Keystone 65 Liberty Medical Only (HMO)
H3952 - 059 - 0
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Keystone 65 Liberty Medical Only (HMO) is a Medicare Advantage (Part C) Plan by Independence Blue Cross.
This page features plan details for 2024 Keystone 65 Liberty Medical Only (HMO) H3952 – 059 – 0 available in Philadelphia, Bucks, Chester, Delaware, Montgomery.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Keystone 65 Liberty Medical Only (HMO) is offered in the following locations.
Plan Overview
Keystone 65 Liberty Medical Only (HMO) offers the following coverage and cost-sharing.
| Insurer: | Independence Blue Cross |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,300 In-network |
| Drugs Covered: | No |
Ready to sign up for Keystone 65 Liberty Medical Only (HMO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Keystone 65 Liberty Medical Only (HMO) qualifies for a monthly Medicare Give Back Benefit of $90.00.
| Premium Reduction: | $90.00 |
Premium Breakdown
Keystone 65 Liberty Medical Only (HMO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $90.00 | $84.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Keystone 65 Liberty Medical Only (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $8,300 In-network |
| No |
| In-network | Yes, contact plan for further details |
| 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $40 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $15-55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0-275 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $45 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $40 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Endodontics | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Periodontics | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | 40% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| $260 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | $25 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $265 per day for days 1 through 7 $0 per day for days 8 through 90 $0 per day for days 90 and beyond (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $265 per day for days 1 through 7 $0 per day for days 8 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $20 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $30 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for Keystone 65 Liberty Medical Only (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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