Keystone 65 Preferred Medical Only (HMO)
Health Insurance Company: Independence Blue Cross
Medicare Advantage Plan Details
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Emergency Room
$100 copay per visit (always covered)
Ambulance Coverage
$150 copay
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: $0 copay
Medicare-covered lab services: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): $0-150 copay
Medicare-covered x-ray services: $40 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: $350 copay per visit
Hospitalization Coverage
Inpatient hospital-acute:
$225 per day for days 1 through 6
$0 per day for days 7 through 90
$0 per day for days 90 and beyond
Inpatient hospital psychiatric:
$225 per day for days 1 through 6
$0 per day for days 7 through 90
Rehabilitation Coverage
Occupational therapy services:
$20 copay
Physical therapy and speech and language therapy services:
$20 copay
Urgent Care Coverage
$5-55 copay per visit (always covered)
Skilled Nursing Facility (SNF)
$0 per day for days 1 through 20
$203 per day for days 21 through 100
Mental Health Coverage
Medicare-covered individual sessions: $30 copay
Medicare-covered group sessions: $20 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams: $0 copay
Prophylaxis (cleaning): $0 copay
Dental x-rays: $0 copay
Vision Benefits
Eye exams:
Routine eye exams: $0 copay
Eyewear:
Contact Lenses: $0 copay
Eyeglasses: $0 copay
Hearing Benefits
Hearing exams:
Routine hearing exams: $40 copay
Hearing aids:
Hearing aids (all types): $499-799 copay
More Additional Benefits
Plan Links
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