As a KelseyCare Advantage member, you have numerous tools and resources available to you.
Evidences of Coverage
Download the KelseyCare Advantage Essential Evidence of Coverage 
PDF 2012. This document gives the details about your Medicare health coverage through KelseyCare Advantage Essential.
Download the KelseyCare Advantage Essential+Choice Evidence of Coverage PDF 2012. This document gives the details about your Medicare health coverage through KelseyCare Advantage Essential+Choice.
Download the KelseyCare Advantage Rx Evidence of Coverage PDF 2012. This document gives the details about your Medicare health and prescription drug coverage through KelseyCare Advantage Rx.
Download the KelseyCare Advantage Rx+Choice Evidence of Coverage PDF 2012. This document gives the details about your Medicare health and prescription drug coverage through KelseyCare Advantage Rx+Choice.
Click here for more information about KelseyCare Advantage's coverage of HIV screening.
Back to Top Summaries of Benefits
- Download the Summary of Benefits for KelseyCare Advantage Essential PDF 2012
- Download the Summary of Benefits for KelseyCare Advantage Essential+Choice PDF 2012
- Download the Summary of Benefits for KelseyCare Advantage Rx PDF 2012
- Download the Summary of Benefits for KelseyCare Advantage Rx+Choice PDF 2012
Back to Top Appointment of Representative Form
If you need someone to file a grievance, coverage determination or appeal on your behalf, you can name a relative, friend, advocate, doctor or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.
To download a copy of Medicare's Appointment of Representative form, click here.
If you want to appoint a representative, you should complete the Appointment of Representative form on the Medicare.gov website and mail it to:
KelseyCare Advantage
ATTN: Member Services
P. O. Box 300427
Houston, Texas 77230
Back to TopHealth Needs Questionnaire
After you enroll, you can complete our Health Needs Questionnaire. The information you provide will help us determine what special programs, if any, are right for you. Go to the Health Needs Questionnaire.
Back to TopCoordination of Benefits Form
After you enroll, if you have more than one medical plan, you can complete the Coordination of Benefits form. Having more than one medical plan may save on medical costs by coordinating your benefits. The information you provide will help us determine if your other medical plan is primary or secondary to your KelseyCare Advantage plan. Go to the Coordination of Benefits Form.
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Transition of Care
During your first few months of membership, you may have questions about transitioning your care to KelseyCare Advantage network providers. If you are currently receiving care from non-KelseyCare Advantage network providers, please call Member Services at 713-442-CARE (2273) or 1-866-535-8343, 8:00 a.m. to 5:00 p.m., Monday through Friday. TTY/TDD users should call 1-866-302-9336.
For more information about KelseyCare Advantage's Transition of Care policy, click here. To go to theTransition of Care request form, click here.
Back to TopOrder New or Replacement ID Card
Your ID card shows information important to your health insurance coverage. You don’t need a new ID card every year. If you change plans, we will send you a new ID card.
For a new or replacement ID card, you may request one here or contact a KelseyCare Advantage Member Services representative at one of the phone numbers below and a new ID card will be sent to the address on file for you.
713-442-CARE (2273) or toll free: 1-800-663-7146
(TTY/TDD 1-866-302-9336)
8 a.m. to 8 p.m., seven days a week
Back to TopHow Do I Change Plans?
To make a change in the Medicare Advantage plan you have with KelseyCare Advantage, print and complete the Change of Plan form PDF. Select the plan you want, and sign the form. Then mail the completed form back to 8900 Lakes at 610 Drive, Suite 1100, Houston, Texas 77054.
Please be aware that you can change health plans only at certain times during the year. Between October 15 to December 7th each year, anyone can join our plan. In addition, from January 1 through February 14, anyone enrolled in our plan has an opportunity to disenroll from our plan and return to Original Medicare. Anyone who disenrolls from a Medicare Advantage plan during this time can join a stand-alone Medicare Prescription Drug Plan during the same period. Generally, you may not make changes at other times unless you meet certain special exceptions, such as if you move out of the plan’s service area.
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When and how to submit a paper claim form for Drugs covered by Part D
Below is a brief description of some of the situations you may submit a paper claim for reimbursement for your Part D drug expenses. For a full description and a complete listing of all situations refer to the Evidence of Coverage, Chapter 7, Asking the plan to pay its share of a bill you have received for covered services or drugs. Some of the situations you may submit a paper claim include:
- When you use an out-of-network pharmacy to get a prescription filled
- When you pay the full cost for a prescription because you don't have your plan membership card with you
- When you pay the full cost for a prescription drug that is not on the plan's List of Covered Drugs (Formulary); or the drug has a requirement or restriction that you didn't know about or don't think should apply to you.
When you send us your request for payment, along with your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records. Make sure you are giving us all the information we need to make a decision. You don't have to use our form, but it's helpful for our plan to process the information faster. Either download a copy of our KelseyCare Advantage/Catalyst Rx Direct Member Reimbursement Form PDF (click here) or call Member Services and ask for the KelseyCare Advantage /Catalyst Rx Direct Member Reimbursement Form.
Mail your request for payment and the KelseyCare Advantage/Catalyst Rx Direct Member Reimbursement Form together with any bills or receipts to this address:
Catalyst Rx
Direct Member Reimbursement
PO Box 1069
Rockville, MD 20849-1069
Back to TopNewsletters
As a KelseyCare Advantage member, you can access the monthly newsletter, House Call, which offers additional convenience by bringing health news directly to your mailbox. Read past newsletters here:
PDFs of past newslettersBack to TopLow Income Subsidy Information
For information about KelseyCare Advantage's Low Income Subsidy premiums, click here.
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