FAQs About Medicare

After you sign up for KelseyCare Advantage, make an appointment with any Kelsey-Seybold Clinic doctor. Schedule your appointment online. Or call our 24/7 Patient Access Center at 713-442-0427.

Once you sign up for a KelseyCare Advantage Plan you stay enrolled as a member of that plan. There is no need to renew during the Annual Enrollment Period. You remain a KelseyCare Advantage member until you switch to another Medicare plan.

All of our plans include preventive dental coverage for routine exams, cleanings, and X-rays. These services help you maintain good oral health. They can also identify possible problems early.

Many of our plans also cover comprehensive dental services. You'll have coverage for the basics and more. These plans have coverage for fillings, extractions, root canals, and dentures. Crowns associated with a bridge are covered, standard crowns are not covered. Refer to the Evidence of Coverage for each plan for detailed dental benefit information, this is only a summary.

Learn more about our dental benefits here.

If you travel outside the Houston area, you can still get care when you need it.

KelseyCare Advantage benefits include Virtual Care appointments with Kelsey-Seybold providers. If you're traveling, you can schedule a Virtual Care appointment to see a provider who has full access to your medical records. Emergency care is covered worldwide, and urgent care is covered within the United States.

Traveling outside the U.S.? You’re covered for emergency care services worldwide.

KelseyCare Advantage is a Medicare Advantage plan. We are a private insurance company with a federal contract with Medicare. With our plans, you get all the benefits that Original Medicare offers, plus more. We offer coverage for dental, vision, hearing, and more.

You must have Medicare Part A and Part B to join. You must continue paying your monthly Medicare Part B premium.

Your specific coverage depends on which KelseyCare Advantage Plan you choose. And all our plans give you access to Kelsey-Seybold Clinics. You'll have a robust network of premier specialists and other providers as your trusted partners in health.

An HMO plan with a Point-of-Service is a type of HMO which allows members to receive some services from out-of-network providers at a higher cost to the member.

KelseyCare Advantage offers one HMO-POS plan, the Freedom plan. Members enrolled in the Freedom plan have open access to all Kelsey-Seybold providers as well as the ability to receive services from an out-of-network provider with no referral.

Providers must be willing to bill KelseyCare Advantage.

You can enroll in a Medicare Advantage plan when:

• You are new to Medicare (a seven-month enrollment period – three months before the month you turn 65, the month you turn 65, and three months after your birthday month).
• You retire and lose your group health coverage. You have eight months to enroll in Medicare once you stop working OR your employer coverage ends (whichever happens first).
• It is during a designated Medicare election period (For example, Medicare's Annual Enrollment Period is October 15 through December 7).

You can enroll in KelseyCare Advantage when you:

• Are already enrolled in Medicare Part A and Part B. Most of our plans do not have a monthly premium but you must continue paying your monthly Medicare Part B premium to Medicare.
• Live within our geographic service area.
• Are a United States citizen or lawfully present in the United States.

Compare all of our KelseyCare Advantage Plans.

If you have questions about plan benefits, please call our local health plan specialists at 713-442-JOIN (5646).

All of our plans include access to Kelsey-Seybold Clinic. You’ll have a wide network of leading specialists and providers as your partners in care. Our network also extends to trusted affiliate specialty providers.

• Find a provider

The 2026 KelseyCare Advantage plans that include Medicare Part D prescription drug coverage are:

• Signature (HMO MAPD)
• Freedom (HMO-POS MAPD)
• Compare all of our 2026 plans

Our licensed insurance agents are ready to assist you. They'll help you understand your options and find a coverage solution to meet your needs. Call us at 713-442-JOIN (5646).

You have choices when it comes to your primary care. Your PCP may practice family medicine, internal medicine, or OB-GYN. Find a Kelsey-Seybold doctor online. Or call our 24/7 Contact Center at 713-442-0427.

Schedule your appointment online via MyKelsey Online. Or, call our 24/7 Contact Center at 713-442-0427.

You may see any Kelsey-Seybold doctor without a referral.

You will need a referral from your PCP:

• To see a non-Kelsey-Seybold doctor.
• To get non-emergency services from an out-of-network hospital.
• To receive services outside of the network. (Unless you are enrolled in the Freedom HMO-POS plan)

If you have an HMO plan and choose to go to a doctor outside of our network, you must pay for these services yourself. Neither KelseyCare Advantage nor Original Medicare will pay for these services.

If you have an HMO-POS plan, you may see out-of-network providers without a referral. You may pay higher costs out of pocket for out-of-network services. Your provider must be willing to bill KelseyCare Advantage. Please see your Evidence of Coverage for complete details.

A preferred pharmacy has a contract with KelseyCare Advantage. They agree to charge less for covered drugs. Use a preferred pharmacy to help save money on your drug costs. Our preferred pharmacies are Kelsey-Seybold Pharmacy, CVS, and H-E-B.

If you use an out-of-network pharmacy, you will likely have to pay the full price when you fill a prescription. In the following situations, we may cover the cost of prescription drugs filled at an out-of-network pharmacy:

• When a network pharmacy isn’t available.
• When you’re traveling within the U.S. but outside of the network area and are in need of prescription medications.
• When a prescription is written as part of your medical emergency or urgent care treatment.

In these cases, you’ll still have to pay the full cost, but you can request that we reimburse you for our share of the cost.

A formulary is a list of the prescription drugs that we help pay for as part of your plan. We work with a team of healthcare providers to develop this list. These providers agree that these drug therapies are necessary for quality treatment.

Prescription drugs are available as brand-name drugs or generic drugs. Most drugs have a brand-name version and a generic version. Both versions have the same active ingredients. The difference is that you may not know the generic name. The generic is often cheaper than the brand-name version.

If your drug is not on the approved list of drugs or is restricted:

• You can change to another drug.
• You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.
• You may be able to get a temporary (transition) supply of the drug. This will give you and your doctor time to change to another drug or to file an exception. Note: Only members in certain situations can get a temporary supply.

Temporary (transition) supply requirements

Under certain circumstances, your KelseyCare Advantage Plan can offer a temporary supply of a drug you need. Doing this gives you time to talk to your doctor about available alternatives.

To be eligible for a temporary supply, you must meet both requirements:

• The change to your drug coverage must be one of the following types:
  • The drug you have been taking is no longer on the plan's drug list (formulary).
  • The drug you have been taking is now restricted in some way.
• You must be in one of the following situations:
  • For members who were in the plan last year and affected by the drug coverage changes: We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we allow multiple refills to provide up to a maximum of a 30-day supply of medication. You must fill the prescription at a network pharmacy. (Long-term care pharmacies may provide the drug in smaller amounts to prevent waste.)
  • For new members affected by drug coverage changes: We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we allow multiple refills to provide up to a maximum of a 30-day supply of medication. You must fill the prescription at a network pharmacy.
  • For those who have been members of the plan for more than 90 days, reside in a long-term care facility, and need a supply right away: We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.

Download our 2026 transition policy

If there’s a change to coverage for a drug you’re taking, we will send you a notice. The FDA may recall a drug if it's found to be unsafe, or for other reasons. If this happens, we will immediately remove the drug from our drug list and let you know of this change. Your doctor will also know about this change and will work with you to find another drug for your condition.

Learn more about prescription drug benefits.

Extra Help is a Medicare program to help people with limited income and resources pay for Medicare prescription drug costs.

If you have limited income, you may be able to get help with your prescription drug costs from Medicare's Extra Help program. If you qualify, Medicare could pay for 75% or more of your:

• Monthly prescription drug premiums
• Annual deductibles
• Prescription copays

Many people qualify and don't know. There's no penalty for applying.

For more information and to apply, visit ssa.gov/medicare/prescriptionhelp/ or call Social Security toll-free at 1-800-772-1213, TTY 1-800-325-0778. You can also call your local Social Security office.

With Extra Help, you won't have a late enrollment penalty (LEP). Also, as long as you're in the program, you can change plans at any time. If you're notified that you no longer qualify, you'll have two months to change plans.

If you take multiple medications, you may qualify for a program that helps you manage your prescriptions.

Your participation is voluntary and doesn’t affect your coverage.

Learn more about our Medication Therapy Management program.