The Evidence of Coverage booklet tells you how to get your Medicare medical care covered through our plan. This booklet explains your rights and responsibilities, what is covered and what you pay as a member of the plan.
here for more information about KelseyCare Advantage's coverage of HIV screening.Back to TopSummaries of BenefitsThe Summary of Benefits tells you some features of each plan. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of benefits for each plan, please review the KelseyCare Advantage Evidence of Coverage.
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Appointment of Representative FormIf 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,
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 AdvantageATTN: Member ServicesP.O. Box 841569Pearland, TX 77584
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Equivalent Notice FormIf 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,
You can return the completed form via email, fax or mail:
Fax: (713) 442-5450
Coordination of Benefits FormAfter 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.
Transition of CareDuring 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
For more information about KelseyCare Advantage's Transition of Care policy,click here. To go to the Transition of Care request form,
Order New or Replacement ID CardYour 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:
1-866-302-9336)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
How Do I Change Plans?To make a change in the Medicare Advantage plan you have with KelseyCare Advantage, print and complete the
Change of Plan form. Select the plan you want, and sign the form. Then mail the completed form back to P.O. Box 841569 Pearland, TX 77584-9832. You can also call KelseyCare Advantage Member Services to complete a telephonic plan change.
Please be aware that you can change health plans only at certain times during the year. Between October 15 to December 7th each year, anyone can join our plan. In addition, from January 1 through February 14, anyone enrolled in our plan has an opportunity to disenroll from our plan and return to Original Medicare. Anyone who disenrolls from a Medicare Advantage plan during this time can join a stand-alone Medicare Prescription Drug Plan during the same period. Generally, you may not make changes at other times unless you meet certain special exceptions, such as if you move out of the plan’s service area.
When and how to submit a paper claim form for Drugs covered by Part DBelow 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:
Please note: you must submit your claim to us within 12 months of the date you received the drug.
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 Direct Member Reimbursement Form (click here) or call Member Services and ask for the KelseyCare Advantage Direct Member Reimbursement Form.
Mail your request for payment and the KelseyCare Advantage Direct Member Reimbursement Form together with any bills or receipts to this address:
KelseyCare AdvantageAttn: Pharmacy ServicesPO Box 841569Pearland, TX 77584You must submit your claim to us within 12 months of the date you received the drug.
NewslettersAs a KelseyCare Advantage member, you can access the member newsletter, House Call, which offers additional convenience by bringing health news directly to your mailbox. Read past newsletters here: