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Keystone 65 Select Medical Only (HMO) Medicare Advantage Plan H3952-048 • 2027

CMS Rating: ☆☆☆☆☆ (4.0 out of 5 stars*)
Monthly Premium
$0.00Plus Part B premium.
Medical Deductible
$0.00
Maximum Out-of-Pocket
$6750.00In-network
Part B Giveback
Not offered
Prescription Coverage
Not Included
Additional Benefits
Dental, Vision, Hearing
Service Area
See List
Total Enrollment
603 beneficiaries
Last update:

Keystone 65 Select Medical Only (HMO) Introduction

CMS Plan ID H3952-048 identifies Keystone 65 Select Medical Only, a Medicare Advantage HMO plan offered by Independence Blue Cross. The plan uses a Health Maintenance Organization (HMO) provider network and comes without prescription drug coverage. Its costs for the 2027 plan year include a $0.00 monthly premium, $0.00 medical deductible, and $6750.00 in-network maximum out-of-pocket.

Plan Benefits

Keystone 65 Select Medical Only has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H3952-048.

Compare 2027 plan benefits with 2026.

Office Visits

Office visit costs by plan year.
Covered Service 2027 2026
Primary care In-network: $0 copay In-network: $0 copay
Specialist In-network: $40 copay In-network: $40 copay

Preventive and Wellness Services

Preventive and wellness service costs and benefits by plan year.
Covered Service 2027 2026
Annual wellness exam In-network: $0 copay In-network: $0 copay
Telehealth benefit In-network: $0-$40 copay In-network: $0-$40 copay
Routine chiropractic In-network: $15 copay In-network: $15 copay
Fitness benefits Coming soon In-network: $0 copay
Health education In-network: $0 copay In-network: $0 copay
Counseling services Not covered Not covered
Over-the-counter drug benefits In-network: $0 copay In-network: $0 copay
Health transportation (non-emergency) Coming soon Not covered

Diagnostic, Lab, and Imaging Services

Diagnostic, laboratory, and imaging service costs by plan year.
Covered Service 2027 2026
Diagnostic radiology services In-network: $0-$280 copay In-network: $0-$225 copay
Lab services In-network: $0 copay In-network: $0 copay
Outpatient x-rays In-network: $50 copay In-network: $40 copay
Diagnostic tests and procedures In-network: $0 copay In-network: $0 copay

Emergency and Urgent Care Services

Emergency, urgent care, hospital, ambulance, and skilled nursing costs by plan year.
Covered Service 2027 2026
Emergency room care $130 copay $130 copay
Worldwide emergency care Coming soon $130 copay
Urgent care $15-$50 copay $15-$50 copay
Inpatient hospital care Tier 1
$295 per day for days 1-7
$0 per day for days 8-90
$0 per stay		 Tier 1
$295 per day for days 1-7
$0 per day for days 8-90
$0 per stay
Skilled Nursing Facility Tier 1
$0 per day for days 1-20
$221 per day for days 21-100		 Tier 1
$0 per day for days 1-20
$218 per day for days 21-100
Ground ambulance In-network: $270 copay In-network: $250 copay

Mental Health Services

Mental health therapy and inpatient psychiatric care costs by plan year.
Covered Service 2027 2026
Outpatient individual therapy In-network: $30 copay In-network: $30 copay
Outpatient group therapy In-network: $20 copay In-network: $20 copay
Inpatient psychiatric hospital care Tier 1
$295 per day for days 1-7
$0 per day for days 8-90
$0 per stay		 Tier 1
$295 per day for days 1-7
$0 per day for days 8-90
$0 per stay

Rehabilitation Services

Physical, speech, and occupational therapy costs by plan year.
Covered Service 2027 2026
Physical therapy and speech and language therapy In-network: $20 copay In-network: $20 copay
Occupational therapy In-network: $20 copay In-network: $20 copay

Medical Equipment and Supplies

Diabetes supplies, durable medical equipment, and prosthetic costs by plan year.
Covered Service 2027 2026
Diabetes supplies In-network: 0%-20% coinsurance In-network: 0%-20% coinsurance
Durable medical equipment In-network: 20% coinsurance In-network: 20% coinsurance
Prosthetics In-network: 20% coinsurance In-network: 20% coinsurance

Medicare Part B Drugs

Chemotherapy and other Medicare Part B-covered drug costs by plan year.
Covered Service 2027 2026
Chemotherapy In-network: 0%-20% coinsurance In-network: 0%-20% coinsurance
Other Part B drugs (Medicare-covered) In-network: 0%-20% coinsurance In-network: 0%-20% coinsurance

Dental Services

Preventive and comprehensive dental service costs by plan year.
Covered Service 2027 2026
Oral exam In-network: $0 copay In-network: $0 copay
Dental x-rays In-network: $0 copay In-network: $0 copay
Cleaning In-network: $0 copay In-network: $0 copay
Periodontics In-network: 20% coinsurance In-network: 20% coinsurance
Endodontics In-network: 20% coinsurance In-network: 20% coinsurance
Restorative services In-network: 20% coinsurance In-network: 20% coinsurance
Implant services Not covered In-network: 40% coinsurance
Orthodontics Not covered Not covered
Oral/Maxillofacial surgery In-network: 20%-40% coinsurance In-network: 20%-40% coinsurance

Vision Services

Routine eye exams, contact lenses, and eyewear costs by plan year.
Covered Service 2027 2026
Routine eye exam In-network: $0 copay In-network: $0 copay
Contact lenses In-network: $0 copay In-network: $0 copay
Eyeglass frames only Not covered Not covered
Eyeglass lenses only Not covered Not covered
Eyeglasses (frames & lenses) In-network: $0 copay In-network: $0 copay
Upgrades Not covered Not covered

Hearing Services

Hearing exams, fittings, and hearing aid costs by plan year.
Covered Service 2027 2026
Hearing exam In-network: $0 copay In-network: $0 copay
Fitting/evaluation In-network: $0 copay In-network: $0 copay
Prescription hearing aids In-network: $499-$799 copay In-network: $499-$799 copay
OTC hearing aids Not covered Not covered

Additional and Special Needs Services

Additional and special needs service costs and benefits by plan year.
Covered Service 2027 2026
Adult day health services Not covered Not covered
Home-based palliative care In-network: $0 copay In-network: $0 copay
Personal emergency response system Coming soon Not covered
Weight management programs Not covered Not covered
Wigs for chemotherapy-related hair loss Coming soon Not covered
Alternative therapies Not covered Not covered
Massage therapy Not covered Not covered
Home/bathroom safety devices Not covered Not covered

Certain preventive services are covered 100% by Keystone 65 Select 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)

The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (Part C) and Part D prescription drug plans each year using a 5-star system. These ratings measure plan performance in areas such as preventive care, management of chronic conditions, 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 ☆☆☆☆☆

Plan Availability

Keystone 65 Select Medical Only (H3952-048-0) is available in the following locations:

Pennsylvania Counties Served

Frequently Asked Questions

Here are some of the most frequently asked questions about this plan (click to open).

Frequently Asked Questions About Keystone 65 Select Medical Only (HMO)

How much does plan H3952-048 cost per month?

The plan’s monthly premium is $0.00 for 2027. The Part B premium is not included.

What is the annual out-of-pocket maximum (MOOP) for this plan?

The annual in-network MOOP is $6750.00 for 2027. After this limit is reached, covered in-network services are fully paid.

What is the current enrollment for Keystone 65 Select Medical Only?

The plan has 603 enrolled beneficiaries according to CMS.

What is the prescription drug deductible for 2027?

For 2027, the prescription drug deductible is $0.00.

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 November 10, 2026
Medicare Part C & D Performance Centers for Medicare & Medicaid Services November 10, 2026
Plan Benefits Package Centers for Medicare & Medicaid Services November 10, 2026
Monthly Enrollment by Contract/Plan/State/County Centers for Medicare & Medicaid Services November 10, 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
Medicare.gov Compare types of Medicare Advantage Plans 25 May, 2025
NCOA.org 5 Steps to Choosing the Right Medicare Plan for You 25 May, 2025
Medicare.gov Compare Original Medicare & Medicare Advantage 25 May, 2025

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Data provenance is documented in accordance with the U.S. Core Data for Interoperability (USCDI) Provenance standard.