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Benefit limits and services not covered

Benefit limits for Keystone First members are:

  • For adult members you are limited to one (1) Inpatient Medical Rehabilitation Hospital admission each year - see exception process below.
  • If you are an adult in the general assistance category, you are also limited to one (1) acute care inpatient hospital admission each year - see exception process below.

These limits do not apply if you are under age 21 or if you are pregnant.

The limit period starts again on July 1 of every year.

Exception process

You or your provider may ask Keystone First to approve services above these limits.

This is called an exception. An exception can be granted if:

  • You have a serious chronic illness or other serious health condition and without the additional service your life would be in danger.
  • You have a serious chronic illness or other serious health condition and without the additional service your health would get much worse.
  • You would need more costly services if the exception is not granted.
  • You would have to go into a nursing home or institution if the exception is not granted.

To ask for an exception before you receive the service:

  1. Call Keystone First Member Services and tell the Member Services representative that you want to ask for an exception to the benefit limits.
  2. You can mail or fax a written request to:
    Benefit Limit Exceptions
    Member Services Department
    Keystone First
    200 Stevens Drive
    Philadelphia, PA 19113-1570
    Fax: 215-937-5367
  3. Your provider can call the Keystone First Patient Care Management department at 1-800-521-6622.

Services not covered

Some of the services that are not covered by the Pennsylvania Medical Assistance program and/or Keystone First include, but are not limited to, the following:

  • Services that are not medically necessary
  • Services given by a provider who is not in the Keystone First provider network, except for:
    • Emergency services
    • Family planning services
    • When there is prior approval from Keystone First
    • When you have Medicare and seek Medicare-covered services from the Medicare provider of your choice
  • Cosmetic surgery, such as face-lifts, tummy tucks or liposuction
  • Experimental and investigational procedures, services and/or drugs
  • Home modifications (for example, chair lifts)
  • Acupuncture
  • Infertility services
  • Paternity testing
  • Any service offered and covered through another insurance program, such as Worker's Compensation, Veterans Administration or other commercial insurance that has not been prior authorized by Keystone First. However, Medicare covered services do not require prior authorization.
  • Services provided outside the United States and its territories. Keystone First is not allowed to make payments outside of the United States.
  • Private duty (also known as shift care) skilled nursing and/or private duty home health aide services for members 21 years of age or older
  • Services not considered to be a "medical service" under Title XIX of the Social Security Act

This is not a complete list of non-covered services.

Keystone First may not cover all of your health care expenses. You may be responsible for payment of services if you have been told in advance that Keystone First does not cover the services. It is important to check with your PCP or Keystone First Member Services department to find out which health care services are covered.

If you cannot find what you are looking for on our website, please call Member Services at 1-800-521-6860.  Our Representatives are there to help you 24 hours a day, 7 days a week.