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Keystone 65 Liberty Medical Only (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone 65 Liberty 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 Liberty Medical Only (HMO) in 2025, please refer to our full plan details page.
Keystone 65 Liberty 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 Liberty 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 Liberty 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 Liberty 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 $90.00. 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 $9350.00 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 Liberty Medical Only (HMO).
Additional Benefits
The Keystone 65 Liberty Medical Only (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services and ambulatory surgical centers have a 20% coinsurance. Emergency services have a copay, and primary care, preventive services, and home health services are covered with no copay. The plan also provides coverage for hearing, vision, and dental services, with specific copays and coinsurance amounts. Additionally, the plan includes benefits for medical equipment, diagnostic services, and skilled nursing facilities. This plan does not cover Cardiac Rehabilitation Services.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered under the Keystone 65 Liberty Medical Only (HMO) plan. For days 1-7 of acute or psychiatric inpatient hospital stays, there is a $285 copay, and days 8-90 have no copay; additional days for inpatient hospital psychiatric are not covered.
Outpatient Services See details
Outpatient Services include Outpatient Hospital Services and Observation Services, both of which have a 20% coinsurance. Ambulatory Surgical Center (ASC) Services also have a 20% coinsurance. Outpatient Substance Abuse Services have a copay of $30 for individual sessions and $20 for group sessions. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Keystone 65 Liberty Medical Only (HMO) plan. This benefit requires prior authorization and has a $30 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Keystone 65 Liberty Medical Only (HMO) plan. Ground and Air Ambulance Services have a $260 copay, and there is no coinsurance; however, transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Keystone 65 Liberty Medical Only (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services have a copay between $15 and $45; all have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Keystone 65 Liberty Medical Only (HMO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $40 copay, mental health specialty services with a copay of $20-$30, podiatry services with a $25 copay, other health care professional services with a copay of $0-$40, psychiatric services with a copay of $20-$30, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a copay of $0-$40, and opioid treatment program services with a $5 copay. Routine chiropractic care and routine foot care are limited to 6 visits per year.
Preventive Services See details
Preventive Services include coverage for Medicare-covered zero dollar services, annual physical exams with no copay, and additional preventive services. In addition, the plan covers kidney disease education services, and other preventive services with no copay.
Hearing Services See details
Hearing Services include Hearing Exams, Routine Hearing Exams, Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids, and OTC Hearing Aids. Hearing Exams have a $40 copay, and Routine Hearing Exams and Fitting/Evaluation for Hearing Aid have no copay. Prescription Hearing Aids (all types) have a copay between $699 and $999, while Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered. OTC Hearing Aids are also not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$40, and routine eye exams with no copay. Eyewear, including contact lenses and eyeglasses (lenses and frames) are covered, with a combined maximum benefit of $250 every year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include a $40 copay for Medicare Dental Services, no copay for oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatment. Restorative Services, Endodontics, Periodontics, Prosthodontics (removable, and fixed), and Implant Services have a coinsurance of 20% to 40%. Oral and Maxillofacial Surgery has a coinsurance of 20% to 40%, while Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Keystone 65 Liberty Medical Only (HMO) plan. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Keystone 65 Liberty Medical Only (HMO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits under the Keystone 65 Liberty Medical Only (HMO) plan include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance; Diabetic Equipment is covered with a coinsurance for some services and a copay for others, and Diabetic Therapeutic Shoes/Inserts have no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $275, Therapeutic Radiological Services have a minimum copay of $80, and Outpatient X-Ray Services have a $45 copay.
Home Health Services See details
Home Health Services are covered under the Keystone 65 Liberty Medical Only (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Keystone 65 Liberty Medical Only (HMO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Keystone 65 Liberty Medical Only (HMO) plan, with a $0 copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for acupuncture with a $15 copay, and over-the-counter (OTC) items with a $30 maximum plan benefit every three months. Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, 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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