Core

2025 Benefits Summary

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.

Download the Summary of Benefits

2025 Medical Benefits

Covered Services
Physician and Lab Services
PCP Visit	$0
Specialist Visit	$20
Video Visit – PCP	$0
Video Visit – Specialist, Mental Health, Other	$15
Annual Wellness Exam	$0
Chiropractor	$20
X-rays and Lab Services	$0
Diagnostic Tests (ex: CT, MRI)	$25-$200
Immunizations	$0
Routine Hearing Exam (1 per year)	$0*
Hearing Aid Allowance	$750 per ear every 3 years
Physical and Speech Therapy	$15
Occupational Therapy	$20
Routine Eye Exam	$0**
Eyewear Allowance	$125 per year
Hospital Services
Inpatient Hospital Care	$325 copay per day for days 1-5; $0 copay for days 6-90
Ambulatory Surgery Center	$300
Outpatient Hospital/Observation	$300
Emergency Care	$125
Urgent Care	$25
Worldwide Emergency Services	20% coinsurance; up to $20,000 per lifetime
Extended Care Services
Skilled Nursing Facility	$0 (days 1-20) $214 (days 21-100)
Other Medical Services
Durable Medical Equipment (DME)	15% to 20% of the total cost
Ground/Air Ambulance	$275 one-way

*Members receive one routine hearing exam per year. Any additional hearing exams will be
charged a specialist copay.

**Members receiving eye exams will have $0 copay for their first visit of the year, regardless of
whether the eye exam is for routine or medical services. Members will be charged the specialist
copay for all subsequent eye exams.

Plan Summaries

$0 Monthly Premium
Medical Coverage
Embedded Dental Coverage
Optional Supplemental Dental Buy Up Coverage available
Over-the-Counter Allowance
Hearing & Vision Allowances

You Must:

Be eligible for Medicare Part A and enrolled in Part B,
Continue to pay Part B premiums,
Live in the plan service area, and

How Much Does it Cost

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.

Provider Network

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 who are referred to a contracted affiliate will pay the in-network cost-share. The health providers in our network can change at any time.

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