Honor
2024 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
| Covered Services | What You Pay |
| Physician Services / Doctor Office Visits | PCP - $0 Specialist - $10 |
| Annual Wellness Visit | $0 |
| Telehealth Benefit | PCP - $0 Specialist - $15 |
| Preventive Health Screenings | $0 |
| Inpatient Hospital Care | $295 per stay |
| Outpatient Diagnostic Tests and Therapeutic Services & Supplies | Diagnostic labs & x-rays $0 Advanced Radiology - $150 |
| Emergency Care | $120 |
| Ambulance Services | $225 |
| Urgently Needed Services | $5 |
| Convenient Care | Per visit: $25 CVS Minute Clinics only |
| OTC Allowances | $50 per quarter |
| Flex Card | N/A |
| Outpatient Hospital Observation | $200 |
| Outpatient Surgery | ASC - $175 Hospital $200 |
| Outpatient Rehab Services | PT and OT - $10 Speech - $10 |
| 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% coinsurance |
| Prosthetic Devices and Related Supplies | 20% coinsurance |
| Medicare Part B Prescription Drugs | 20% coinsurance (including chemotherapy) |
| Services to Treat Kidney Disease | 20% coinsurance coinsurance |
| Pulmonary Rehabilitation Services | $20 |
| Cardiac Rehabilitation Services | $20 |
| Chiropractic Services | $20 |
| Acupuncture | $20 |
| Podiatry Services | $20 |
| Home Health Agency Care | $10 |
| Inpatient Mental Health Care | $295 per stay |
| Medical Nutrition Therapy | $0 |
| Dental Services | $0 copayment |
| Preventative Dental | included |
| Comprehensive Dental | $0 coinsurance up to $2,000 combined preventive and comprehensive benefit maximum |
| Diabetes Self Management Training, Diabetic Services and Supplies | 0% - 20% coinsurance |
| Immunizations | $0 |
| Transportation | $0 - You pay nothing. 20 one-way trips to approved medical appointments. |
| Smoking Cessation | $0 |
| Hearing Services | $0 for routine exam and $750 per ear towards the cost of hearing aid(s) every 3 years |
| Vision Care | $0 for routine exam and $125 plan allowance per year |
| LiveWell Rewards | included |
Plan Premium
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.
| Plan | Monthly Premium |
| Honor | $0 |
Plan Summaries
- Medical Coverage
- Preventive and Comprehensive Dental
- Over-the-Counter Allowance
- Wellness Benefit Allowance
- Hearing & Vision Allowances
- And more
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 are referred to an affiliate and pay the in-network cost-share. The health providers in our network can change at any time.