KelseyCare Advantage offers answers to frequently asked questions about our Medicare Advantage plans, our provider network and other important topics. These links will guide you to further information on our website or from other sources. Should you have any further questions about anything, including your Medicare benefits, please Contact Us.
How much do I pay for Medicare coverage?
As a KelseyCare Advantage member, will I have to use one clinic or doctor?
When can I make an appointment?
How do KelseyCare Advantage plans work?
What out-of-network services are covered if I enroll in one of the "Choice" plans?
How much do I pay for Medicare coverage?
Part A Monthly Premiums
Most people do not pay for Part A, because they have paid Medicare taxes for 40 or more quarters while working. Those with 30 to 39 quarters of covered employment can buy Part A coverage.
When you join KelseyCare Advantage, you generally must receive your care from a network provider. Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment in full. We have arranged for these providers to deliver covered services to members in our plan. The cornerstone of the KelseyCare Advantage network is Kelsey-Seybold Clinic.
In most cases, care you receive from a non-Kelsey-Seybold doctor will not be covered.
Here are two exceptions:
You may decide to see any Kelsey-Seybold Clinic primary care physician or specialist within the clinic at any time without a referral. It is not necessary to notify Member Services if you decide to change doctors. Simply schedule an appointment with the Kelsey-Seybold physician of your choice. However, you can contact Member Services if you need assistance.
Important Note about Affiliate Contract Providers: When Kelsey-Seybold Clinic does not have the staff specialist you need at any of their locations, you can be referred to a specialist who has been selected by Kelsey-Seybold physicians. Your PCP will submit a request to KelseyCare Advantage for approval of non-Kelsey-Seybold providers. Both you and the specialist to whom you are referred will receive written confirmation if the service is approved.
If you are a KelseyCare Advantage Essential+Choice or a KelseyCare Advantage Rx+Choice member, you can choose a physician or other health care specialist who is outside of the KelseyCare Advantage provider network. As a member of one of these plans, you can access certain services from a non-Kelsey-Seybold Clinic provider without a referral. You will want to confirm with these non-Kelsey-Seybold Clinic providers that they will accept reimbursement from KelseyCare Advantage.
For a list of current network providers, download a Provider Directory, or search for a Kelsey-Seybold Clinic provider by specialty, location, gender or languages spoken.
For personal assistance in finding a doctor or scheduling an appointment, call the KelseyCare Advantage concierge. Our knowledgeable representatives are ready to assist KelseyCare Advantage members. Call 713-442-9540 or toll free 1-866-535-8405. You may also schedule a future appointment online at Kelsey-Seybold Clinic.
To join KelseyCare Advantage, you must have Medicare Part A and Part B. You will continue to pay your monthly Medicare Part B premium to Medicare.
Once you join a KelseyCare Advantage plan, you use the health insurance card provided by the plan. KelseyCare Advantage offers extra Medicare benefits and often lower co-payments than the original Medicare plan. KelseyCare Advantage contracts with Kelsey-Seybold Clinic, which means you can choose physicians and other health care providers who are part of Kelsey-Seybold Clinic.
Members of KelseyCare Advantage with the plans that offer the Point-of-Service (POS) benefits in addition to the covered services under their specific KelseyCare Advantage plan. The POS benefit covers certain medically necessary services the member may access from out-of-network providers. When a member utilizes the POS benefit, he/she is usually responsible for more of the cost of care. The POS benefit includes a coinsurance or co-payment, which is a percentage of the allowed payment amount, usually Medicare allowable or a co-payment for specific services. Certain services are not covered under the POS benefit. For more information, refer to the Evidence of Coverage.
As a KelseyCare Advantage member, you will be responsible for a coinsurance or copayment for all services provided outside of the KelseyCare Advantage network.
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Can I choose my doctors?
Does my plan cover prescription drugs?
Am I protected?
How can I get more information?
713-442-9540 orToll free 1-866-535-8405TTY/TDD 1-866-302-93368:00 a.m. to 5:00 p.m., Monday Through Friday
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How do I choose a PCP?
How do I schedule appointments?
Do I need to see my PCP to get a referral to other providers?
What happens if I go to a doctor who’s not in the KelseyCare Advantage network?
How can I find a KelseyCare Advantage provider in my area?
Download a PDF of our Provider Directory, or search for a provider by specialty, location, gender or languages spoken.
713-442-9540 orToll free 1-866-535-8405TTY/TDD 1-866-302-9336
Where can I get my prescriptions filled?
What is a preferred pharmacy?
What if I must use an out-of-network pharmacy?
The pharmacies in our network can change at any time. To verify if a pharmacy is part of our network, please call a KelseyCare Advantage health plan specialist at:
713-442-9540 orOptum Rx Toll free 1-866-589-5222TTY/TDD 1-888-206-8041
You will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription.
What is a drug list (formulary)?
What does the drug list (formulary) include?
What is not on the drug list?
Why do some drugs have restrictions?
What is a prior authorization?
What is Step Therapy?
What is a Quantity Limit?
Does my plan cover Medicare Part B drugs or Part D drugs?
Can the formulary change?
How will I find out if my drug’s coverage has changed?
Are there programs to help people with limited resources pay for their prescription drugs?
Where can I get information about Low Income Subsidy?
What is a Medication Therapy Management (MTM) Program?
A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs.