Keystone 65 Preferred Medical Only (HMO) 2024 Benefit Details for Plan H3952-008-0 in Bucks County, PA
Keystone 65 Preferred Medical Only is a 2024 HMO Medicare Advantage plan {with_without_pdp} prescription drug plan benefits (Part D).
This Independence Blue Cross option offers the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may also include additional, valuable benefits not covered by Part A or Part B.
See more Medicare Advantage Plans in Bucks County, Pennsylvania.
Plan Basics | |
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Plan ID: | H3952 008 0 |
Plan Type: | Local HMO |
Plan Year: | 2024 |
Premium: | $175.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $3,800/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Not Included |
Rx Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | Bucks County, PA |
Insured By: | Independence Blue Cross |
Summary of Benefits |
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Health Plan Cost Sharing
This Independence Blue Cross Medicare Advantage plan has cost-sharing. These are costs you must pay out-of-pocket when you use approved health services.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
The following table summarizes the most common out-of-pocket costs you will incur if you join this plan unless you go out-of-network:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 Copay |
Specialist: | $40 Copay |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $20 Copay |
Routine foot care: | $20 Copay |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $20 Copay |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $100 Copay |
Urgent care: | $55 Copay |
Ground ambulance: | $150 Copay |
Inpatient hospital coverage: | $225.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
Outpatient hospital coverage: | $125 Copay Authorization Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $30 Copay |
Outpatient group therapy visit with a psychiatrist: | $20 Copay |
Inpatient hospital - psychiatric: | $225.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
Outpatient group therapy visit: | $20 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $20 Copay Authorization Required |
Occupational therapy visit: | $20 Copay Authorization Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | 20% Coinsurance Authorization Required |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $150 Copay Authorization Required |
Lab services: | $0 Copay Authorization Required |
Outpatient x-rays: | $40 Copay Authorization Required |
Diagnostic tests and procedures: | $0 Copay Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Keystone 65 Preferred Medical Only Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Independence Blue Cross includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | $0 Copay Limitations Apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay |
Vision | Maximum vision benefit: | $250.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
Routine eye exam (In-Network) | $0 Copay |
Contact lenses (In-Network) | Covered Limits may apply |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
2024 CMS Rating Marks
The following table shows the quality ratings for this Independence Blue Cross plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories based on a 5-star rating system. Here are the most recent ratings for Keystone 65 Preferred Medical Only.
CMS Measure | Star Rating |
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2024 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 Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
- Keystone 65 Liberty Medical Only
- Keystone 65 Focus Rx
- Keystone 65 Basic Rx
- Keystone 65 Select Rx
- Keystone 65 Preferred Rx
Contact Independence Blue Cross
Plan Website: | http://www.ibxmedicare.com |
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Formulary Information: | http://www.ibxmedicare.com |
Pharmacy Information: | Independence Blue Cross Pharmacy Page |
Prospective Members: | (877)393-6733 |
TTY Users: | 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 Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- Independence Blue Cross, http://www.ibxmedicare.com, Last Accessed February 20, 2024
- Medicare.gov, "Medicare Advantage Plans cover all Medicare services", Last Accessed February 20, 2024
- Medicare.gov, "Compare Original Medicare & Medicare Advantage", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
About This H3952-008-0 Plan Detail Page
The data on this Keystone 65 Preferred Medical Only plan detail page is derived from the 2024 Landscape Source Files, Plan Benefit Package, and Medicare Part C and Part D Performance Data published by CMS.
The author interprets these files, and their associated data dictionary, with great care, making every attempt to communicate the data submitted by Independence Blue Cross to CMS as clearly and accurately as possible. Given the complexity of the data, the author recommends that all potential enrollees request an official Summary of Benefits from Independence Blue Cross, at (877)393-6733, prior to enrollment.