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Keystone First VIP Choice (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone First VIP Choice (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Keystone First VIP Choice (HMO D-SNP) in 2025, please refer to our full plan details page.
Keystone First VIP Choice (HMO D-SNP) is a HMO D-SNP plan offered by Independence Health Group, Inc. available for enrollment in 2025 to people living in Southeastern Pennsylvania. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Keystone First VIP Choice (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Keystone First VIP Choice (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Keystone First VIP Choice (HMO D-SNP).
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 First VIP Choice (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $48.40. 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.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
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
The Keystone First VIP Choice (HMO D-SNP) plan has a defined standard for drug coverage. The plan has a deductible of $590.00. If you qualify for the low-income subsidy, your monthly premium for Part D is $48.40. After your deductible is met, you will pay the costs for drugs in each tier until your total drug costs reach $2000.00.
Additional Benefits
The Keystone First VIP Choice (HMO D-SNP) plan offers a range of benefits, including coverage for inpatient hospital stays, outpatient services, and emergency care. You'll encounter cost-sharing through copays and coinsurance, such as a $1092 copay for inpatient hospital stays (days 1-2), a $110 copay for emergency services, and 35% coinsurance for various outpatient and therapy services. Additional benefits include coverage for hearing and vision services, with no copay for routine eye exams and hearing exams, and a yearly allowance for eyewear and hearing aids. Dental services are also covered, including oral exams, X-rays, and other procedures, with orthodontic services covered up to a maximum. The plan also provides coverage for home health services and medical equipment, with no copay for home health services, as well as an over-the-counter allowance.
Inpatient Hospital See details
The Keystone First VIP Choice (HMO D-SNP) plan covers Inpatient Hospital services, including acute and psychiatric care, with prior authorization required. For Inpatient Hospital-Acute, you'll pay a copay of $1092 for days 1-2, and no copay for days 3-90, while Inpatient Hospital Psychiatric has a copay of $240 for days 1-8, and no copay for days 9-90. Additional days, non-Medicare-covered stays, and upgrades for both are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services and observation services, each with a 35% coinsurance, and outpatient substance abuse services, including individual and group sessions, also with a 35% coinsurance. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Keystone First VIP Choice (HMO D-SNP) plan, but requires prior authorization. You will pay 35% coinsurance for this benefit.
Ambulance and Transportation Services See details
The Keystone First VIP Choice (HMO D-SNP) plan covers ambulance services with a 35% coinsurance for both ground and air ambulance services, and transportation services to plan-approved health-related locations, with 35 one-way trips per year via taxi. Transportation services to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Keystone First VIP Choice (HMO D-SNP) plan. Emergency Services have a $110 copay, Urgently Needed Services have a 35% coinsurance, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have no copay.
Primary Care See details
Primary Care Physician Services and Physician Specialist Services have a coinsurance of 0% - 35%. Chiropractic Services have a 35% coinsurance, but routine chiropractic care is not covered. Occupational Therapy Services, Individual and Group Sessions for Mental Health Specialty Services, Other Health Care Professional Services, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, and Opioid Treatment Program Services have a 35% coinsurance. Podiatry Services have a 35% coinsurance for Routine Foot Care, with a limit of 6 visits per year.
Preventive Services See details
Preventive services are covered, but annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, 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 benefits, home-based palliative care, in-home support services, and support for caregivers of enrollees are not covered. Kidney disease education services and diabetes self-management training have a 35% coinsurance, and other preventive services including Medicare-covered barium enemas have a coinsurance.
Hearing Services See details
Hearing services include hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are covered with no coinsurance for one visit per year, and fitting/evaluation for hearing aids are covered for three visits every three years. Prescription hearing aids are covered up to a maximum of $2000 every three years, but prescription hearing aids - inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision services include coverage for eye exams and eyewear. Routine eye exams have no coinsurance, and are limited to one per year. Eyewear is covered with a combined maximum benefit of $500 per year, and contact lenses and eyeglasses (lenses and frames) are covered, limited to one per year; however, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, including oral exams (1 every six months), dental x-rays (4 every 5 years), other diagnostic dental services (1 every 5 years), prophylaxis (cleaning, 1 every six months), fluoride treatment (1 every six months), and other preventive dental services (1). Orthodontic services are covered up to a $5,000 maximum per year. Restorative services, endodontics, periodontics, prosthodontics (removable, fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery are covered, but require prior authorization. Adjunctive general services and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered under the Keystone First VIP Choice (HMO D-SNP) plan. Medicare Part B Insulin Drugs have a $35 copay and 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Keystone First VIP Choice (HMO D-SNP) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered by the Keystone First VIP Choice (HMO D-SNP) plan, including Durable Medical Equipment (DME) with a 20% coinsurance, and Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic Equipment is covered, with a 0-20% coinsurance for Diabetic Supplies and a 20% coinsurance for Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services, are covered with no copay, but require coinsurance of at most 35%. Therapeutic Radiological Services are covered with no copay, but require coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Keystone First VIP Choice (HMO D-SNP) plan with no copay and no coinsurance. However, 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 First VIP Choice (HMO D-SNP) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The "Other Services" benefit for Keystone First VIP Choice (HMO D-SNP) includes over-the-counter items with a $220 monthly allowance, and meal benefits covered with a doctor's referral, but acupuncture, 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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