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Keystone 65 Liberty Medical Only (HMO) Medicare Advantage Plan H3952-059 • 2027 • Philadelphia County, PA

CMS Rating: ☆☆☆☆☆ (4.0 out of 5 stars*)
Monthly Premium
$0.00Plus Part B premium.
Medical Deductible
$0.00
Maximum Out-of-Pocket
$7150.00In-network
Part B Giveback
−$120.00 reduction
Prescription Coverage
Not Included
Additional Benefits
Dental, Vision, Hearing
Service Area
Philadelphia County, PA
Local Enrollment
201 beneficiaries in Philadelphia County
Last update:

Keystone 65 Liberty Medical Only (HMO) Introduction

This Medicare Advantage HMO plan, Keystone 65 Liberty Medical Only, is offered by Independence Blue Cross and uses a Health Maintenance Organization (HMO) provider network. It comes without prescription drug coverage. For the 2027 plan year, the monthly premium is $0.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $7150.00. The plan is identified by CMS Plan ID H3952-059.

Enrollment in this plan requires residence in Philadelphia County, Pennsylvania. CMS enrollment data reports 201 plan members in Philadelphia County. New members can call the plan directly at (877)393-6733 (TTY 711) for assistance.

Compare Similar Plans in Philadelphia County

Compare this plan with the two most-enrolled HMO plans available in Philadelphia County, Pennsylvania. Enrollment is based on CMS local enrollment data.

HMO plan comparison for Philadelphia County, Pennsylvania
Plan Detail Keystone 65 Liberty Medical Only Keystone 65 Basic Rx Humana Total Complete
CMS Plan ID H3952-059-0 H3952-055-0 H6622-037-0
Local Enrollment 201 13,816 4,961
Monthly Premium $0.00 $15.00 $0.00
Medical Deductible $0.00 $0.00 $0.00
Maximum Out-of-Pocket $7,150.00 $9,500.00 $8,200.00
Part B Giveback −$120.00 reduction Not offered Not offered
Primary Care $0 copay $0 copay $0 copay
Specialist $55 copay $35 copay $35 copay
Part D Deductible Not Applicable $700.00 $700.00
CMS Star Rating 4.0 4.0 4.0
Dental $0 copay $0 copay $0 copay
Vision $0 copay $0 copay $0 copay
Hearing $0 copay Not covered $0 copay

Want to explore more options? Browse all Medicare Advantage plans in Philadelphia County, or compare Medicare Advantage plans across Pennsylvania, including premiums, out-of-pocket costs, CMS ratings, and enrollment.

Plan Benefits

Keystone 65 Liberty Medical Only includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The tables below outline the most common in-network out-of-pocket costs associated with plan H3952-059.

You can also compare 2027 costs and coverage with last year, side-by-side: Plan H3952-059-0 Cost Compare.

Office Visits

Primary care
In-network: $0 copay
Specialist
In-network: $55 copay

Preventive and Wellness Services

Annual wellness exam
In-network: $0 copay
Telehealth benefit
In-network: $0-$55 copay
Routine chiropractic
In-network: $15 copay
Fitness benefits
Coming soon
Health education
In-network: $0 copay
Counseling services
Not covered
Over-the-counter drug benefits
In-network: $0 copay
Health transportation (non-emergency)
Coming soon

Diagnostic, Lab, and Imaging Services

Diagnostic radiology services
In-network: $0-$375 copay
Lab services
In-network: $0 copay
Outpatient x-rays
In-network: $50 copay
Diagnostic tests and procedures
In-network: $0 copay

Emergency and Urgent Care Services

Emergency room care
$130 copay
Worldwide emergency care
Coming soon
Urgent care
$15-$50 copay
Inpatient hospital care
Tier 1
$390 per day for days 1-6
$0 per day for days 7-90
$0 per stay
Skilled Nursing Facility
Tier 1
$0 per day for days 1-20
$221 per day for days 21-100
Ground ambulance
In-network: $280 copay

Mental Health Services

Outpatient individual therapy
In-network: $30 copay
Outpatient group therapy
In-network: $20 copay
Inpatient psychiatric hospital care
Tier 1
$390 per day for days 1-6
$0 per day for days 7-90
$0 per stay

Rehabilitation Services

Physical therapy and speech and language therapy
In-network: $50 copay
Occupational therapy
In-network: $50 copay

Medical Equipment and Supplies

Diabetes supplies
In-network: 0%-20% coinsurance
Durable medical equipment
In-network: 20% coinsurance
Prosthetics
In-network: 20% coinsurance

Medicare Part B Drugs

Chemotherapy
In-network: 0%-20% coinsurance
Other Part B drugs (Medicare-covered)
In-network: 0%-20% coinsurance

Dental Services

Oral exam
In-network: $0 copay
Dental x-rays
In-network: $0 copay
Cleaning
In-network: $0 copay
Periodontics
In-network: 20% coinsurance
Endodontics
In-network: 20% coinsurance
Restorative services
In-network: 20% coinsurance
Implant services
Not covered
Orthodontics
Not covered
Oral/Maxillofacial surgery
In-network: 20%-40% coinsurance

Vision Services

Routine eye exam
In-network: $0 copay
Contact lenses
In-network: $0 copay
Eyeglass frames only
Not covered
Eyeglass lenses only
Not covered
Eyeglasses (frames & lenses)
In-network: $0 copay
Upgrades
Not covered

Hearing Services

Hearing exam
In-network: $0 copay
Fitting/evaluation
In-network: $0 copay
Prescription hearing aids
In-network: $699-$999 copay
OTC hearing aids
Not covered

Additional and Special Needs Services

Adult day health services
Not covered
Home-based palliative care
In-network: $0 copay
Personal emergency response system
Coming soon
Weight management programs
Not covered
Wigs for chemotherapy-related hair loss
Coming soon
Alternative therapies
Not covered
Massage therapy
Not covered
Home/bathroom safety devices
Not covered

Certain preventive services are covered 100% by Keystone 65 Liberty Medical Only as a Part B benefit.

Prescription Drug Coverage

This plan does not include a Medicare Part D plan for prescriptions.

CMS 5-Star Performance Ratings (Contract ID: H3952)

CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.

2027 Medicare Star Ratings for Contract H3952
CMS Measure Star Rating
2027 Overall Rating ☆☆☆☆☆
Staying Healthy: Screenings, Tests, Vaccines ☆☆☆☆☆
Managing Chronic (Long Term) Conditions ☆☆☆☆☆
Member Experience with Health Plan ☆☆☆☆☆
Complaints and Changes in Plans Performance ☆☆☆☆☆
Health Plan Customer Service ☆☆☆☆☆
Drug Plan Customer Service ☆☆☆☆☆
Complaints and Changes in the Drug Plan ☆☆☆☆☆
Member Experience with the Drug Plan ☆☆☆☆☆
Drug Safety and Accuracy of Drug Pricing ☆☆☆☆☆
Medicare Advantage Plan Availability

Keystone 65 Liberty Medical Only is available to eligible Medicare beneficiaries residing in Philadelphia County, Pennsylvania, including communities such as Philadelphia, and other areas throughout the county. Enrollment eligibility is based on county of residence, not city.

Medicare Plan Data Sources and Methodology
Primary CMS datasets used for this Medicare Advantage Plan resource.
Data Source Publisher Last Accessed
Landscape Source Files Centers for Medicare & Medicaid Services October 5, 2026
Medicare Part C & D Performance Centers for Medicare & Medicaid Services October 5, 2026
Plan Benefits Package Centers for Medicare & Medicaid Services October 5, 2026
Monthly Enrollment by Contract/Plan/State/County Centers for Medicare & Medicaid Services October 5, 2026

Data sources and methodology documentation.

Official plan information and secondary Medicare references.
Publisher Reference Last Accessed
Independence Blue Cross (official source) http://www.ibxmedicare.com October 4, 2026
CMS.gov Medicare Advantage Plan Fact Sheet 25 May, 2025
Medicare.gov Joining a plan 25 May, 2025
Medicare.gov Your coverage options 25 May, 2025

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Data provenance documentation is maintained in alignment with the U.S. Core Data for Interoperability (USCDI) Provenance standard.