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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
Equivalent Notice
Equivalent Notice
 How Do I Change
My Plan?
How Do I Change My Plan?

Coordination of
Benefits Form
Coordination of Benefits

    Evidence of CoverageEvidence of Coverage

Order New or
Replacement ID Card
Order New ID Card


  Newsletters
Newsletters


EFTEFT


VSPEFT


Optum RxEFT
Rights and Responsibilities 


Summaries of BenefitsSummaries of Benefits


Transition of Care
Transition of Care

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


When and How to Submit a Paper Claim 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


 Privacy Policy
 privacypolicy.jpg


Ask an Expert
Ask an Expert


Compliance & Fraud
Compliance and Fraud

​​About Medicare's Best Available Evidence Policy
About Medicare's Best Available Evidence Policy

Organization Determination and Payment Request
Organization Determination and Payment Request

Quality Assurance Policies & Procedures

Quality Assurance Policies and Procedures
Evidences of Coverage

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.

  • 2017 Essential Evidence of CoveragePDF
    SpanishPDF
  • 2017 Essential+Choice Evidence of CoveragePDF
    SpanishPDF
  • 2017 Rx Evidence of CoveragePDF
    SpanishPDF
  • 2017 Rx+Choice Evidence of CoveragePDF
    Spanish PDF

Click here for more information about KelseyCare Advantage's coverage of HIV screening.

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Summaries of Benefits
The 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. 

  • 2017 Summary of Benefits for KelseyCare Advantage EssentialPDF 
    SpanishPDF
  • 2017 Summary of Benefits for KelseyCare Advantage Essential+ChoicePDF 
    SpanishPDF
  • 2017 Summary of Benefits for KelseyCare Advantage RxPDF 
    SpanishPDF
  • 2017 Summary of Benefits for KelseyCare Advantage Rx+ChoicePDF 
    SpanishPDF


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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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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.

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When and how to submit a paper claim form for Drugs covered by Part D
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 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 use an out­-of­-network pharmacy to get a prescription filled under one of the following three circumstances:
      1. Non-routine situations when a network pharmacy is not available
      2. If you are traveling within the United States and territories and you become ill,           run out or lose your drugs
      3. Prescriptions that are written as part of a medical emergency or urgent care visit.

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 Advantage
Attn: Pharmacy Services
PO Box 841569
Pearland, TX 77584

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

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Newsletters
As 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:

PDFs of past newsletters

 
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-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
 
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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