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Your Choice Benefits Supplemental Life Insurance What You Must Do Now A Quick Look at Keystone Pont of Service Home |
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Personal Choice
You can elect the Personal Choice plan. This is the most costly plan offered by the Fund. If you choose this option, you will not receive benefit credits.  Keystone Point of Service
Choose Keystone Point of Service Plan and get the best features of both a traditional indemnity plan and a managed care plan in one. And receive benefit credits to buy additional Choice benefits. 
Dual Income Option
Get the most benefit credits if you have coverage elsewhere and choose the Dual Income Option. This plan provides up to $5,200 (for deductibles, co-payments, and coinsurance) per year per person in addition to your other coverage. The Dual Income Option If you have other medical coverage (through another job, or your spouse’s employer, for example), the Dual Income option may be the right choice for you. Here’s how it works to fill in the gaps of your other coverage-deductibles, co-payments and coinsurance amounts you and your spouse are required to pay. The Dual Income option does not pay benefits for services not covered under the other medical plan. |
| Total Medical Expenses | Dual Income Option Pays |
| $25,000 |
20%
$5,000 }
$5,200 |
| $200 |
100%
$200 } |
| The Fund will cover the first $200 of eligible expenses
in full and 20% of the next $25,000
in eligible medical expenses up to a yearly maximum benefit of $5,200 ($200 plus 20% of $25,000)
per person. If you choose this option, you will receive benefit credits, which can be used to purchase additional Choice benefits. A QUICK LOOK AT KEYSTONE PONT OF SERVICE |
FEATURE |
IN-NETWORK |
OUT-OF NETWORK |
| Calendar Year Deductible |
None | $500 per person $1,500 per family |
| Calendar-year Out-of- Pocket Maximum (not including deductible) | $1,000 per person $2.000 per family |
$2,500 per person $7,500 per family |
| Doctor's Visits Primary Care |
$15 co-pay | 80% UCR after deductible |
| Specialist | $25 co- pay | 80% UCR after deductible |
| Routine Adult Physicals | $15 co -pay | Not covered |
| Routine Gyn | $25 co -pay | 80% no deductible |
| Routine Mammogram | 100% | 80% no deductible |
| Well Child Care/ Immunizations |
$15 co -pay | 80% no deductible |
| Hospital (semiprivate room) |
100% | 80% UCR after deductible * |
| Surgery | 100% | 80% UCR after deductible |
| X-ray and Lab | 100% | 80% UCR after deductible |
| Maternity Care | $25 co-pay first visit only; then 100% |
80% UCR after deductible |
| Hospital Emergency Room Care | $35
co-pay (waived if admitted) |
$35
co-pay (waived if admitted) |
| Skilled Nursing Facility (custodial care not covered) |
100% up to 180 days | 80%UCR after deductible * |
| Mental Health Inpatient |
100% up to 35 days/yr | 80%UCR after deductible* |
| Outpatient | $25 co-pay per visit up to 20 visits per year |
50% UCR after deductible up to 60 visits per year/$30 per visits |
| Substance Abuse Inpatient | 100% up to 30 days/yr | 80% UCR after deductible* |
| Outpatient | $25 co-pay up to 60 visits per year |
80% UCR after deductible up to 30 visits per year |
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* precertification required |