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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2022 Independence Blue Cross Medicare Advantage Plan Costs

Name:
Keystone 65 Preferred Medical Only (HMO)
Plan ID:
H3952-008
Provider:Independence Blue Cross
Year:2022
Type: Local HMO *
Monthly Premium C+D: $178.00
Part C Premium:
MOOP: $3,800
Similar Plan: H3952-020
New Plan: 2023 H3952-020




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

*This will be updated with 2022 data when available.



Additional Benefits


No



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



Deductible


$0



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



Doctor Visits


Primary $0 copay
Specialist $40 copay per visit



Emergency care/Urgent Care


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



Foot Care (podiatry services)


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



Ground Ambulance


$150 copay



Hearing


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



Inpatient Hospital Coverage


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



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



Medicare Part B Drugs


Chemotherapy 20% coinsurance
Other Part B drugs 20% coinsurance



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



MOOP


$4,000 In-network



Option


Yes, contact plan for further details



Optional supplemental benefits


No



Outpatient Hospital Coverage


$350 copay per visit



Preventive Care


$0 copay



Preventive Dental


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



Rehabilitation Services


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



Skilled Nursing Facility


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



Transportation


Not covered



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



Wellness Programs (e.g. fitness nursing hotline)


Covered




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



2021 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


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

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


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

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


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

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes



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.

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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system.