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Frequently Asked Questions

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.​ 

FAQ Categories

General Information


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.  

Part B Monthly Premiums
Part B does have a monthly premium. Most people will pay the standard premium amount.  You also pay a Part B deductible each year before Medicare starts to pay its share. The Part B premium and deductable can change every year. 
As a KelseyCare Advantage member, will I have to use one clinic or doctor?

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:

  • The plan covers emergency care or urgently needed care that you get from a non-network provider.
  • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from a non-network provider. An authorization should be obtained from the plan prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider. 

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. 

When can I make an appointment?
Once enrolled in our Medicare Advantage plan, you may schedule an appointment with any Kelsey-Seybold Clinic physician. You will need to present a KelseyCare Advantage membership card at the time of your appointment.

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.

How do KelseyCare Advantage plans work?
KelseyCare Advantage is a Medicare Advantage plan that is contracted and approved by Medicare. As a KelseyCare Advantage member, you receive all your Medicare benefits through the KelseyCare Advantage plan that you select.

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.   

What out-of-network services are covered if I enroll in one of the “Choice” plans?
You may use the point-of-service benefit for the following services:
  • Specialist physician office visits and physician services in ambulatory surgery centers and in outpatient and inpatient hospital settings.
  • Outpatient hospital and ambulatory services and surgery.
  • Procedures and other testing such as x-rays and bloodwork.
  • Diagnostic radiology services.
  • Inpatient hospital stays.

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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About KelseyCare Advantage Plan
Can I choose my doctors?
KelseyCare Advantage members will receive most of their medical care from the doctors as Kelsey-Seybold Clinc.  Also, KelseyCare Advantage has formed an outstanding network of affiliate doctors, specialists and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. For the most up-to-date list of providers in our network, click Find a Doctor.
Does my plan cover prescription drugs?
KelseyCare Advantage covers both Medicare Part B and Medicare Part D prescription drugs.
 Am I protected?
All Medicare Advantage plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage plan leaves the program, you will not lose Medicare coverage. If a plan decides to discontinue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
How can I get more information?
Please call a KelseyCare Advantage health plan specialist at:

713-442-9540 or
Toll free 1-866-535-8405
TTY/TDD 1-866-302-9336
8:00 a.m. to 5:00 p.m., Monday Through Friday 

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How do I choose a PCP? 
When you become a member of KelseyCare Advantage, you will choose a Kelsey-Seybold doctor to be your Primary Care Physician (PCP).  Your routine or basic care will come from your PCP. Your PCP can also coordinate the rest of the covered services you need. You may select a physician who specializes in Family Medicine or Internal Medicine as your PCP. In addition to a PCP, you also have the right to designate an OB/GYN and access care from that physician without a referral.

Download a PDF of our Provider Directory, or search for a provider by specialty, location, gender or languages spoken.

How do I schedule appointments? 
For personal assistance in finding a doctor or scheduling an appointment, call the Kelsey-Seybold Clinic Customer Service Contact Center at 713-442-0000. The Contact Center is open 24 hours a day, 7 days a week. You may also schedule a future appointment on-line at Kelsey-Seybold Clinic.
Do I need to see my PCP to get a referral to other providers? 
You may see any Kelsey-Seybold Clinic physician without a referral. However, you will get most of your routine or basic care from your PCP. Your PCP can also coordinate your covered services. You will need a referral to obtain services from a non-Kelsey-Seybold Clinic doctor, hospital or other health care provider. If you don't obtain a referral ahead of time from your Kelsey-Seybold Clinic physician, you may have to pay for these services yourself.
What happens if I go to a doctor who’s not in the KelseyCare Advantage network? 
If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither KelseyCare Advantage nor the original Medicare plan will pay for these services. Point-of-service benefits, are available to certain employer-sponsored groups.  These plans  provide limited out-of-network coverage. 
How can I find a KelseyCare Advantage provider in my area? 
You may search for a provider by specialty, location, gender or languages spoken. You can also call a KelseyCare Advantage member services representative at:

713-442-9540 or
Toll free 1-866-535-8405
TTY/TDD 1-866-302-9336

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Where can I get my prescriptions filled?
In most cases, your prescriptions are covered only if they are filled at the plan's network pharmacies.

A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. The term "covered drugs"means all of the Part D prescription drugs that are covered by the plan.

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 or
Optum Rx
Toll free 1-866-589-5222
TTY/TDD 1-888-206-8041

What is a pharmacy that offers preferred cost-sharing?
Our network includes pharmacies that offer standard cost-sharing and pharmacies that offer preferred cost-sharing.  You may go to either type of network pharmacy to receive your covered prescription drugs.  Your cost-sharing may be less at pharmacies with preferred cost-sharing.
What if I must use an out-of-network pharmacy?

You will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription.

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
  • Non-routine situations when a network pharmacy is not available.
  • If you are traveling within the United States and territories and you become ill, run out or lose your drugs.
  • Prescriptions that are written as part of a medical emergency or urgent care visit.
You can ask us to reimburse you for our share of the cost. (Please refer to your Evidence of Coverage, which explains how to ask the plan to pay you back.)

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Rx Drugs
What is a drug list (formulary)? 
The plan has a “List of Covered Drugs (Formulary).”  The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list includes both brand name and generic drugs and must meet requirements set by Medicare. Medicare has approved the plan’s Drug List. 
What does the drug list (formulary) include? 
The drug list includes both brand-name and generic drugs.  A generic drug is a prescription drug that has the same active ingredients as the brand-name drug. Generally it works just as well as the brand-name drug, but it costs less. There are generic drug substitutes available for many brand-name drugs. 

What is not on the drug list?
The plan does not cover all prescription drugs.
  • In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more information about this, refer to your Evidence of Coverage, Chapter 5).
  • In other cases, we have decided not to include a particular drug on the Drug List  
Why do some drugs have restrictions?
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you get a drug that works for your medical condition and is safe. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your doctor to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing. 
What is a prior authorization? 
For certain drugs, you or your doctor need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization. Sometimes plan approval is required so we can be sure that your drug is covered by Medicare rules. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan 

What is Step Therapy?
This is a type of requirement that encourages you to try a less costly but, just as effective drug before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called "step therapy". 

What is a Quantity Limit?
For certain drugs, we limit the amount of the drug that you can have. For example, the plan might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
Does my plan cover Medicare Part B drugs or Part D drugs? 
KelseyCare Advantage covers a limited number of Medicare Part B drugs and all Medicare Part D drugs on the plan’s drug list.
Can the formulary change? 
Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make many kinds of changes to the Drug List. For example, the plan might:
  • Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.
  • Move a drug to a higher or lower cost-sharing tier.
  • Add or remove restriction on coverage for a drug.
  • Replace a brand-name drug with a generic drug.
In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug List. 
How will I find out if my drug's coverage has changed? 
If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time. Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. Your doctor will also know about this change, and can work with you to find another drug for your condition. For questions regarding the formulary, please call OptumRx Customer Service 24 hours a day, 7 days a week, toll free at 1-866-589-5222. TTY/TDD 1-888-206-8041.
Are there programs to help people with limited resources pay for their prescription drugs? 
You might qualify to get help in paying for your drugs. There are two basic kinds of help:
  • “Extra Help” from Medicare. This program is also called the “low-income subsidy” or LIS. People whose yearly income and resources are below certain limits can qualify for this help. See Section III of the Medicare & You Handbook or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.
  • Help from your state’s pharmaceutical assistance program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules. Check with your State Health Insurance Assistance Program (Please refer to your Evidence of Coverage, Chapter 2).

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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.  

We provide services to those members who meet the following CMS directed MTM Qualification Criteria. To be considered for participation in this program a member is required to:
  • Have any three of the following chronic diseases: Alzheimer’s disease, Chronic heart failure (CHF), Hypertension, Diabetes, Respiratory Disease such Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disorders or Bone Disease-Arthritis such as Osteoporosis, Osteoarthritis, or Rheumatoid Arthritis
  • Take six or more Part D medications
  • Spend an expected total of more than $3,507.00 per year for Part D medications, (the expected total is the amount paid by the plan for Part D medications, added to the amount the member pays). 

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