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This is a summary of what our plan covers and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please refer to the Evidence of Coverage, this legal member contract is the primary source of the coverage information and supersedes all other information.
|Covered Services||What You Pay|
|Physician Services / Doctor Office Visits||PCP - $0 Specialist - $20|
|Annual Wellness Visit||$0|
|Telehealth Benefit||PCP - $0 Specialist - $15|
|Preventive Health Screenings||$0|
|Inpatient Hospital Care||$325 per stay|
|Skilled Nursing Facility Care (SNF)||$0/day - days 1-20 $125/day - days 21-100|
|Outpatient Diagnostic Tests and Therapeutic Services & Supplies||Diagnostic labs & x-rays $0 Advanced Radiology - $150|
|Urgently Needed Services||$25|
|Convenient Care||Per visit: $25 CVS Minute Clinics only|
|Over-the-Counter Items (OTC)||$50 every quarter|
|Outpatient Hospital Observation||$250|
|Outpatient Surgery||ASC - $225 Hospital $250|
|Outpatient Rehab Services||PT and OT - $10 Speech - $20|
|Outpatient Mental Health Care||Individual or Group - $20|
|Outpatient Substance Abuse Services||Individual or Group - $20|
|Durable Medical Equipment (DME) and Related Supplies||15-20%|
|Prosthetic Devices and Related Supplies||20%|
|Medicare Part B Prescription Drugs||20% coinsurance (including chemotherapy)|
|Services to Treat Kidney Disease||20% coinsurance|
|Pulmonary Rehabilitation Services||$20|
|Cardiac Rehabilitation Services||$20|
|Home Health Agency Care||$10|
|Inpatient Mental Health Care||$325 per stay|
|Medical Nutrition Therapy||$0|
|Dental Services||$20 copayment|
|Diabetes Self Management Training, Diabetic Services and Supplies||0% - 20%|
|Transportation||- 20 one-way trips to approved medical appointments.|
|Hearing Services||$0-$20 and $750 per ear towards the cost of hearing aid(s) every 3 years|
|Vision Care||$0-$20 and $125 plan allowance per year|
|Optional Supplemental Buy-Up||Not available|
|Healthy Living Rewards||Included|
|COVID-19 Benefit||Acute inpatient hospital copay waived with COVID-19 diagnosis. Post hospital discharge meal delivery included.|
The monthly fee you pay the plan for your health care. The amount shown does not include the Part B premium you already pay to the government.
The monthly plan premium to enroll in the Gold plan is $0. Additionally, you must maintain your Medicare Part B coverage to be a member of any Medicare Advantage plan. Most people will pay the standard Part B premium amount. Please call Social Security at 1-800-772-1213 for information about your Part B premium.
Members will receive most of their medical care from the doctors at Kelsey-Seybold Clinic or contracted individual provider groups. KelseyCare Advantage also contracts with an affiliate network of doctors to provide care that is not offered at Kelsey-Seybold Clinic, members are referred to an affiliate and pay the in-network cost-share. The health providers in our network can change at any time.