Plan H3952-008-0: Keystone 65 Preferred Medical Only (HMO) – 2025 Coverage Details for Bucks County, PA
This page provides coverage, cost, and availability details for Independence Blue Cross’s H3952-008-0 Medicare Advantage plan for 2025.
See more Medicare Advantage Plans in Bucks County, Pennsylvania.
*CMS rated this Independence Blue Cross plan (H3952-008-0) 4.5 (Good+) out of 5 stars.
Keystone 65 Preferred Medical Only Basic Plan Details
- Plan ID
- H3952-008-0
- Plan Type
- HMO
- Plan Year
- 2025
- Premium
- $129.50/mo
Plus your Medicare Part B premium. - Health Plan Deductible
- $0.00
- Out-of-Pocket Maximum
- 4,000.00 /yr (in-network)
- Part B Reduction
- $0.00/mo
- Drug Plan Benefit
- Not Included
- Supplemental Benefits
- Vision, Hearing
- Availability
- Bucks County, PA
- Insured By
- Independence Blue Cross
| Summary of Benefits |
|---|
Health Plan Out-of-Pocket Costs
This Independence Blue Cross Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H3952-008-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
- Primary
- $0 Copay
- Specialist
- $40 Copay
Emergency, Urgent, and Inpatient Hospital Coverage
- Emergency room care
- $140 Copay
- Urgent care
- $55 Copay
- Ground ambulance
- $150 Copay
- Inpatient hospital care
- $225.00 per day for days 1 through 6
$0.00 per day for days 7 and beyond - Skilled Nursing Facility
- $0.00 per day for days 1 through 20
$214.00 per day for days 21 and beyond
Foot Care
- Foot Exams and Treatments (Medicare-covered)
- $20 Copay
- Routine Foot Care
- $20 Copay
Chiropractic Care
- Medicare-covered chiropractic
- $20 Copay
- Routine chiropractic
- Not Covered
Mental Health Services
- Outpatient individual therapy
- $30 Copay
- Outpatient group therapy
- $20 Copay
- Inpatient psychiatric hospital care
- $225.00 per day for days 1 through 6
$0.00 per day for days 7 and beyond
Rehabilitation Services
- Physical therapy and speech and language therapy
- $20 Copay
- Occupational therapy
- $20 Copay
Medical Equipment and Supplies
- Diabetes supplies
- 20% Coinsurance
Prior Authorization Required - Durable medical equipment
- 20% Coinsurance
Prior Authorization Required - Prosthetics
- 20% Coinsurance
Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services
- $150 Copay
Prior Authorization Required - Lab services
- $0 Copay
Prior Authorization Required - Outpatient x-rays
- $40 Copay
Prior Authorization Required - Diagnostic tests and procedures
- $0 Copay
Prior Authorization Required
Medicare Part B Drugs
- Chemotherapy
- 20% Coinsurance
- Other Part B drugs (Medicare-covered)
- 20% Coinsurance
Dental Services
- Medicare Covered Preventive Dental
- $40 Copay
- Oral exam
- $0 Copay
- Dental x-rays
- $0 Copay
- Cleaning
- $0 Copay
- Periodontics
- Not Covered
- Endodontics
- Not Covered
- Restorative Services
- Not Covered
Hearing Aids and Services
- Fitting/evaluation
- Covered
Limits may apply - Hearing aids
- Not Covered
- Hearing exam
- Covered
Limits may apply
Vision Services
- Medicare-covered eye exam
- $ to $40 Copay
- Routine eye exam
- $0 Copay
1 Every year - Eyewear benefits
- None
Get a copy of the Keystone 65 Preferred Medical Only Summary of Benefits.
Prescription Drug Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent CMS ratings for Keystone 65 Preferred Medical Only .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall 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 |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- Keystone 65 Focus Rx (HMO-POS)
- Keystone 65 Liberty Medical Only (HMO)
- Keystone 65 Focus Rx (HMO-POS)
- Keystone 65 Select Medical Only (HMO)
- Keystone 65 Select Medical Only (HMO)
- Keystone 65 Essential Rx (HMO-POS)
- Keystone 65 Select Rx (HMO)
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Us About Independence Blue Cross
| Website: | Independence Blue Cross Plan Page (opens in new tab) |
|---|---|
| Providers: | Independence Blue Cross Providers Page (opens in new tab) |
| New Member Health Plan Help: | (877)393-6733 |
| New Member Health Plan TTY: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Independence Blue Cross, http://www.ibxmedicare.com, Last Accessed March 1, 2025
- Medicare.gov, "Understanding Medicare Advantage Plans", Last Accessed January 21, 2024
- Medicare.gov, "Your Medicare coverage choices", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed March 19, 2025
- Medicare.gov, "Is Your Test, Item, or Service Covered?", Last Accessed March 19, 2025
- CMS.gov, Landscape Source Files, Last Accessed March 15, 2025
- CMS.gov, Medicare Part C & D Performance, Last Accessed March 15, 2025
- CMS.gov, Plan Benefits Package,Last Accessed March 15, 2025
Research Note: This content is based on independent analysis of CMS data by David Bynon, Medicare analyst and founder of MedicareWire.
For details on how this plan was analyzed and constructed using CMS data, see our Medicare Plan Research Methodology.
Disclaimer: MedicareWire does not endorse or rank Medicare plans. Plan information is provided for educational and research purposes only and may not reflect the most current data available from CMS or the plan provider.
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