City of Houston Medicare Plans | KelseyCare Advantage

Benefits

Covered Services	What You Pay
Physician Services/Doctor Office Visits	PCP - $0
Physician Services/Doctor Office Visits	Specialist $25
Annual Wellness Visit	$0
Telehealth Benefit	E-Visit PCP - $0
	E-Visit Specialist - $15
	Video Visit PCP - $0
	Video Visit Specialist - $15
Preventive Health Screenings	$0
Inpatient Hospital Care	$300 per admission
Inpatient Hospital Care	No limit to the number of days covered
Skilled Nursing Facility (SNF)	$0/Day - Days 1-20
Skilled Nursing Facility (SNF)	$100/ Day - Days 21-100
Outpatient Diagnostic Tests and Therapeutic Services & Supplies	Diagnostic labs & x-rays - $0
	Cardiac Stress Test - $25
	Advanced Radiology - $100
	MRI - $100
	PET Scan - $100
	Radiation Therapy, IMRT - $15
Emergency Care	$120
Ambulance Services	$100
Urgently Needed Services	$25
Outpatient Hospital Observation	$175
Outpatient Hospital Services	ASC - $150
Outpatient Hospital Services	Hospital $175
Outpatient Surgery	ASC - $150
Outpatient Surgery	Hospital $175
Outpatient Rehab Services	PT and OT - $15
	Speech - $15
	Would Care/Lymphedema - $15
Outpatient Mental Health Care	Individual or Group - $20
Outpatient Substance Abuse Services	Individual or Group - 20
Durable Medical Equipment (DME) and related Supplies	20% meters, test strips, lancets, lancet devices and control solutions
Durable Medical Equipment (DME) and related Supplies	All other DME is 10% coinsurance
Prosthetic Devices and Related Supplies	20% coinsurance
Medicare Part B Prescription Drugs	15% coinsurance (including chemotherapy)
Services to Treat Kidney Disease	20% coinsurance
Services to Treat Kidney Disease	$0 for education services
Pulmonary Rehabilitation Services	$15
Cardiac Rehabilitation Services	$15
Chiropractic Services	$15
Acupuncture	$20
Podiatry Services	$15
Home Health Agency Care	$0
Inpatient Mental Health Care	$300 per admission
Medical Nutrition Therapy	$0
Dental Services	$0 - Medicare Covered
Diabetes Self Management Training, Diabetic Services and Supplies	20% for diabetic shoes & inserts
	10% for insulin pump & supplies
Immunizations	$0
Transportation	$0 (20 one-way trips per year)
Smoking Cessation	$0
Hearing Services	Diagnostic - $15
	Routine - $0
	Hearing Aid Fitting - $15
Vision Care	Diagnostic - $0
	Routine - $0
	$200 plan allowance per year

Eligibility and Service Area

You are eligible for membership in our plan as long as you:

Have both Medicare Part A and Medicare Part B
and you live in our geographic service area (listed below)
and you are a United States citizen or are lawfully present in the United States
and you meet the eligibility requirements of the sponsor of the City of Houston.

Service Area

You must reside in one of the following counties to be eligible for this plan:

Harris
Fort Bend
Montgomery
Galveston
Brazoria
Chambers
Liberty
Austin
San Jacinto
Waller
Walker
Wharton

Prescription Drug Information

2023 Drug Search – See if your drug is covered

Click here to search the 2023 City of Houston KelseyCare Advantage Formulary.

2023 Schedule of Copayments for Prescription Drugs

Your pharmacies with preferred cost-sharing include Kelsey Pharmacies, H-E-B, CVS retail pharmacies and CVS Mail Service Pharmacy. If you fill your prescription at these pharmacies, you may pay lower cost sharing than at other pharmacies.

Preferred Retail and Mail Order Pharmacies
Tier	30-Day Supply	60-Day Supply	90-Day Supply
1	$10	$20	$30
2	$15	$30	$45
3	$30	$60	$90
4	$45	$90	$135
5	$75	N/A	N/A

Standard Retail Pharmacy (Non-Preferred)
Tier	30-Day Supply	60-Day Supply	90-Day Supply
1	$15	$30	$45
2	$20	$40	$60
3	$35	$70	$105
4	$50	$100	$150
5	$80	N/A	N/A

Value Added Benefits

Silver Sneakers®

Free Gym Membership access through SilverSneakers. SilverSenakers gives you a variety of ways to keep moving and connect with others.
SilverSneakers Live. Join full-length, live classes and workshops on the SilverSneakers website via Zoom. Multiple activities led by expert trainers are available per day, and no equipment is needed.
SilverSneakers On-Demand. Access 200+ online workout videos, plus information on topics like nutrition, fitness challenges and more. Go to SilverSneakers On-Demand to view videos.
SilverSneakers GO mobile app. Find workout programs that can be tailored to your fitness levels, schedule activities and get notifications to stay on track. Download the app today at SilverSneakers GO.
Memberships to thousands of participating locations. Visit as many as you want to use equipment, pools, and other amenities, and take group execise classes at select locations. Find locations here.

Vision Coverage

$200 allowance each year towards the purchase of contacts or lenses.
KelseyCare Advantage plans include vision benefits through Vision Services Providers (VSP) which provides coverage for routine eye exams and diagnosis and treatment of eye diseases and injuries, and some allowance for glasses and contacts.
You can also search for a VSP provider online, or call VSP at 1-800-877-7195 for assistance finding a provider in your area.

Transportation

20 one-way trips each year for transportation to medical appointments. We understand that transportation to and from medical appointments is an important benefit for many members. KelseyCare Advantage offers free Medicare transportation benefits.

Virtual Health and MyKelseyOnline

Video and E-Visits with a Kelsey PCP covered at $0 copay. Specialist virtual health visits $15. Correspond with your providers, view test results, schedule appointment through your secure patient portal. For more information visit MyKelseyOnline.

Plan Documents