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Best Medicare Advantage Plans for 2019 Rating is from U.S. News and World Report, a leading publisher of annual authoritative rankings including Best Medicare Plans. Our plan does not have a direct relationship with U.S. News. This award was not given by Medicare. Our overall rating from Medicare for 2019 is 5.0. Our plan’s official CMS Star Rating can be found at www.Medicare.gov.

Important Documents

As a KelseyCare Advantage member, you have numerous tools and resources available to you.
 
  Appeals and GrievancesAppeals and Grievances Appointment of Representative FormAppointment of Representative Coordination of
Benefits Form
Coordination of Benefits
Rights and Responsibilities
Rights and Responsibilities 

Transition of Care
Transition of Care

EFTEFT

VSPEFT

Equivalent NoticeEquivalent Notice



Part D Coverage DecisionPart D Coverage Decision



Part D Temporary Transition SupplyPart D Temporary Transition Supply

 Part D Coverage Determination
PDF Form
Online FormPart D Coverage Determination Form


Part D Coverage Redetermination
Online FormPart D Coverage Determination Form

Reimbursement form for Part D DrugsSubmitting a Paper Claim Form for Part D Drugs

Low Income Subsidy InformationLow Income Subsidy

Medication Therapy Management ProgramMedication Therapy Management

Order New or
Replacement ID Card
Order New ID Card



Privacy Policy
 privacypolicy.jpg



Ask an Expert
Ask an Expert



Compliance & Fraud
Compliance and Fraud

​​About Medicare's Best Available Evidence Policy
Prescription Drug Coverage

​​ Organization Determination and Payment Request
Organization Determination

Appointment of Representative Form
If you need someone to file a grievance, coverage determination or appeal on your behalf, you can name a relative, friend, advocate, doctor or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

To download a copy of Medicare's Appointment of Representative form, click here.

If you want to appoint a representative, you should complete the Appointment of Representative form on the Medicare.gov website and mail it to:

KelseyCare Advantage
ATTN: Member Services
P.O. Box 841569
Pearland, Tx 77584

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Equivalent Notice Form
If you need someone to speak to Member Services on your behalf, you can name a relative, friend or advocate your appointed representative. You and that person must sign and date a statement that gives the person permission to act as your appointed representative.

To download a copy of the Equivalent Notice form, click here.

You can return the completed form via email, fax or mail:

Email: memberservices@kelseycareadvantage.com

Fax: (713) 442-5450

KelseyCare Advantage
ATTN: Member Services
P.O. Box 841569
Pearland, Tx 77584

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Coordination of Benefits Form
After you enroll, if you have more than one medical plan, you can complete the Coordination of Benefits form.  Having more than one medical plan may save on medical costs by coordinating your benefits.  The information you provide will help us determine if your other medical plan is primary or secondary to your KelseyCare Advantage plan.  Go to the Coordination of Benefits Form.

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Transition of Care
During your first few months of membership, you may have questions about transitioning your care to KelseyCare Advantage network providers. If you are currently receiving care from non-KelseyCare Advantage network providers, please call Member Services at 713-442-CARE (2273) or 1-866-535-8343, 8:00 a.m. to 5:00 p.m., Monday through Friday. TTY/TDD users should call 1-866-302-9336.

For more information about KelseyCare Advantage's Transition of Care policy,click here. To go to the Transition of Care request form, click here.

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Order New or Replacement ID Card
Your ID card shows information important to your health insurance coverage. You don’t need a new ID card every year. If you change plans, we will send you a new ID card.

For a new or replacement ID card, you may request one here or contact a KelseyCare Advantage Member Services representative at one of the phone numbers below and a new ID card will be sent to the address on file for you.

713-442-CARE (2273) or toll free: 1-800-663-7146
(TTY/TDD 1-866-302-9336)
8 a.m. to 8 p.m., seven days a week

Press 2 if you are a current member of KelseyCare Advantage

Press 1 if you have a question regarding your medical benefits

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Reimbursement form for Part D Drugs
Below is a brief description of some of the situations you may submit a paper claim for reimbursement for your Part D drug expenses. For a full description and a complete listing of all situations refer to the Evidence of Coverage, Chapter 7, Asking the plan to pay its share of a bill you have received for covered services or drugs. Some of the situations you may submit a paper claim include:

  • When you use an out-of-network pharmacy to get a prescription filled
  • When you pay the full cost for a prescription because you don't have your plan membership card with you
  • When you pay the full cost for a prescription drug that is not on the plan's List of Covered Drugs (Formulary); or the drug has a requirement or restriction that you didn't know about or don't think should apply to you.


When you send us your request for reimbursement, include a copy of your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records. Make sure you are giving us all the information we need to make a decision. You don't have to use our form, but it's helpful for our plan to process the information faster. Either download a copy of our KelseyCare Advantage/OptumRx Direct Member Reimbursement Form (click here) or call Member Services and ask for the KelseyCare Advantage /​OptumRx Direct Member Reimbursement Form.

Mail your request for payment and the KelseyCare Advantage/OptumRx Direct Member Reimbursement Form together with any bills or receipts to this address:

OptumRx
Direct Member Reimbursement
PO Box 968021
Schaumburg, IL 60196-8021​

You must submit your claim to us within 12 months of the date you received the drug.

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Low Income Subsidy Information
Information about KelseyCare Advantage's Low Income Subsidy premiums.
 
 
Ask an Expert
For more information about your KelseyCare Advantage benefits, contact us at:
 
713-442-9540 or toll free: 1-866-535-8405
(TTY/TDD 1-866-302-9336)
8 a.m. to 5 p.m., Monday Through Friday
 
Or, you may request a phone call to request a phone call from a KelseyCare Advantage member service representative.
 
You may also contact Medicare at 1-800-MEDICARE 1-800-633-4277 (TTY/TDD 1-877-486-2048), 24 hours a day, seven days a week.
 
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