No referrals required for 2018 Keystone 65 HMO Plans

We recently asked our Medicare members for suggestions to improve their experience as a member. One answer stood out: referrals. In response to this feedback, we are pleased to announce that, effective January 1, 2018, we no longer require referrals from a primary care physician (PCP) to see a specialist in the Keystone 65 HMO network.

Currently, HMO plans require a referral from a PCP before members can see any other health care professional, except in an emergency, a requirement some members found frustrating.

We anticipate this change will address this request and help Medicare members get the most from their health plans.

Other key features of our Keystone 65 HMO plans

•	Members must continue to choose a PCP and other plan providers that are part of the plan’s network. Checking whether a doctor or specialist is in the plan’s network is easy with the online Provider Finder Tool. Members can also call the Member Help Team at the number on the back of their ID cards.
•	Since the PCP is responsible for coordinating and arranging most of the member’s health care services, he or she has identified designated sites, or specific providers, for certain services such as laboratory, radiology, occupational therapy, and physical therapy services. This process is also known as capitation.
•	A doctor may write a prescription for medical care. A prescription, or “script,” will direct members to a lab or radiology center for blood work, X-rays, MRIs, and similar procedures. The process for prescriptions is determined by the doctor’s office.
•	In some cases, for specific covered services, the PCP may need to get approval in advance from our plan (this is called getting “prior authorization”). Covered services that need approval in advance are noted in the plan's Evidence of Coverage.

How will members be notified of this change?

Members will be notified of this change as part of their Annual Notice of Change (ANOC) which they receive on or before September 30, 2017 as well as in a post-ANOC mailing which highlights some of the more important changes which mails mid-October. In addition, we have other sales and marketing materials which describe this change.

If you have any questions about this article, please contact your Medicare account executive.

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.