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Keystone 65 Select Medical Only (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone 65 Select 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 Select Medical Only (HMO) in 2026, please refer to our full plan details page.
Keystone 65 Select Medical Only (HMO) is a HMO plan offered by Independence Health Group, Inc. available for enrollment in 2025 to people living in Chester, Delaware, Montgomery Counties. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Keystone 65 Select 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 Select 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 Select 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. Additionally, this plan comes with a Part B Premium reduction of $18.60. You must continue to pay paying your reduced 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 $6750.00 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:
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Drug Coverage
Prescription drugs are not covered by Keystone 65 Select Medical Only (HMO).
Additional Benefits
The Keystone 65 Select Medical Only (HMO) plan offers robust medical coverage with no copays for primary care visits, preventive services, and home health care. For specialized care, members pay a $40 copay for specialist visits, while inpatient hospital stays require a $295 daily copay for days 1 through 7 and no copay for days 8 through 90. Outpatient hospital services carry a $390 copay, and emergency room visits have a $130 copay, both with no coinsurance. Routine dental, vision, and hearing exams are covered with no copays, and the plan provides a $250 annual eyewear allowance alongside up to $1,500 in comprehensive dental benefits with 20% to 40% coinsurance. Diagnostic lab services are provided with no copay, while durable medical equipment and dialysis services require a 20% coinsurance. Members also benefit from a $30 quarterly over-the-counter allowance and prescription hearing aid coverage with copays ranging from $499 to $799.
Inpatient Hospital See details
Keystone 65 Select Medical Only (HMO) covers inpatient hospital services with no coinsurance, requiring a $295 daily copay for days 1 to 7 and no copay for days 8 to 90. Unlimited additional acute care days are covered with no copay, though additional psychiatric care days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Keystone 65 Select Medical Only (HMO) covers outpatient services with no coinsurance, featuring a $390 copay for outpatient hospital services, a $295 copay per stay for observation services, and a $250 copay for ambulatory surgical center services. Outpatient substance abuse services require a $20 copay for group sessions and a $30 copay for individual sessions with no coinsurance, while outpatient blood services are provided with no copay and no coinsurance.
Partial Hospitalization See details
Keystone 65 Select Medical Only (HMO) covers partial hospitalization services with a $30.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Keystone 65 Select Medical Only (HMO) covers Medicare-approved ground and air ambulance services with a $250 copay and no coinsurance, subject to prior authorization. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Keystone 65 Select Medical Only (HMO) covers emergency services with a $130 copay and urgently needed services with a $15 to $50 copay, both with no coinsurance. Worldwide emergency and urgent services are partially covered with a $130 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Primary care services are covered by Keystone 65 Select Medical Only (HMO) with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Chiropractic benefits are partially covered because other chiropractic services are not covered, though routine chiropractic and podiatry care are covered for a $15 copay and no coinsurance, and other therapy and mental health services range from a $0 to $40 copay and no coinsurance.
Preventive Services See details
Keystone 65 Select Medical Only (HMO) covers key preventive services, including annual physical exams, kidney disease education, and diabetes self-management training, with no copay and no coinsurance. While supplemental benefits like fitness and health education are covered at no cost, several services—such as weight management, in-home safety assessments, and personal emergency response systems—are not covered.
Hearing Services See details
Keystone 65 Select Medical Only (HMO) covers Medicare-covered hearing exams with a $40 copay and no coinsurance, while routine hearing exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with copays ranging from $499 to $799 and no coinsurance for up to two devices per year, but inner ear, outer ear, over-the-ear, and OTC hearing aids are not covered.
Vision Services See details
Keystone 65 Select Medical Only (HMO) partially covers vision services with no deductibles or coinsurance, featuring a $0 to $40 copay for eye exams and a $250 annual limit for eyewear with no copay. Routine eye exams and combined eyeglasses or contacts are covered, but other eye exam services, separate eyeglass lenses, separate eyeglass frames, and upgrades are not covered.
Dental Services See details
Keystone 65 Select Medical Only (HMO) provides partially covered dental services, including Medicare-covered dental for a $40 copay and no coinsurance, and routine preventive care with no copay or coinsurance. Comprehensive treatments like root canals, implants, and oral surgery are covered up to a $1,500 annual maximum with no copay and 20% to 40% coinsurance, while orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Keystone 65 Select Medical Only (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin requires a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Keystone 65 Select Medical Only (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Keystone 65 Select Medical Only (HMO) covers medical equipment, including durable medical equipment (DME) and prosthetics, with no copay and 20% coinsurance. Diabetic equipment and supplies are also covered, featuring no copay for therapeutic shoes or inserts and no coinsurance to 20% coinsurance for supplies, with prior authorization required.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Keystone 65 Select Medical Only (HMO) with no coinsurance, though prior authorization is required. Members pay no copay for lab services, diagnostic procedures, and diagnostic radiological services, while outpatient X-rays carry a $40 copay and therapeutic radiological services require a minimum copay of $85.
Home Health Services See details
Keystone 65 Select Medical Only (HMO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Keystone 65 Select Medical Only (HMO) plan with no copay and no coinsurance. While some services are covered, sub-services such as cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Keystone 65 Select Medical Only (HMO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, no prior three-day hospital stay is needed, and additional days beyond the standard 100 days are not covered.
Other Services See details
Keystone 65 Select Medical Only (HMO) offers partial coverage for other services, including acupuncture for a $15 copay and no coinsurance for up to 6 treatments per year. Over-the-counter (OTC) items are covered with no copay and no coinsurance up to $30 every three months via reimbursement, while meal benefits and nicotine replacement therapy are not covered.
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