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Benefits
How to Choose the Right Plan for You
When you enroll in KelseyCare Advantage, you can choose from a KelseyCare Advantage plan available in your area, each with benefits tailored to specific needs and budgets. All plans provide Original (also called Traditional) Medicare Parts A and B coverage in addition to other benefits. And all plans give you access to Kelsey-Seybold Clinic’s premier multispecialty physician group and referrals to other contracted providers.
Plans with drug coverage:
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Rx Plan
Plan Summary
KelseyCare Advantage Rx provides Medicare Part D prescription drug coverage in addition to the medical benefits of Medicare Parts A and B.
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Who should join?
-
You must:
-
How much does it cost?
-
Provider Network
The KelseyCare Advantage Rx plan works well for Medicare beneficiaries that need comprehensive coverage and low out-of-pocket expenses for their hospital, medical, and prescription drug benefits. This plan also offers worldwide emergency coverage as well as coverage for routine vision, hearing, and medical transportation.
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).There is no monthly plan premium to enroll in the Rx plan. However, you must maintain your Medicare Part B coverage to be a member of any Medicare Advantage 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 Rx members will receive most of their medical care from the doctors at Kelsey-Seybold Clinic. KelseyCare Advantage also 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 health 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 Rx nor the Original Medicare plan will pay for these services.
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.
-
Medical Benefits
-
Prescription Drug Benefits
-
Premium
Covered Service What You Pay PHYSICIAN SERVICES / DOCTOR OFFICE VISITS
PCP - $0
Specialist - $35ANNUAL WELLNESS VISIT $0 TELEHEALTH BENEFIT
E-Visit PCP- $0
E-Visit Spec - $0
Video Visit PCP - $0
Video Visit Spec - $35
PREVENTIVE HEATLH SCREENINGS $0
INPATIENT HOSPITAL CARE $500 per admission SKILLED NURSING FACILITY CARE (SNF) $0/day - days 1-20
$125/day - days 21-100OUTPATIENT 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 - $50EMERGENCY CARE $120 AMBULANCE SERVICES $100 URGENTLY NEEDED SERVICES $25 OUTPATIENT HOSPITAL OBSERVATION $300 OUTPATIENT HOSPITAL SERVICES ASC - $225
Hospital $300OUTPATIENT SURGERY
ASC - $225
Hospital - $300OUTPATIENT REHAB SERVICES PT and OT - $10
Speech - $35
Wound Care/Lymphedema - $35OUTPATIENT MENTAL HEALTH CARE Group - $20
Individual - $35OUTPATIENT SUBSTANCE ABUSE SERVICES Group - $20
Individual - $35DURABLE 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 servicesPULMONARY REHABILITATION SERVICES $30 CARDIAC REHABILITATION SERVICES $35 CHIROPRACTIC SERVICES $20 PODIATRY SERVICES
$35 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 & suppliesIMMUNIZATIONS $0 TRANSPORTATION $0 SMOKING CESSATION $0 HEARING SERVICES
Diagnostic - $35
Routine- $35
Hearing Aid Fitting- $35
$125 plan allowance per yearVISION CARE Diagnostic - $35
Routine- $0
$75 plan allowance per yearThis table gives you basic information about the prescription drug benefits that are available with some of our plans. For more details, see the Comprehensive Formulary (PDF) in the Plan Documents section.
Initial Coverage
You will pay a yearly deductible of $100 on Tiers 3, 4 and 5 drugs. You must pay the full cost of your Tiers 3, 4 and 5 drugs until you reach the plan’s deductible amount. After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $4,020. Total yearly drug costs are the total drug cost paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies.
Preferred Retail Cost-Sharing
Tier One-month supply Three-month supply Tier 1 (Preferred Generic) $3 copay $7.50 copay Tier 2 (Generic)
$5 copay $12.50 copay Tier 3 (Preferred Brand)
$40 copay $100 copay Tier 4 (Non-Preferred Brand)
$60 copay $150 copay Tier 5 (Specialty Tier)
31% of the cost A long-term supply is not available for drugs in Tier 5 Specialty.
Standard Retail Cost-SharingTier One-month supply Three-month supply Tier 1 (Preferred Generic) $8 copay $24 copay Tier 2 (Generic) $10 copay $30 copay Tier 3 (Preferred Brand) $45 copay $135 copay Tier 4 (Non-Preferred Brand) $70 copay $210 copay Tier 5 (Specialty Tier) 31% of the cost A long-term supply is not available for drugs in Tier 5 Specialty Stage Description Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug’s tier. See the chart that follows to find out how much it will cost you.Catastrophic Coverage Stage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of: - 5% of the cost, or
- $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs.
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 Rx $0 -
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Rx+Choice Plan
Plan Summary
KelseyCare Advantage Rx+Choice provides Medicare Part D prescription drug coverage in addition to the medical benefits of Medicare Parts A and B. This plan also offers a point-of-service benefit.
With this plan, you have the option of accessing certain specialists who are in or out of the KelseyCare Advantage provider network.-
Who should join?
-
You must:
-
How much does it cost?
-
Provider Network
The KelseyCare Advantage Rx+Choice plan works well for Medicare beneficiaries that need comprehensive coverage and low out-of-pocket expenses for their hospital, medical, and prescription drug benefits. This plan also offers worldwide emergency coverage as well as coverage for routine vision, hearing, and medical transportation. The Rx+Choice plan offers members the option to access certain specialists who are outside of the KelseyCare Advantage provider network.
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).The monthly plan premium to enroll in the Rx+Choice plan is $77.00. Additionally, you must maintain your Medicare Part B coverage to be a member of any Medicare Advantage 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 Rx+Choice members will receive most of their medical care from the doctors at Kelsey-Seybold Clinic. KelseyCare Advantage also contracts with an affiliate network of doctors to provide care that is not offered at Kelsey-Seybold. You can use specialists who are in or out of the KelseyCare Advantage provider network. 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.
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.
The information listed below is for in-network services only. Out-of-Network cost-share for select services is between 20% and 50%, please review the Evidence of Coverage (EOC) for detailed out-of-network cost-share information.
-
Medical Benefits
-
Prescription Drug Benefits
-
Premium
The information listed below is for in-network services only. Out-of-Network cost-share for select services is between 20% and 50%, please review the Evidence of Coverage (EOC) for detailed out-of-network cost-share information.Covered Service What You Pay PHYSICIAN SERVICES / DOCTOR OFFICE VISITS
PCP - $0
Specialist - $35ANNUAL WELLNESS VISIT $0 TELEHEALTH BENEFIT E-Visit PCP- $0
E-Visit Spec - $0
Video Visit PCP - $0
Video Visit Spec - $35PREVENTIVE HEATLH SCREENINGS $0
INPATIENT HOSPITAL CARE $500 per admission SKILLED NURSING FACILITY CARE (SNF) $0/day - days 1-20
$125/day - days 21-100OUTPATIENT 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 $300 OUTPATIENT HOSPITAL SERVICES ASC - $225
Hospital $300OUTPATIENT SURGERY ASC - $225
Hospital - $300OUTPATIENT REHAB SERVICES PT and OT - $10
Speech - $35
Wound Care/Lymphedema - $35OUTPATIENT MENTAL HEALTH CARE Group - $20
Individual - $35OUTPATIENT SUBSTANCE ABUSE SERVICES Group - $20
Individual - $35DURABLE 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 servicesPULMONARY REHABILITATION SERVICES $30 CARDIAC REHABILITATION SERVICES $35 CHIROPRACTIC SERVICES $20 PODIATRY SERVICES $35 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 & suppliesIMMUNIZATIONS $0 TRANSPORTATION $0 SMOKING CESSATION
$0 HEARING SERVICES
Diagnostic - $35
Routine- $35
Hearing Aid Fitting- $35
$125 plan allowance per yearVISION CARE Diagnostic - $35
Routine- $0
$75 plan allowance per yearThis table gives you basic information about the prescription drug benefits that are available with some of our plans. For more details, see the Comprehensive Formulary (PDF) in the Plan Documents section.
Initial Coverage
You will pay a yearly deductible of $100 on Tiers 3, 4 and 5 drugs. You must pay the full cost of your Tiers 3, 4 and 5 drugs until you reach the plan’s deductible amount. After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $4,020. Total yearly drug costs are the total drug cost paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies.
Preferred Retail Cost-Sharing
Tier One-month supply Three-month supply Tier 1 (Preferred Generic) $3 copay $7.50 copay Tier 2 (Generic)
$5 copay $12.50 copay Tier 3 (Preferred Brand)
$40 copay $100 copay Tier 4 (Non-Preferred Brand)
$60 copay $150 copay Tier 5 (Specialty Tier)
31% of the cost A long-term supply is not available for drugs in Tier 5 Specialty.
Standard Retail Cost-SharingTier One-month supply Three-month supply Tier 1 (Preferred Generic) $8 copay $24 copay Tier 2 (Generic) $10 copay $30 copay Tier 3 (Preferred Brand) $45 copay $135 copay Tier 4 (Non-Preferred Brand) $70 copay $210 copay Tier 5 (Specialty Tier) 31% of the cost A long-term supply is not available for drugs in Tier 5 Specialty Stage Description Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug’s tier. See the chart that follows to find out how much it will cost you.Catastrophic Coverage Stage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of: - 5% of the cost, or
- $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs.
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 Rx + Choice $77 -
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Rx Select Plan
Plan Summary
KelseyCare Advantage Rx Select provides Part D prescription drug coverage in addition to the medical benefits of Medicare Parts A and B. This plan also offers a point-of-service benefit.
With this plan, you have the option of accessing certain specialists who are in or out of the KelseyCare Advantage provider network.-
Who should join?
-
You must:
-
How much does it cost?
-
Provider Network
The KelseyCare Advantage Rx Select plan works well for Medicare beneficiaries that need comprehensive coverage and low out-of-pocket expenses for their hospital, medical and prescription drug benefits. This plan also offers worldwide emergency coverage as well as coverage for routine vision, hearing, and medical transportation. The Rx Select plan offers members the option to access certain specialists who are outside of the KelseyCare Advantage provider network.
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).The monthly plan premium to enroll in the Rx Select plan is $15.00. Additionally, you must maintain your Medicare Part B coverage to be a member of any Medicare Advantage 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 Rx Select members will receive most of their medical care from the doctors at Kelsey-Seybold Clinic. KelseyCare Advantage also contracts with an affiliate network of doctors to provide care that is not offered at Kelsey-Seybold. You can use specialists who are in or out of the KelseyCare Advantage provider network. 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.
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.
-
Medical Benefits
-
Prescription Drug Benefits
-
Premium
The information listed below is for in-network services only. Out-of-Network cost-share for select services is between 20% and 50%, please review the Evidence of Coverage (EOC) for detailed out-of-network cost-share information.Covered Service What You Pay PHYSICIAN SERVICES / DOCTOR OFFICE VISITS
PCP - $0
Specialist - $35ANNUAL WELLNESS VISIT $0 TELEHEALTH BENEFIT E-Visit PCP- $0
E-Visit Spec - $0
Video Visit PCP - $0
Video Visit Spec - $35PREVENTIVE HEATLH SCREENINGS $0
INPATIENT HOSPITAL CARE $350 per admission SKILLED NURSING FACILITY CARE (SNF) $0/day - days 1-20
$125/day - days 21-100OUTPATIENT 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 - $50EMERGENCY CARE $120 AMBULANCE SERVICES $200 URGENTLY NEEDED SERVICES $25 OUTPATIENT HOSPITAL OBSERVATION $300 OUTPATIENT HOSPITAL SERVICES ASC - $225
Hospital $300OUTPATIENT SURGERY ASC - $225
Hospital - $300
OUTPATIENT REHAB SERVICES PT and OT - $10
Speech - $35
Wound Care/Lymphedema - $35OUTPATIENT MENTAL HEALTH CARE Group - $20
Individual - $35OUTPATIENT SUBSTANCE ABUSE SERVICES Group - $20
Individual - $35DURABLE 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 servicesPULMONARY REHABILITATION SERVICES $30 CARDIAC REHABILITATION SERVICES $35 CHIROPRACTIC SERVICES $20
PODIATRY SERVICES $35 HOME HEALTH AGENCY CARE $10 INPATIENT MENTAL HEALTH CARE $350 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 & suppliesIMMUNIZATIONS $0 TRANSPORTATION $0 SMOKING CESSATION $0 HEARING SERVICES Diagnostic - $35
Routine- $35
Hearing Aid Fitting- $35
$125 plan allowance per yearVISION CARE Diagnostic - $35
Routine- $0
$75 plan allowance per yearThis table gives you basic information about the prescription drug benefits that are available with some of our plans. For more details, see the Comprehensive Formulary (PDF) in the Plan Documents section.
Initial Coverage
You will pay a yearly deductible of $100 on Tiers 3, 4 and 5 drugs. You must pay the full cost of your Tiers 3, 4 and 5 drugs until you reach the plan’s deductible amount. After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $4,020. Total yearly drug costs are the total drug cost paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies.
Preferred Retail Cost-Sharing
Tier One-month supply Three-month supply Tier 1 (Preferred Generic) $3 copay $7.50 copay Tier 2 (Generic)
$5 copay $12.50 copay Tier 3 (Preferred Brand)
$40 copay $100 copay Tier 4 (Non-Preferred Brand)
$60 copay $150 copay Tier 5 (Specialty Tier)
31% of the cost A long-term supply is not available for drugs in Tier 5 Specialty.
Standard Retail Cost-SharingTier One-month supply Three-month supply Tier 1 (Preferred Generic) $8 copay $24 copay Tier 2 (Generic) $10 copay $30 copay Tier 3 (Preferred Brand) $45 copay $135 copay Tier 4 (Non-Preferred Brand) $70 copay $210 copay Tier 5 (Specialty Tier) 31% of the cost A long-term supply is not available for drugs in Tier 5 Specialty Stage Description Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug’s tier. See the chart that follows to find out how much it will cost you.Catastrophic Coverage Stage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of: - 5% of the cost, or
- $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs.
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 Rx Select $15 -
Plans without drug coverage
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Essential Plan
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?
-
You must:
-
How much does it cost?
-
Provider Network
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.
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).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.
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.
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 - $20ANNUAL WELLNESS VISIT $0 TELEHEALTH BENEFIT E-Visit PCP- $0
E-Visit Spec - $10
Video Visit PCP - $0
Video Visit Spec - $20PREVENTIVE HEATLH SCREENINGS $0 INPATIENT HOSPITAL CARE $500 per admission SKILLED NURSING FACILITY CARE (SNF) $0/day - days 1-20
$125/day - days 21-100OUTPATIENT 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 - $50EMERGENCY CARE $120 AMBULANCE SERVICES $100 URGENTLY NEEDED SERVICES $25 OUTPATIENT HOSPITAL OBSERVATION $250 OUTPATIENT HOSPITAL SERVICES ASC - $225
Hospital - $250OUTPATIENT SURGERY ASC - $225
Hospital - $250OUTPATIENT REHAB SERVICES PT and OT - $10
Speech - $20
Wound Care/Lymphedema - $20OUTPATIENT MENTAL HEALTH CARE Group - $20
Individual - $35OUTPATIENT SUBSTANCE ABUSE SERVICES Group - $20
Individual - $35DURABLE 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 servicesPULMONARY 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 & suppliesIMMUNIZATIONS $0 TRANSPORTATION $0 SMOKING CESSATION $0 HEARING SERVICES Diagonostic - $20
Routine - $20
Hearing Aid Fitting - $20 $500 plan allowance every yearVISION CARE Diagnostic - $20
Routine- $0
$75 plan allowance per yearPlan 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 -
-
Essential+Choice Plan
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+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?
-
You must:
-
How much does it cost?
-
Provider Network
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).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.
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.
-
Medical Benefits
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Premium
The information listed below is for in-network services only. Out-of-Network cost-share for select services is between 20% and 50%, please review the Evidence of Coverage (EOC) for detailed out-of-network cost-share information.Covered Service What You Pay PHYSICIAN SERVICES / DOCTOR OFFICE VISITS
PCP - $0
Specialist - $20ANNUAL 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 21-100OUTPATIENT 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 - $50EMERGENCY CARE $120 AMBULANCE SERVICES $100 URGENTLY NEEDED SERVICES $25 OUTPATIENT HOSPITAL OBSERVATION $250 OUTPATIENT HOSPITAL SERVICES ASC - $225
Hospital - $250OUTPATIENT SURGERY ASC - $225
Hospital - $250OUTPATIENT REHAB SERVICES PT and OT - $10
Speech - $20
Wound Care/Lymphedema - $20OUTPATIENT MENTAL HEALTH CARE Group - $20
Individual - $35OUTPATIENT SUBSTANCE ABUSE SERVICES Group - $20
Individual - $35DURABLE 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 servicesPULMONARY 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 & suppliesIMMUNIZATIONS $0 TRANSPORTATION $0
SMOKING CESSATION $0 HEARING SERVICES Diagonostic - $20
Routine - $20
Hearing Aid Fitting - $20 $500 plan allowance every yearVISION CARE Diagnostic - $20
Routine- $0
$75 plan allowance per yearPlan 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 + Choice $0 -
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Essential Select Plan
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 Select.
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.
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Who should join?
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You must:
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How much does it cost?
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Provider Network
The KelseyCare Advantage Essential Select 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 Select 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).You’ll pay no monthly plan premium to enroll in the Essential Select plan. You must maintain your Medicare Part B coverage to be a member of the Essential Select 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 Select 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.
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.
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Medical Benefits
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Premium
The information listed below is for in-network services only. Out-of-Network cost-share for select services is between 20% and 50%, please review the Evidence of Coverage (EOC) for detailed out-of-network cost-share information.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 - $20PREVENTIVE HEATLH SCREENINGS $0 INPATIENT HOSPITAL CARE $350 per admission SKILLED NURSING FACILITY CARE (SNF) $0/day - days 1-20
$125/day - days 21-100OUTPATIENT 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 - $50EMERGENCY CARE $120 AMBULANCE SERVICES $200 URGENTLY NEEDED SERVICES $25 OUTPATIENT HOSPITAL OBSERVATION $250 OUTPATIENT HOSPITAL SERVICES ASC - $225
Hospital - $250OUTPATIENT SURGERY ASC - $225
Hospital - $250OUTPATIENT REHAB SERVICES PT and OT - $10
Speech - $20
Wound Care/Lymphedema - $20OUTPATIENT MENTAL HEALTH CARE Group - $20
Individual - $35OUTPATIENT SUBSTANCE ABUSE SERVICES Group - $20
Individual - $35DURABLE 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 servicesPULMONARY REHABILITATION SERVICES $20 CARDIAC REHABILITATION SERVICES $20 CHIROPRACTIC SERVICES $20
PODIATRY SERVICES $20 HOME HEALTH AGENCY CARE $10 INPATIENT MENTAL HEALTH CARE $350 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 & suppliesIMMUNIZATIONS $0 TRANSPORTATION $0 SMOKING CESSATION $0 HEARING SERVICES Diagonostic - $20
Routine - $20
Hearing Aid Fitting - $20 $500 plan allowance every yearVISION CARE Diagnostic - $20
Routine- $0
$75 plan allowance per yearPlan 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 Select $0 -
Value-Added Benefits
Every KelseyCare Advantage plan includes added benefits to help you get even more for your Medicare dollar, from vision coverage to health club membership.