limits apply, authorization required)
• Diagnostic services: Not covered
• Restorative services: $0 copay (limits apply, authorization required)
• Endodontics: $0 copay (limits apply, authorization required)
• Periodontics: $0 copay (limits apply, authorization required)
• Extractions: $0 copay (limits apply, authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply, authorization required)
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Some coverage
• Transportation services for non-emergency care: Plan-approved locations: Not covered
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Not covered
• Telehealth: Not covered
• WorldWide emergency: Not covered
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Some coverage
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• $0 copay (limits apply)
Foot care (podiatry services)
• Foot exams and treatment: $0 copay
• Routine foot care: $0 copay (limits apply)
Medicare Part B drugs
• Chemotherapy: $0 copay (authorization required)
• Other Part B drugs: $0 copay (authorization required)

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The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
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If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
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