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Keystone 65 Preferred Medical Only (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone 65 Preferred Medical Only (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Keystone 65 Preferred Medical Only (HMO) in 2025, please refer to our full plan details page.
Keystone 65 Preferred Medical Only (HMO) is a HMO plan offered by Independence Health Group, Inc. available for enrollment in 2025 to people living in Philadelphia, Bucks, Chester, Delaware, Montgomery. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Keystone 65 Preferred Medical Only (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Keystone 65 Preferred Medical Only (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Keystone 65 Preferred Medical Only (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
Sign up for Keystone 65 Preferred Medical Only (HMO)
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Drug Coverage
Prescription drugs are not covered by Keystone 65 Preferred Medical Only (HMO).
Additional Benefits
The Keystone 65 Preferred Medical Only (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and ambulance services with a $150 copay for both ground and air. The plan covers primary care, specialist visits, and mental health services with copays, along with preventive services, hearing exams, and vision services with copays. Additionally, it provides coverage for home infusion, dialysis, medical equipment, diagnostic services, home health services, and skilled nursing facility stays.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for acute and psychiatric hospital stays. For acute stays, you will pay a $225 copay for days 1-6, and no copay for days 7-90; for psychiatric stays, you will pay a $225 copay for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and additional days for Inpatient Hospital Psychiatric and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $350 copay, Observation Services with a $350 copay, Ambulatory Surgical Center (ASC) Services with a $125 copay, Individual and Group Sessions for Outpatient Substance Abuse with copays ranging from $20 to $30, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Keystone 65 Preferred Medical Only (HMO) plan, requiring prior authorization. You will have a $30 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Keystone 65 Preferred Medical Only (HMO) plan. Ground and Air Ambulance Services have a $150 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Keystone 65 Preferred Medical Only (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay, while Urgently Needed Services have a copay between $5 and $55; all have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Keystone 65 Preferred Medical Only (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $20 copay, physician specialist services with a $40 copay, and physical therapy and speech-language pathology services with a $20 copay. Mental health and psychiatric services copays range from $20 to $30, and additional telehealth benefits have copays from $0 to $40.
Preventive Services See details
Preventive Services include an annual physical exam with no copay. Additionally, Health Education, Home-Based Palliative Care, Support for Caregivers of Enrollees, Fitness Benefit, Enhanced Disease Management, Remote Access Technologies, Kidney Disease Education Services, and Other Preventive Services are covered with no copay. However, In-Home Safety Assessment, Personal Emergency Response System, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, Counseling Services, and Additional Sessions of Smoking and Tobacco Cessation Counseling are not covered.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Hearing exams have a $40 copay, routine hearing exams have no copay, and fitting/evaluation for hearing aids have no copay. Prescription hearing aids have a copay between $499 and $799, and prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a copay of $0-$40, and for eyewear, including contact lenses and eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $40 copay, and other dental services including oral exams, dental x-rays, and prophylaxis (cleaning). Oral exams, dental x-rays, and prophylaxis (cleaning) have no copay. Fluoride treatment, orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, maxillofacial prosthetics, implant services, prosthodontics, fixed, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Keystone 65 Preferred Medical Only (HMO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical equipment is covered, including durable medical equipment with no copay and a coinsurance of up to 20%, and medical supplies, prosthetic devices and diabetic equipment, with a coinsurance of 20% for medical supplies, and the copay and coinsurance for diabetic equipment and diabetic supplies vary. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services, lab services with no copay, and diagnostic radiological services with a copay of up to $150.00. Therapeutic radiological services have a copay of at least $60.00, and outpatient X-ray services have a copay of $40.00.
Home Health Services See details
Home Health Services are covered by the Keystone 65 Preferred Medical Only (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Keystone 65 Preferred Medical Only (HMO) plan. The plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Keystone 65 Preferred Medical Only (HMO) plan. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Under "Other Services", the Keystone 65 Preferred Medical Only (HMO) plan covers acupuncture with a $20 copay per visit, up to 6 treatments per year, and over-the-counter (OTC) items with a maximum benefit of $30 every three months. Meal benefit, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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