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Frequently Asked Questions

KelseyCare Advantage offers answers to frequently asked questions about our Medicare Advantage plans, our provider network and other important topics.  These links will guide you to further information on our website or from other sources. Should you have any further questions about anything, including your Medicare benefits, please Contact Us.​ 

FAQ Categories

General Information

 

How much do I pay for Medicare coverage? 

Part A Monthly Premiums

Most people do not pay for Part A, because they have paid Medicare taxes for 40 or more quarters while working. Those with 30 to 39 quarters of covered employment can buy Part A coverage.  

Part B Monthly Premiums
Part B does have a monthly premium. Most people will pay the standard premium amount.  You also pay a Part B deductible each year before Medicare starts to pay its share. The Part B premium and deductable can change every year. 
 
KelseyCare Advantage Monthly Premiums
The KelseyCare Advantage Rx+Choice plan has a monthly premium. Your monthly plan premium for KelseyCare Advantage Rx+Choice is $77.00 in addition to your monthly Medicare Part B premium.
  
As a KelseyCare Advantage member, will I have to use one clinic or doctor?

When you join KelseyCare Advantage, you generally must receive your care from a network provider. Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care 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. The cornerstone of the KelseyCare Advantage network is Kelsey-Seybold Clinic. 

In most cases, care you receive from a non-Kelsey-Seybold doctor will not be covered.

Here are two exceptions:

  • The plan covers emergency care or urgently needed care that you get from a non-network provider.
  • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from a non-network provider. An authorization should be obtained from the plan prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider. 

You may decide to see any Kelsey-Seybold Clinic primary care physician or specialist within the clinic at any time without a referral. It is not necessary to notify Member Services if you decide to change doctors. Simply schedule an appointment with the Kelsey-Seybold physician of your choice. However, you can contact Member Services if you need assistance. 

Important Note about Affiliate Contract Providers: When Kelsey-Seybold Clinic does not have the staff specialist you need at any of their locations, you can be referred to a specialist who has been selected by Kelsey-Seybold physicians. Your PCP will submit a request to KelseyCare Advantage for approval of non-Kelsey-Seybold providers. Both you and the specialist to whom you are referred will receive written confirmation if the service is approved.

If you are a KelseyCare Advantage Essential+Choice or a KelseyCare Advantage Rx+Choice member, you can choose a physician or other health care specialist who is outside of the KelseyCare Advantage provider network. As a member of one of these plans, you can access certain services from a non-Kelsey-Seybold Clinic provider without a referral. You will want to confirm with these non-Kelsey-Seybold Clinic providers that they will accept reimbursement from KelseyCare Advantage. 

For a list of current network providers, download a Provider Directory, or search for a Kelsey-Seybold Clinic provider by specialty, location, gender or languages spoken. 

When can I make an appointment?
Once enrolled in our Medicare Advantage plan, you may schedule an appointment with any Kelsey-Seybold Clinic physician. You will need to present a KelseyCare Advantage membership card at the time of your appointment.
 

For personal assistance in finding a doctor or scheduling an appointment, call the KelseyCare Advantage concierge. Our knowledgeable representatives are ready to assist KelseyCare Advantage members. Call 713-442-9540 or toll free 1-866-535-8405. You may also schedule a future appointment online at Kelsey-Seybold Clinic.

Do I have to renew my enrollment with KelseyCare Advantage every year or is renewal automatic?

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.

Whether you’re a prospective or current member, for more information about how to enroll in, change or leave a KelseyCare Advantage plan, call:

Prospective Members
713-442-JOIN (5646) or toll free 1-800-663-7146
TTY/TDD 713-442-9537 or 1-866-302-9336

Current Members
713-442-CARE (2273) option 2 or toll free at 1-866-535-8343
(TTY/TDD 713-442-9537 or 1-866-302-9336)

From October 1 to February 14, our hours are 8:00 a.m. to 8:00 p.m. seven days per week. From February 15 to September 30, our hours are 8:00 a.m. to 8:00 p.m., seven days a week. However, during this time period on Saturdays, Sundays, and holidays, calls are handled by our voice mail system. 

Does KelseyCare Advantage offer dental coverage? 

In general, preventative or routine dental services are not covered. 

Does KelseyCare Advantage provide coverage outside the Houston area? 

In the case of an emergency, you may receive care anywhere in the United States. Continuing or follow-up treatment is not covered unless specifically authorized or approved by your KelseyCare Advantage health plan.

When outside of the United States, you are covered for emergency care if you are enrolled in KelseyCare Advantage Essential and Essential+Choice. Co-payment amounts for emergency care and hospitalization are the same whether in or out of the service area. 

As a member of KelseyCare Advantage Essential+Choice or Rx+Choice, you may access certain health care services outside the service area. However, your Primary Care Physician must be a network provider. 

Emergency care refers to services that are:

  • Furnished by a provider qualified to furnish emergency services, and
  • Needed to evaluate or stabilize an emergency medical condition.

A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.  THe medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

If you receive emergency care at an out-of-network hospital and need inpatient care after your emergency condition is stabilized, you must have your inpatient care at the out-of-network hospital authorized by the plan and your cost is the cost-sharing you would pay at a network hospital.

How do KelseyCare Advantage plans work?
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 Medicare Part A and Part B. You will continue to pay your monthly Medicare Part B premium to Medicare. 

Once you join a KelseyCare Advantage plan, you use the health insurance card provided by the plan. KelseyCare Advantage offers extra Medicare benefits and often lower co-payments than the original Medicare plan. KelseyCare Advantage contracts with Kelsey-Seybold Clinic, which means you can choose physicians and other health care providers who are part of Kelsey-Seybold Clinic.

Members of KelseyCare Advantage Essential+Choice or Rx+Choice have Point-of-Service (POS) benefits in addition to the covered services under their specific KelseyCare Advantage plan. The POS benefit covers certain medically necessary services the member may access from out-of-network providers. When a member utilizes the POS benefit, he/she is usually responsible for more of the cost of care. The POS benefit includes a coinsurance or co-payment, which is a percentage of the allowed payment amount, usually Medicare allowable or a co-payment for specific services. Certain services are not covered under the POS benefit. For more information, refer to the Evidence of Coverage for Essential+Choice or Rx+Choice.   

 
What out-of-network services are covered if I enroll in one of the “Choice” plans?
You may use the point-of-service benefit for the following services:
  • Specialist physician office visits and physician services in ambulatory surgery centers and in outpatient and inpatient hospital settings.
  • Outpatient hospital and ambulatory services and surgery.
  • Procedures and other testing such as x-rays and bloodwork.
  • Diagnostic radiology services.
  • Inpatient hospital stays.

As a KelseyCare Advantage Essential+Choice or KelseyCare Advantage Rx+Choice member, you will be responsible for a coinsurance or copayment for all services provided outside of the KelseyCare Advantage network.

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About KelseyCare Advantage Plan
When can I join KelseyCare Advantage?
You may join or leave our Medicare Advantage plan only at certain times. For more information, please call a KelseyCare Advantage health plan specialist at:

713-442-JOIN (5646) or
Toll free 1-800-663-7146
TTY/TDD 1-866-302-9336
8:00 a.m. to 8:00 p.m., seven days a week

You may also call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week. 

How can I compare my options?
2016 Summary of Benefits for KelseyCare Advantage

These Summary of Benefits tell you some of the features of our KelseyCare Advantage plan. They do not list every service that we cover, every limitation or every exclusion. If you have any questions about our plans, please call a KelseyCare Advantage health plan specialist at:

713-442-JOIN (5646) or
Toll free 1-800-663-7146
TTY/TDD 1-866-302-9336
8:00 a.m. to 8:00 p.m., seven days a week 

Where is KelseyCare Advantage available?
Click here to view a map of our Service Area.
The KelseyCare Advantage service area includes zip codes in four counties: Fort Bend, Galveston, Harris and Montgomery. You must live in one of these zip codes to join the plan. 
 
Can I choose my doctors?
KelseyCare Advantage members will receive most of their medical care from the doctors as Kelsey-Seybold Clinc.  Also, KelseyCare Advantage has formed an outstanding network of affiliate doctors, specialists and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. For the most up-to-date list of providers in our network, click Find a Doctor.
 
Does my plan cover prescription drugs?
KelseyCare Advantage Rx and Rx+Choice cover both Medicare Part B and Medicare Part D prescription drugs. KelseyCare Advantage Essential and Essential+Choice cover Medicare Part B Covered Drugs. They do NOT cover Medicare Part D prescription drugs.

To search our Drug Formulary or for more information about prescription drug coverage, click Find a Drug.  
 
Am I protected?

All Medicare Advantage plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage plan leaves the program, you will not lose Medicare coverage. If a plan decides to discontinue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
 
How can I get more information?
Please call a KelseyCare Advantage health plan specialist at:

713-442-CARE (2273) or
Toll free 1-800-663-7146
TTY/TDD 1-866-302-9336
8:00 a.m. to 8:00 p.m., seven days a week

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Doctors
 
How do I choose a PCP? 
When you become a member of KelseyCare Advantage, you will choose a Kelsey-Seybold doctor to be your Primary Care Physician (PCP).  Your routine or basic care will come from your PCP. Your PCP can also coordinate the rest of the covered services you need. You may select a physician who specializes in Family Medicine or Internal Medicine as your PCP. In addition to a PCP, you also have the right to designate an OB/GYN and access care from that physician without a referral.

Download a PDF of our Provider Directory, or search for a provider by specialty, location, gender or languages spoken.

 
How do I schedule appointments? 
For personal assistance in finding a doctor or scheduling an appointment, call the Kelsey-Seybold Clinic Customer Service Contact Center at 713-442-0000. The Contact Center is open 24 hours a day, 7 days a week. You may also schedule a future appointment on-line at Kelsey-Seybold Clinic.
 
Do I need to see my PCP to get a referral to other providers? 
You may see any Kelsey-Seybold Clinic physician without a referral. However, you will get most of your routine or basic care from your PCP. Your PCP can also coordinate your covered services. You will need a referral to obtain services from a non-Kelsey-Seybold Clinic doctor, hospital or other health care provider. If you don't obtain a referral ahead of time from your Kelsey-Seybold Clinic physician, you may have to pay for these services yourself.
 
What happens if I go to a doctor who’s not in the KelseyCare Advantage 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 benefits, are available with the Essential + Choice and Rx + Choice plans.  These plans  provide limited out-of-network coverage. 
 
How can I find a KelseyCare Advantage provider in my area? 
You may search for a provider by specialty, location, gender or languages spoken. You can also call a KelseyCare Advantage member services representative at:

713-442-CARE (2273) or
Toll free 1-866-535-8343
TTY/TDD 1-866-302-9336

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Pharmacies
 
Where can I get my prescriptions filled?
In most cases, your prescriptions are covered only if they are filled at the plan's network pharmacies.

A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. The term "covered drugs"means all of the Part D prescription drugs that are covered by the plan.
 

To download a copy of our 2017 Pharmacy Directory or search our online directory, please visit our Find a Pharmacy webpage. You can go to all the pharmacies on this list, but your costs for some drugs may be lower at pharmacies in this list that offer preferred cost sharing

The pharmacies in our network can change at any time. To verify if a pharmacy is part of our network, please call a KelseyCare Advantage health plan specialist at:

 

713-442-CARE (2273) or
Optum Rx
Toll free 1-866-589-5222
TTY/TDD 1-888-206-8041

 
What is a pharmacy that offers preferred cost-sharing?
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 receive your covered prescription drugs.  Your cost-sharing may be less at pharmacies with preferred cost-sharing.
 
What if I must use an out-of-network pharmacy?

You will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription.

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
  • Non-routine situations when a network pharmacy is not available.
  • If you are traveling within the United States and territories and you become ill, run out or lose your drugs.
  • Prescriptions that are written as part of a medical emergency or urgent care visit.
You can ask us to reimburse you for our share of the cost. For more information about how to ask the plan to pay you back, please refer to your Evidence of Coverage or visit our Important Documents webpage.

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Prescription  Drugs
 
What is a drug list (formulary)? 
The plan has a “List of Covered Drugs (Formulary).”  The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the plan’s Drug List. 
 
What does the drug list (formulary) include? 
The drug list includes both brand-name and generic drugs.  A generic drug is a prescription drug that has the same active ingredients as the brand-name drug. Generally it works just as well as the brand-name drug, but it costs less. There are generic drug substitutes available for many brand-name drugs. 

What is not on the drug list?
 
The plan does not cover all prescription drugs.
  • In some cases, we have decided not to include a particular drug on the Drug List  
  • Also, by law, these categories of drugs are not covered by Medicare drug plans:
    • Non-prescription drugs (also called over-the-counter drugs)
    • Drugs when used to promote fertility
    • Drugs when used for the relief of cough or cold symptoms
    • Drugs when used for cosmetic purposes or to promote hair growth
    • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
    • Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
    • Drugs when used for treatment of anorexia, weight loss, or weight gain
    • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
Why do some drugs have restrictions?
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you get a drug that works for your medical condition and is safe. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your doctor to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing. 
 
What is a prior Authorization? 
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 do not get this approval, your drug might not be covered by the plan 

What is Step Therapy?
 
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 does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called "step therapy". 

What is a Quantity Limit?
 
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. For example, if it is 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.
 
Does my plan cover Medicare Part B drugs or Part D drugs? 
KelseyCare Advantage Rx and Rx+Choice cover a limited number of Medicare Part B drugs and all Medicare Part D drugs on the plan’s drug list. KelseyCare Advantage Essential and Essential+Choice only cover Medicare Part B drugs, and do NOT cover Medicare Part D drugs.
 
Can the formulary change? 
Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make many kinds of changes to the Drug List. For example, the plan might:
  • Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.
  • Move a drug to a higher or lower cost-sharing tier.
  • Add or remove restriction on coverage for a drug.
  • Replace a brand-name drug with a generic drug.
In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug List. 
 
How will I find out if my drug's coverage has changed? 
If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time. Once in a while, 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. We will let you know of this change right away. Your doctor will also know about this change, and can 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.
 
Are there programs to help people with limited resources pay for their prescription drugs? 
You might qualify to get help in paying for your drugs. There are two basic kinds of help:
  • “Extra Help” from Medicare. This program is also called the “low-income subsidy” or LIS. People whose yearly income and resources are below certain limits can qualify for this help. See Section III of the Medicare & You Handbook or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.
  • Help from your state’s pharmaceutical assistance program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules. Check with your State Health Insurance Assistance Program (Please refer to your Evidence of Coverage, Chapter 2).

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What is a Medication Therapy Management (MTM) Program?

A Medication Therapy Management (MTM) Program is a free service we may offer.  You may be invited to participate in a program designed for your specific health and pharmacy needs.  

We provide services to those members who meet the following CMS directed MTM Qualification Criteria. To be considered for participation in this program a member is required to:
  • Have any three of the following chronic diseases: Alzheimer’s disease; Chronic heart failure (CHF); Diabetes; Hepatitis C; HIV/AIDS; Multiple Sclerosis; Respiratory Diseases such as Asthma, Chronic Lung Disorders, or Chronic Obstructive Pulmonary Disease (COPD); or Bone Diseases such as Osteoarthritis, Osteoporosis, or Rheumatoid Arthritis
  • Take eight or more Part D medications
  • Spend an expected total of more than $3,919.00 per year for Part D medications, (the expected total is the amount paid by the plan for Part D medications, added to the amount the member pays). 

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