Part A Original (also called Traditional) Medicare is no cost, in most cases, because people 65 years of age and older have typically paid Medicare taxes for 40 or more quarters during their working years.  Part B Original Medicare premiums are normally a standard monthly premium determined by Medicare. Both Medicare Parts A and B also have deductibles as well as coinsurance amounts you pay for some services.  

Your KelseyCare Advantage monthly premiums will depend on which plan you choose. All Medicare Advantage plans require members to pay Part B monthly premiums in addition to Medicare Advantage premiums. Please view our plans for more information. 

When you join KelseyCare Advantage, you generally must receive your care from a network provider. Network providers are the doctors and other healthcare professionals, medical groups, hospitals, and other healthcare 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.

Since Kelsey-Seybold Clinic is where most of our network providers practice, in most cases care you receive from a non-Kelsey-Seybold or non-affiliate contract provider will not be covered. The exceptions to this are emergency or urgent care and necessary medical care that cannot be provided by a network physician. KelseyCare Advantage also offers plans with a point-of-service benefit that does allow you to access non-network providers.

Once enrolled in a KelseyCare Advantage plan, you can schedule an appointment with any Kelsey-Seybold Clinic physician. We make it easy with online scheduling. You can also call our 24/7 Contact Center at 713-442-9540 to schedule an appointment or for personal assistance in finding a doctor.

Once enrolled in KelseyCare Advantage, you remain a member of the plan unless you specifically cancel your membership. There is no need to renew during the annual enrollment period. Enrollment in another Medicare Advantage plan or prescription drug plan will end your enrollment with KelseyCare Advantage.

While dental coverage isn’t generally covered under KelseyCare Advantage medical plans, we do offer a supplemental dental rider. Our dental coverage offers extra benefits not covered by Original Medicare and not included in your benefits package as a plan member – such as 100% coverage of preventive services and a $25 copayment for dental visits. Learn more about our dental benefits here.

In general, only emergency or urgent care is covered if you receive treatment outside of the Houston area. Emergency care is covered anywhere in or out of the United States. All other care must be specifically authorized or approved by KelseyCare Advantage.

If you’re a member of a KelseyCare Advantage POS plan, you have access to non-network providers in or out of the Houston area.

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 Original Medicare Part A and Part B. You will continue to pay your monthly Medicare Part B premium to Medicare.

Your specific coverage depends on which of the KelseyCare Advantage plans you choose. All of our plans give you access to Kelsey-Seybold Clinic’s premier multispecialty physician group and other contracted providers, as well as the peace of mind that comes from knowing you’re covered for your current health needs and unexpected future medical expenses.

You may use the point-of-service (POS) benefit for the following services:

• Specialist physician office visits and physician services in ambulatory surgery centers and hospitals
• Outpatient surgery and other hospital and ambulatory services
• Bloodwork and testing, such as X-rays
• Diagnostic radiology services
• Inpatient hospital stays

Please note that, although the services will be covered by your plan, you are still responsible for any copayment or coinsurance.

You can enroll in a Medicare Advantage plan when you’re new to Medicare (seven-month period), when you retire and lose group coverage, or during a designated Medicare election period like the Annual Enrollment Period (October 15 through December 7).

You can view all of our KelseyCare Advantage Plans here. If you still have questions about plan benefits, please call our health plan specialists at 713-442-JOIN (5646) (TTY/TDD 711) from 8 a.m. to 8 p.m., seven days a week, from October 1 to March 31 and 8 a.m. to 8 p.m., Monday through Friday, from April 1 to September 30.

See a map of our service area here.

As a KelseyCare Advantage member, you’ll have your choice of multispecialty providers practicing at Kelsey-Seybold Clinics. We are also contracted with numerous specialists and hospitals throughout the Greater Houston area. Find a provider

The KelseyCare Advantage plans that include Medicare Part D prescription drug coverage are:

• Rx
• Rx+Choice
• Rx Select

Compare all of our plans

Our health plan specialists are always at your service. Call us at 713-442-JOIN (5646), 8 a.m. to 8 p.m., seven days a week, from October 1 to March 31 and 8 a.m. to 8 p.m., Monday through Friday, from April 1 to September 30. We’ll help you evaluate your options and find a solution that meets your needs.

Once you become a KelseyCare Advantage member, choosing your primary care physician is easy. Search for a provider here or call our 24/7 Care Center at 713-442-0000 and one of our representatives will help you find a provider near you.

There are two convenient ways to make an appointment with a Kelsey-Seybold Clinic physician. Schedule online or call our 24/7 Care Center at 713-442-0000.

You don’t need a referral to see any physician at a Kelsey-Seybold Clinic but will need a referral from your PCP to see a non-Kelsey-Seybold doctor, use a hospital, or get services outside of the 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 (POS) benefits, available with the Essential+Choice and Rx+Choice plans, provide limited out-of-network coverage.

In most cases, your prescriptions are covered only if filled at a KelseyCare Advantage network pharmacy. Search our 2020 Pharmacy Directory.

The pharmacies in our network can change at any time. To verify that a pharmacy is part of our network, please call a KelseyCare Advantage health plan specialist at 713-442-JOIN (5646).

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 get your covered prescription drugs. Your drug costs may be less at pharmacies with preferred cost-sharing.

If you use an out-of-network pharmacy, you will likely have to pay the full price when you fill a prescription. In the following situations, we may cover the cost of prescription drugs filled at an out-of-network pharmacy:

• When a network pharmacy isn’t available
• When you’re traveling within the U.S. but outside of the network area and are in need of prescription medications
• When a prescription is written as part of your medical emergency or urgent care treatment

In these cases, you’ll still have to pay the full cost, but you can request that we reimburse you for our share of the cost.

• A formulary is a list of covered drugs, selected by KelseyCare Advantage in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.
• KelseyCare Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the U.S. Food and Drug Administration as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.
• KelseyCare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a KelseyCare Advantage network pharmacy, and other plan rules are followed.

If there’s a change to coverage for a drug you’re taking, the plan will send you a notice. Normally, we’ll let you know at least 30 days ahead of time. Occasionally, 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 (KelseyCare Advantage Formulary). We’ll let you know of this change right away. Your doctor will also know about this change and will 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).

Yes. One such program is called Low Income Subsidy Premiums, which is available through Medicare. Learn more about this program here.

As a new or continuing member in our plan, you may be taking drugs that aren’t on our formulary – or you may be taking a drug that’s on our formulary, but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.

Talk to your doctor to determine whether you should switch to a drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to decide the right course of action, we may cover your drug in certain cases during the first 90 days you’re a member of our plan. For each of your drugs that isn’t on our formulary, or if your ability to get your drugs is limited, we’ll cover a temporary 30-day supply.

When you transfer from one treatment setting to another, such as moving from an inpatient hospital setting to home, it’s called a level-of-care change. These types of changes often don’t leave you enough time to determine whether a new prescription drug is on the plan formulary.

In these unexpected situations, KelseyCare Advantage will cover a temporary transition supply of up to 30 days. If your level-of-care change involves moving to a long-term care facility and a new drug is prescribed, the plan covers a temporary supply of up to 31 days.

If you’re in a Medicare drug plan and take medications for different medical conditions, you may be eligible to get services, at no cost to you, through a Medication Therapy Management (MTM) program that can help you and your doctor make sure your medications are working to improve your health. Your participation is voluntary and doesn’t affect your coverage. This program is open to those invited to participate. The program isn’t a benefit for all members.

A pharmacist will provide a comprehensive review of all your medications and talk with you about:

• How to best take your medications
• How to get the most benefit from the drugs you take
• Any questions or problems you have about your prescription and over-the-counter medication, medication costs, and/or drug reactions

• Generally, if you’re taking a drug on our 2020 formulary that was covered at the beginning of the year, we won’t discontinue or reduce coverage of the drug during the 2020 coverage year except when a new, less expensive generic drug becomes available, when a drug’s safety or effectiveness is a concern, or the drug is removed from the market.
• Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year.
• If the U.S. Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who are taking it.

If your drug isn’t included on this formulary drug list, you should first contact Member Services and ask if the drug is covered. If KelseyCare Advantage doesn’t cover the drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by KelseyCare Advantage. Show the list to your doctor and ask him or her to prescribe one of the similar drugs covered by KelseyCare Advantage.
• You can ask KelseyCare Advantage to make an exception and cover your drug. See Question 27 for information about how to request an exception.

Some covered drugs may have additional requirements or limits on coverage that may include prior authorization, quantity limits, and step therapy. This information can be found by searching the formulary.

• Download 2020 Prior Authorization Criteria
• Download 2020 Step Therapy Criteria

You can request an exception by:

• Asking us to cover a drug not on our formulary. If approved, the drug will be covered at a predetermined cost-sharing level.
• Asking us to cover a formulary drug at a lower cost-sharing level (provided it’s not on the specialty tier), lowering the amount you pay for the drug.
• Asking us to waive coverage restrictions or quantity limits on a drug.

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 don’t get this approval, your drug might not be covered by the plan.

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 doesn’t work for you, the plan will then cover Drug B. This requirement is called step therapy.

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. If it’s 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.

KelseyCare Advantage Rx, Rx+Choice, and Rx Select cover a limited number of Medicare Part B drugs and all Medicare Part D drugs on the plan’s drug list. KelseyCare Advantage Essential, Essential+Choice, and Essential Select only cover Medicare Part B drugs and do NOT cover Medicare Part D drugs.