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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

2024 Medical 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
2024 Premiums

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:

  1. Be eligible for Medicare Part A and enrolled in Part B,
  2. Continue to pay Part B premiums,
  3. 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.

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