Out-of-Network Coverage

When Is Out-of-Network Care Covered?

KelseyCare Advantage members enjoy access to Kelsey-Seybold Clinic's premier multispecialty physician group, along with a broad network of primary care providers and specialists.

In certain situations, care received from an out-of-network provider may be covered. Members enrolled in the KelseyCare Advantage Freedom (HMO-POS) plan may have coverage for some out-of-network medical services when the provider agrees to bill KelseyCare Advantage.

If you are enrolled in either the KelseyCare Advantage Signature or Core (HMO) plan, out-of-network services may be covered when:

• You need emergency or urgently needed care and an in-network provider is not available.
• You need a Medicare-covered service that cannot be provided by an in-network provider. In these situations, prior authorization from KelseyCare Advantage is required before receiving non-emergency care from an approved out-of-network provider. If approved, you will pay the same cost-sharing you would pay for in-network care.

Please refer to your Evidence of Coverage (EOC) for complete details about your plan's out-of-network coverage and authorization requirements.

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