2022 Keystone 65 Preferred Medical Only (HMO)

Keystone 65 Preferred Medical Only (HMO) H3952-008 is a 2022 Medicare Advantage Plan or Part-C by Independence Blue Cross available to residents in Pennsylvania. This plan does not provide additional prescription drug (Part-D) coverage. The Keystone 65 Preferred Medical Only (HMO) has a monthly premium of $178.00 and has an in-network maximum out-of-pocket limit of $3,800 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,800 out-of-pocket. This can be a extremely nice safety net.

Keystone 65 Preferred Medical Only (HMO) is a Local HMO *. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Independence Blue Cross works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Keystone 65 Preferred Medical Only (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Independence Blue Cross and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Independence Blue Cross except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

2022 Independence Blue Cross Medicare Advantage Plan Costs

2021 Keystone 65 Preferred Medical Only (HMO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$0-150 copay
Diagnostic tests and procedures	$0 copay
Lab services	$0 copay
Outpatient x-rays	$40 copay

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Doctor Visits

Primary	$0 copay
Specialist	$40 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$5-40 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$20 copay
Routine foot care	$20 copay

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Ground Ambulance

$150 copay

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Hearing

Fitting/evaluation	$0 copay
Hearing aids	$499-799 copay
Hearing exam	$40 copay

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Inpatient Hospital Coverage

$225 per day for days 1 through 6 $0 per day for days 7 through 90

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$225 per day for days 1 through 6 $0 per day for days 7 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay

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MOOP

$4,000 In-network

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Option

Yes, contact plan for further details

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$350 copay per visit

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Preventive Care

$0 copay

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Preventive Dental

Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Fluoride treatment	Not covered
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$20 copay
Physical therapy and speech and language therapy visit	$20 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $170 per day for days 21 through 100

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Transportation

Not covered

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Vision

Contact lenses	$0 copay
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$10 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Keystone 65 Preferred Medical Only (HMO) H3952

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Keystone 65 Preferred Medical Only (HMO) Plans Performance

Health Plan Customer Service Rating for Keystone 65 Preferred Medical Only (HMO)

Keystone 65 Preferred Medical Only (HMO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Keystone 65 Preferred Medical Only (HMO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.