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Essential (HMO) Plan

Benefits Summary

This is a summary of what our plan covers and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please refer to the Evidence of Coverage, this legal member contract is the primary source of the coverage information and supersedes all other information.

  • Member Benefits
  • Premium
Covered Service What You Pay
PHYSICIAN SERVICES / DOCTOR OFFICE VISITS
PCP - $0
Specialist - $20
ANNUAL WELLNESS VISIT $0
TELEHEALTH BENEFIT E-Visit PCP- $0
E-Visit Spec - $10
Video Visit PCP - $0
Video Visit Spec - $20
PREVENTIVE HEATLH SCREENINGS $0
INPATIENT HOSPITAL CARE $500  per admission
SKILLED NURSING FACILITY CARE (SNF) $0/day - days 1-20
$125/day - days 21-100
OUTPATIENT DIAGNOSTIC TESTS AND THERAPUTIC SERVICES & SUPPLIES Diagnostic labs & x-rays $0
Cardiac Stress Test - $25
Advanced Radiology - $150
MRI - $150
PET scan - $150
Radiation Th, IMRT - $50
EMERGENCY CARE $120
AMBULANCE SERVICES $100
URGENTLY NEEDED SERVICES $25
OUTPATIENT HOSPITAL OBSERVATION $250
OUTPATIENT HOSPITAL SERVICES ASC - $225 
Hospital - $250
OUTPATIENT SURGERY ASC - $225
Hospital - $250
OUTPATIENT REHAB SERVICES PT and OT - $10
Speech - $20
Wound Care/Lymphedema - $20
OUTPATIENT MENTAL HEALTH CARE Group - $20
Individual - $35
OUTPATIENT SUBSTANCE ABUSE SERVICES Group - $20
Individual - $35
DURABLE MEDICAL EQUIPMENT (DME) AND RELATED SUPPLIES 20% coinsurance
PROSTHETIC DEVICES AND RELATED SUPPLIES 20% coinsurance
MEDICARE PART B PRESCRIPTION DRUGS 20% coinsurance
(Including chemotherapy)
SERVICES TO TREAT KIDNEY DISEASE $25 for renal dialysis treatment
$0 for education services
PULMONARY REHABILITATION SERVICES $20
CARDIAC REHABILITATION SERVICES $20
CHIROPRACTIC SERVICES $20
PODIATRY SERVICES $20
HOME HEALTH AGENCY CARE $10
INPATIENT MENTAL HEALTH CARE $500 per admission
MEDICAL NUTRITION THERAPY $0
DENTAL SERVICES 20% coinsurance - Medicare covered
DIABETES SELF MGMT TRAINING, DIABETIC SERVICES AND SUPPLIES 0% for testing supplies
20% for diabetic shoes & inserts
20% for insulin pump & supplies
IMMUNIZATIONS $0
TRANSPORTATION $0
SMOKING CESSATION $0
HEARING SERVICES Diagonostic - $20
Routine - $20
Hearing Aid Fitting - $20  $500 plan allowance every year
VISION CARE Diagnostic - $20
Routine- $0
$75 plan allowance per year

Plan Premium

The monthly fee you pay the plan for your health care. The amount shown does not include the Part B premium you already pay to the government. 
 
Plan Monthly Premium
Essential $0

Plan Summary

This plan provides the coverage of Medicare Part A (hospital) and Medicare Part B (medical), but does not provide prescription drug coverage.

This plan may be right for you if you have prescription drug coverage through another source such as TRICARE, federal employee health benefits coverage, VA benefits, state pharmaceutical assistance programs, or private insurance, such as employer-sponsored drug coverage.

If you have prescription drug coverage through a former employer, you should contact the employer to be sure your drug coverage won’t be interrupted by enrolling in KelseyCare Advantage Essential.

Who Should Join?

The KelseyCare Advantage Essential plan works well for Medicare beneficiaries that need comprehensive coverage and low out-of-pocket expenses for their hospital and medical benefits, but don’t need prescription drug coverage. This plan also offers worldwide emergency coverage as well as coverage for routine vision, routine hearing, and medical transportation.

You Must:

1.  Be eligible for Medicare Part A and enrolled in Part B,
2.  Continue to pay Part B premiums,
3.  Live in the plan service area, and
4.  Not have End-Stage Renal Disease (permanent kidney failure).

How Much Does it Cost?

You’ll pay no monthly plan premium to enroll in the Essential plan. The Essential plan includes a Part B premium reduction of up to $10 per month. Which means you'll pay $10 less for your Part B by joining this plan. If Medicaid is paying your Part B premium, however, you will not get the Part B premium reduction offered by the plan. You must maintain your Medicare Part B coverage to be a member of the Essential plan. Most people will pay the standard Part B premium amount. Please call Social Security at 1-800-772-1213 for information about your Part B premium.

Provider Network

KelseyCare Advantage Essential members receive most of their medical care from a Kelsey-Seybold Clinic. KelseyCare Advantage contracts with an affiliate network of doctors to provide care that is not offered at Kelsey-Seybold. You can only use doctors who are part of our network. The affiliate providers in our network can change at any time. A referral may be required to access some network doctors. If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither KelseyCare Advantage Essential nor the Original Medicare plan will pay for these services.

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