Special Care and Adultbasic: Comparison Chart

COMPARISON CHART
Special CareSM and adultBasic
Special Care adultBasic

Single adults and families Adults between 19 and 65 years of age
$148.70/one adult; $211.70/one adult & child(ren)*;
Monthly cost $36 for Low-Cost; $629.00 At-Cost
$297.35/two adults; $360.50/ two adults & child(ren)*
Traditional Blue Cross & Blue Shield Keystone Health Plan East HMO
Type of coverage
limited benefit plan limited benefit plan
Family size and income
Age, family size and income, and uninsured 3 months, unless
Eligibility based on (income review will be waived for individuals transferring from
uninsured as a direct result of no longer working
adultBasic by 5/2/2011)
Wait period (if eligible) None Yes
Yes
Coverage excluded for one year for medical condition for which
medical advice or treatment was received during the 12 months
Pre-existing condition rule No
prior to the effective date of the policy.
(unless transferring from another Blue plan within 30 days or for
individuals transferring from adultBasic by 5/2/2011)
4 doctor office visits per year at
Copays $10 PCP/$20 Specialist/$50 ER
$15 PCP/$25 Specialist copay
BENEFITS BENEFITS BENEFITS
4 doctor office visits per year at $10 PCP copay (except for preventive care)
Doctor Office Visits $15 PCP/$25 Specialist copay $20 Specialist copay
Hospitalization limited to 21 days per benefit period unlimited
Surgery and Anesthesia covered covered
Emergency Accident and Medical covered $50 copay (waived if admitted)
Diagnostic Services covered 10% coinsurance/$1,000 maximum per year for all coinsurance
Chemotherapy, Dialysis and Radiation
covered 10% coinsurance/$1,000 maximum per year for all coinsurance
Therapy
Maternity Care covered 10% coinsurance/$1,000 maximum per year for all coinsurance
covered for up to 31 days following birth, 10% coinsurance/$1,000
covered for up to 31 days following birth
Newborn Care maximum per year for all coinsurance
Dental not covered not covered
Vision and Hearing not covered not covered
not covered, except for diabetic supplies and insulin and

not covered immunosuppressant's related to transplants which are covered at
10% coinsurance/$1,000 maximum per year for all coinsurance
Prescription Drugs
not covered, except for diabetic supplies and insulin and

not covered immunosuppressant's related to transplants which are covered at
10% coinsurance/$1,000 maximum per year for all coinsurance
Diabetic Supplies
not covered, except for diabetic supplies and insulin which are
not covered covered at 10% coinsurance/$1,000 maximum per year for all
Durable Medical Equipment (DME) coinsurance
Mental Health/Substance Abuse not covered not covered
Physical, Occupational and Speech
not covered 10% coinsurance/$1,000 maximum per year for all coinsurance
Therapy
Cardiac Rehabilitation not covered 10% coinsurance/$1,000 maximum per year for all coinsurance
(36 sessions for a 12-week period)
Pulmonary Rehabilitation not covered 10% coinsurance/$1,000 maximum per year for all coinsurance
(36 sessions for a 12-week period)
Respiratory Therapy
(18 sessions per calendar year 36 not covered 10% coinsurance/$1,000 maximum per year for all coinsurance
sessions for a 12-week period)
Home Infusion not covered 10% coinsurance/$1,000 maximum per year for all coinsurance
Home Health Care not covered 10% coinsurance/$1,000 maximum per year for all coinsurance
Skilled Nursing Facility Care
(60 days per calendar year)
Inpatient Rehabilitation Therapy
(45 days per calendar year)
For more information, visit our website at www.ibx.com/adultbasic_options or call: 1-866-282-2702.
*All children will be screened automatically for the Children's Health Insurance Program (CHIP) and Medical Assistance.
The Independence Blue Cross & Highmark Blue Shield Caring Foundation For Children, along with Keystone Health Plan East, independent licensees of the Blue Cross and Blue
Shield Association, is an administrator of adultBasic. For additional information regarding adultBasic, call 1-800-GO-BASIC.
Special Care is not affiliated with SPECIAL CARE Inc., a home care company.
Jan 2011

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COMPARISON CHART

Special CareSM and adultBasic

Special Care adultBasic

not covered, except for diabetic supplies and insulin and

not covered, except for diabetic supplies and insulin and

For more information, visit our website at www.ibx.com/adultbasic_options or call: 1-866-282-2702.

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