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Essential+Choice (HMO-POS) Plan
2021 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.
2021 Medical Benefits
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+Choice.
This plan offers a point-of-service benefit. With this plan, you have the option of accessing certain specialists in or out of the KelseyCare Advantage provider network.
Who Should Join?
The KelseyCare Advantage Essential+Choice 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. The Essential+Choice plan offers members the option to access certain specialists who are outside of the KelseyCare Advantage provider network without a referral.
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+Choice plan. You must maintain your Medicare Part B coverage to be a member of the Essential+Choice 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.
KelseyCare Advantage Essential+Choice 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. The point-of-service benefit means you can use certain specialists who are in or out of the KelseyCare Advantage provider network without a referral. The health providers in our network can change at any time. Members can elect to have their Kelsey-Seybold Clinic physician “coordinate” their care or they can choose to “self-refer” for care from certain specialists outside of Kelsey-Seybold Clinic. Members receive a higher level of benefits and pay lower out-of-pocket costs when they use in-network providers.