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Best Medicare Advantage Plans for 2019 Rating is from U.S. News and World Report, a leading publisher of annual authoritative rankings including Best Medicare Plans. Our plan does not have a direct relationship with U.S. News. This award was not given by Medicare. Our overall rating from Medicare for 2019 is 5.0. Our plan’s official CMS Star Rating can be found at www.Medicare.gov.

​​Regulatory Compliance

Below you will find information on the KelseyCare Advantage Privacy Policy, Protected Health Information, Compliance and Fraud.  If you have further questions please Contact Us.

Privacy Policy 

KelseyCare Advantage’s Notice of Privacy Practices

KS Plan Administrators LLC is committed to ensuring the privacy and confidentiality of our members’ Protected Health Information (PHI) and fully supports the provisions of the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

KS Plan Administrators LLC is committed to safeguarding the confidentiality of your personal health information. In order to effectively provide and administer services and benefits to you, KS Plan Administrators LLC must collect and disclose certain protected health information. This is only done, however, in accordance with KS Plan Administrators LLC’s privacy policies. In addition, Federal law requires that we guard the privacy of your protected health information.

This Notice of Privacy Practices describes how KS Plan Administrators LLC may collect, use and disclose your protected health information, and your rights concerning your protected health information. Protected health information is information about you or your dependents, including demographic information, that can reasonably be used to identify you and that relates to your past, present, or future physical or mental health or condition, the provision of health care service to you or our payment for that care. We are required to safeguard your protected health information and to provide you with this notice about our legal duties and privacy practices. We must follow the privacy practices described in this notice while it is in effect.

This notice takes effect April 1, 2007 and will remain in effect until we replace or modify it.

What is Protected Health Information (PHI)?

Whether based on our confidentiality policy or pertinent law, KS Plan Administrators LLC safeguards the privacy of your protected health information (“PHI”). PHI is information that alone, or in conjunction with other data that we collect from or about you, would allow you to be identified. For example, medical information used to help members get needed care, or information about payments for services you have received, as well as descriptive information about those services, is PHI.

How we may use and disclose your PHI

In order to provide coverage for treatment and pay for those services, we need to use and disclose your PHI in a number of different ways. KS Plan Administrators LLC staff is trained in the appropriate handling of your PHI and execute their specific responsibilities using only that information required for their role. KS Plan Administrators LLC maintains and enforces policies governing the use of PHI by workforce members to ensure their proper handling. Procedures to afford these internal protections against mishandling of PHI throughout the workforce include provisions pertinent to physical

and technical safeguards taken in order to protect verbal, written and electronic PHI from being mishandled by workforce members as they execute their responsibilities. The following are examples of the types of uses and disclosures of your PHI that we are permitted to make without your authorization:

FOR PAYMENT

KS Plan Administrators LLC will use and disclose your PHI to administer your health benefits policy or contract, which may involve the determination of eligibility; claims payment; utilization review activities; medical necessity review; coordination of benefits and responding to complaints, appeals, and external review requests. Examples include:

  • Using PHI in order to pay claims that have been submitted to us by physicians and hospitals for payment.
  • Transmitting PHI to a third party to facilitate administration of a Flexible Spending Account, a Health Savings Account, a Health Reimbursement Account or a dental benefits plan, if you have one
  • Additional PHI of dependents may be shared with subscriber when administering a family membership contract (e.g., the current status of co-payments and deductible amounts for dependents) 

FOR HEALTH CARE OPERATIONS

KS Plan Administrators LLC may use and disclose your PHI for operational purposes. For example, your PHI may be disclosed to staff members within KS Plan Administrators LLC, such as medical-management, risk-management or quality-improvement personnel, and others to:

  • Assess the quality of care and outcomes in your cases and similar cases
  • Learn how to improve our services and facilities through the use of internal and external surveys
  • Determine how to continuously improve the quality and effectiveness of health care services our members receive
  • Evaluate the performance of our staff, for example, to review our member service representatives’ call documentation

In addition, your PHI may be used for the following purposes, each of which is also considered health care operations:

  • Sharing of data used for enrollment, disenrollment, and premium billing, as well as summary renewal data with your Plan Sponsor (your employer and/or their representatives, if you are enrolled through an employer)
  • Other information beyond what is listed above may be shared only after KS Plan Administrators LLC receives appropriate certifications that the PHI will not be used by your employer for employment decisions or other non-intended purposes.
  • If you have a primary care physician who manages your care, we may furnish his or her name to your Plan Sponsor in order to permit your Sponsor to evaluate the effects of changes to the network available to you.
  • Providing contact information to an external surveyor selected by the Federal government to conduct routine satisfaction surveys with our KelseyCare Advantage beneficiaries.
  • Quality assessment and improvement activities, such as peer review and credentialing of our affiliated providers.
  • Accreditation by independent organizations such as the National Committee for Quality Assurance.
  • Performance measurement and outcomes assessment, health claims analysis and health services research.
  • Preventive health, early detection, disease management, case management and coordination of care programs, including sending preventive health service reminders.
  • Underwriting, rate making and determining cost sharing amounts, as well as administration of reinsurance policies.
  • Risk management, auditing and detection of unlawful conduct.
  • Transfer of policies or contracts from and to other insurers, health plans or third party administrators.
  • Facilitation of any potential sale, transfer, merger or consolidation of all or part of a "covered entity" like KS Plan Administrators LLC, with another covered entity, and due diligence related to that activity.
  • Other general administrative activities, including data and information systems management, customer service and collecting premiums.

FOR TREATMENT

KS Plan Administrators LLC may disclose your PHI to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers) who request it in connection with your treatment. For example, for your safety, we may provide a list of medications you've received through your KS Plan Administrators LLC coverage to emergency room clinicians treating you in an effort to minimize the potential for adverse drug interactions. This information will only be furnished to emergency room clinicians with your consent, unless you are unable to provide consent. We may also disclose your PHI to health care providers in connection with preventive health initiatives, early detection programs, and disease management programs. For example, KS Plan Administrators LLC may disclose information to physicians involved in your care that includes a list of medications you've filled using your KS Plan Administrators LLC coverage (this will alert those physicians treating you to those medications prescribed for you by others and will help minimize potential adverse drug interactions). KS Plan Administrators LLC may also disclose information to your primary care physician to suggest a disease management or wellness program that could help improve your health.

At times, KS Plan Administrators LLC may contract with other organizations to provide services on our behalf. As these services are performed, PHI is accessed or disclosed. In these cases, KS Plan Administrators LLC will enter into an agreement explicitly outlining the requirements associated with the protection, use and disclosure of your PHI.

Examples of such "business associates" include behavioral health management companies and pharmacy benefit managers.

Other permitted or required uses and disclosures of PHI that do not require your authorization include the following:

PARENTS AS PERSONAL REPRESENTATIVES OF MINORS

In most cases, your minor child’s PHI may be disclosed to you. However, we may be required by law to deny a parent’s access to a minor’s PHI for certain diagnoses or treatment such as sexually transmitted diseases, family planning services, etc.

WORKERS’ COMPENSATION

Your PHI may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation.

PUBLIC HEALTH ACTIVITIES

Your PHI may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury or disability, tracking of prescription drug or medical device problems, or for other health oversight activities.

RESEARCH

KS Plan Administrators LLC may use your PHI for research purposes when our Quality Improvement Committee has reviewed the research proposal and approved the research based on established protocols to ensure the privacy of your PHI.

LEGAL PROCEEDINGS

Your PHI may be disclosed in the course of any legal proceeding, in response to an order of a court or an administrative tribunal and, in certain cases, in response to a subpoena, discovery request or other lawful process.

IF YOU ARE ENROLLED IN A GROUP HEALTH PLAN

If you are enrolled in KS Plan Administrators LLC through your work or through a family member’s policy, you are enrolled in a “Group Health Plan.” If your employer has established procedures to safeguard your PHI as required by federal law, and the Group Health Plan elects to receive PHI from KS Plan Administrators LLC, we may disclose

this information to your sponsoring employer and/or their representative. Talk to your sponsoring employer to get more details.

HEALTH OVERSIGHT

Your PHI may be disclosed to a government agency authorized to oversee the health care system or government programs or its contractors, [e.g., the U.S. Department of Health and Human Services (HHS), a state insurance department or the US Department of Labor] for activities authorized by law, such as audits, examinations, investigations, inspections and licensure activity. Although we do not anticipate the following situations will occur frequently, these potential uses and disclosures can occur without your written authorization:

AS REQUIRED BY LAW

KS Plan Administrators LLC may use and disclose information about you as required by law. For example, KS Plan Administrators LLC may disclose information for the following purposes:

  • To report information related to victims of abuse, neglect or domestic violence;
  • To assist law enforcement officials in performing their duties.

GOVERNMENT FUNCTIONS

Your PHI may be disclosed to prevent serious threat to your health or safety or that of any person pursuant to applicable law. We may also disclose your protected health information to authorized federal officials for national security purposes. In addition, under certain conditions, we may disclose your PHI if you are, or were a member of the Armed Forces, for those activities deemed necessary by appropriate military authorities.

INMATES

If you are an inmate, your PHI may be disclosed to a correctional institution or a law enforcement official having lawful custody, if the provision of such information is necessary to provide you with health care, protect your health and safety, and that of others, or maintain the safety and security of the correctional institution.

DECEDENTS

PHI may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

ORGAN/TISSUE DONATION

Your PHI may be used or disclosed to organ procurement organizations to facilitate cadaveric organ, eye or tissue donation/transplantation purposes only subsequent to your prior authorization.

USES AND DISCLOSURES THAT REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION

Uses and disclosures of PHI other than those listed above in Section II will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke such an authorization, at any time in writing, except to the extent that we have already taken an action based on a previously executed authorization.

If a written authorization is obtained from you, your PHI may be disclosed to your personal representative, a person (an adult or an emancipated minor) that KS Plan Administrators LLC recognizes as having the authority to act on behalf of another individual in making decisions related to health care. Many members ask us to disclose their PHI to third parties for reasons not described in this notice. For example, elderly members often ask us to make their records available to family members or caregivers. To authorize us to disclose any of your PHI to a person or organization for reasons other

than those described in this notice, please call the toll free number on your ID card and you will be provided with the appropriate authorization form. You should send the completed form to our Member Services Department. You may revoke the authorization at any time by sending a letter to our Member Services Department at 11511 Shadow Creek Parkway, Pearland, Texas, 77584.

It is important for you to note that once you give us authorization to release your health information, the PHI that we release is out of KS Plan Administrators LLC’s control. KS Plan Administrators LLC is unable to safeguard such PHI from redisclosure by the person(s) that you have authorized us to release it to. Finally, KS Plan Administrators LLC will not use your PHI to offer you services or products unrelated to your health care coverage or your health status without your authorization.

 

YOUR RIGHTS REGARDING YOUR PHI

The following are your rights with respect to your PHI.

RIGHT TO ACCESS AND RECEIVE COPIES OF YOUR PHI

You have the right to receive a copy of your PHI. We may ask you to request access to copies of your records in writing and to provide us with the specific information we need to fulfill your request. We reserve the right to charge a reasonable fee for the cost of producing and mailing the copies of such information. We will endeavor to provide you the requested PHI within fifteen days of receipt of a complete request and fees. There are certain cases in which we are not permitted to fulfill your request to access or receive your PHI.

You may not inspect or copy:

  • Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding;
  • Psychotherapy notes that may be submitted to KS Plan Administrators LLC incidental to a member complaint or appeal. (These confidential notes are never requested by KS Plan Administrators LLC.)
  • PHI that is subject to the Clinical Laboratory Improvements Amendments of 1988; Information created or obtained by KS Plan Administrators LLC in the course of research that includes treatment. Access to these records may be temporarily suspended for as long as the research is in progress;
  • PHI that was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

RIGHT TO AMEND YOUR PHI

If you believe that your protected health information is incorrect or incomplete, you have the right to ask us to amend your PHI. All requests for amendment must be in writing. In certain cases, we may deny your request. For example, we may deny a request if we did not create the information, as is often the case for medical information that is generated by a provider and stored in our records, or if we believe the current information is correct. All denials will be made in writing. You may respond by filing a written statement of disagreement with KS Plan Administrators LLC and we would have the right to rebut that statement.

If you believe someone has received un-amended PHI from us, you should inform us at the time of the request if you want him or her to be informed of any amendment we may subsequently agree to execute.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS

KS Plan Administrators LLC recognizes that members have the right to receive communications regarding their PHI in a manner and at a location that the individual feels is safe from unauthorized use or disclosure. To support this commitment, KS Plan Administrators LLC will permit individuals to request that they receive PHI by alternative means or at alternative locations. We will attempt to accommodate reasonable requests. All requests must be in writing.

RIGHT TO AN ACCOUNTING OF DISCLOSURES OF PHI

You have the right to request an accounting of those instances in which we have disclosed your PHI for any purpose other than the following:

  • For treatment, payment or health care operations;
  • To others involved in your health care;
  • Disclosures that you or your designated personal representative have authorized;
  • Certain other disclosures, such as disclosures for national security purposes;
  • Information disclosed to correctional institutions, law enforcement agencies, or health oversight agencies;
  • Information that was disclosed or used as part of a limited data set for research, public health or health care operations purposes.
  • All requests must be made in writing. KS Plan Administrators LLC will require you to provide us with the specific information we need to fulfill your request. If you request this accounting more than once in a twelve-month period, we may charge you a reasonable fee.

RIGHT TO REQUEST LIMITS ON USES AND DISCLOSURES OF YOUR PHI

You have the right to ask us to place restrictions on the way we use or disclose your PHI for treatment, payment or health care operations or as described in the section of this notice entitled “Other Permitted Or Required Uses And Disclosures of PHI.” We are not, however, required by law to agree to these requested restrictions. If we do agree to a restriction, we may not use or disclose your PHI in violation of that restriction, unless it is related to an emergency. We may ask that you request these limits in writing.

RIGHT TO RECEIVE KS PLAN ADMINISTRATORS LLC’S NOTICE OF PRIVACY PRACTICES

You have a right to receive a paper copy of the Notice of Privacy Practices upon request at any time.  You may be entitled to additional rights under state law.

HOW TO OBTAIN INFORMATION ABOUT THIS NOTICE OR COMPLAIN ABOUT OUR PRIVACY PRACTICES

To request a copy of this Notice of Privacy Practices at any time, or obtain additional

information about this notice, you may contact:

KS Plan Administrators LLC

Member Services Department

11511 Shadow Creek Parkway

Pearland, Texas 77584

1-866-535-8343

If you believe your privacy rights have been violated, you may file a written complaint with:

Privacy Officer,

KS Plan Administrators LLC Health Care

11511 Shadow Creek Parkway

Pearland, Texas 77584

or by contacting this office at 713-442-CARE (2273).

You may also notify the Secretary of the Department of Health and Human Services (HHS). 

Send your complaint to:

Medical Privacy, Complaint Division, Office for Civil Rights (OCR)

United States Department of Health and Human Services,

200 Independence Avenue

SW, Room 509F, HHH Building

Washington DC, 20201

You may also contact OCR’s Voice Hotline Number at (800) 368-1019 or send the information to their Internet address www.hhs.gov/ocr.

KS Plan Administrators LLC will not take retaliatory action against you if you file a complaint about our privacy practices either with OCR or KS Plan Administrators LLC.

CHANGES TO THIS NOTICE

We may make a change to this notice and our privacy practices at any time, as long as the change is consistent with our current privacy policies or state or federal law. If we make an important change to our policies, we will promptly provide you with the new notice by mail and post it on our web site

EFFECTIVE DATE OF THIS NOTICE

The effective date of this notice is April 1, 2007. Non-English speaking members may also call KS Plan Administrators LLC’s Member Services Department at 1-866-535-8343 to have their questions answered. 

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Compliance and Fraud

MEDICARE FRAUD

The Scope of Fraud, Waste and Abuse on our healthcare System
 
The National Healthcare Anti-fraud Association (NHCAA) cites an average of 3% (at the low end) and 10% (at the high end) of healthcare spending is lost due to fraud.  That's between $67 billion and $230 billion lost each year to fraud, waste or abuse.  That estimates to between $184 million and $630 million loss per day, and this number is expected to increase every year as healthcare costs rise.  Healthcare fraud is believed to be the second largest white-collar crime in the United States.  It is often mistaken for a victimless crime, but it affects everyone.  Fraud causes insurance premiums to rise, and victims may be put thorugh unnecessary or unsafe procedures.  Victims of identity theft may find their insurance information used to submit false claims.  This is a staggering cost, and we are committed to battling these unnecessary expenditures every step of the way.
 

OUR COMMITMENT TO ADDRESS FRAUD, WASTE AND ABUSE

KelseyCare Advantage is committed to fighting healthcare fraud, waste, and abuse.
 
We have a dedicated staff whose mission is to protect our employees, members, providers, first tier, downstream, and related entities, and the Medicare Trust Fund by administering an effective plan to prevent and detect fraud, waste, and abuse.
 
Our team works diligently to investigate all allegations, correct known offenses, recover lost funds, and partner with Federal and state agencies to prosecute violators to the fullest extent of the law.
 

EXAMPLES OF HEALTHCARE FRAUD

  • A healthcare provider bills for medical services, supplies or items that were not provided.
  • A healthcare provider bills for more expensive services or procedures than what was actually provided or performed.
  • A healthcare provider performs medically unnecessary services to obtain the insurance payment.
  • A healthcare provider misrepresents a non-covered services as medically necessary to obtain the insurance payment.
  • A healthcare provider or pharmacy charges a beneficiary a price over the copay amount.
  • A healthcare provider or pharmacy waves the patient copay amount and overbills the insurance plan to recoup the cost.
  • A pharmacy bills for prescripts that were not dispensed.
  • A pharmacy dispensed a generic drug, but billed for a brand name drug.
  • Prescriptions drug shorting by pharmacy (i.e., billing for 60 tablets, but dispensing 30)
  • A pharmacy adding unauthorized refills to prescriptions.
  • Drug diversion
  • A pharmacy, beneficiary or policy holder forges or alters a prescription.
  • A beneficiary or policyholder misrepresents their personal information such as identity, eligibility, or medical condition in order to illegally receive a benefit.
  • Someone steals or purchases a beneficiary's policyholder's personal information to submit false or phantom claims to obtain the insurance benefit.
  • A beneficiary or policyholder allows a third party to use their benefit information to obtain medication and/or medical services.
  • A third party pretends to represent Medicare, the Social Security Administration, or an insurance plan for the purpose of obtaining personal and/or financial information.

PROTECT YOURSELF AGAINST FRAUD

  • Treat your Medicare card, Social Security card, and insurance ID card like you would your credit card.  It could be very costly if they fell into the wrong hands.
  • Do not give out personal information over the phone or through mail unless you have initiated the contact.
  • Be cautious of providers who offer "free" testing or screening but require your Medicare and/or insurance card first.  Thieves use this scam to get personal information then use it to commit fraud or sell it.
  • Avoid utilizing a healthcare provider or pharmacy who tells you that the item or services is not usually covered, but they know how to bill Medicare to get it paid.
  • Review your Explanation of Benefits (EOB) promptly.  Look for:
    • Charges for a service, drug, equipment and/or supplies you did not get.
    • Billing for the same service, drug equipment and/or supplies twice.
    • Services that were not ordered by the doctor.
  • Report fraud.  Contact the Special Investigation Unit if you suspect fraud, waste or abuse.

HELP FIGHT FRAUD 

If you suspect someone of committing insurance fraud against KelseyCare Advantage or think you may be a victim, please report the suspicious activity by calling, mailing or e-mailing us.

Fraud, Waste, and Abuse Hotline: 

713-442-9595
MedicareFraudHotline@KelseyCareAdvantage.com

In writing:

KelseyCare Advantage
Attn:  Compliance
11511 Shadow Creek Parkway
Pearland, Texas 77584

All communications are confidential and may be anonymous.

www.insurancefraud.org
www.stopmedicarefraud.gov

KelseyCare Advantage's Compliance Policies and Procedures

Please view KelseyCare Advantage's Fraud, Waste, and Abuse Training and Contact Information:
 
The Centers for Medicare and Medicaid Services (CMS) now requires that all employees of the Plan's first-tier, downstream, and related entities must review Compliance Policies & Procedures, Standards of Conduct, and the Anti-Fraud Plan on an annual basis, and upon 90 days of hire or contracting.
 
Our Compliance Policies & Procedures, Standards of Conduct, and Anti-Fraud Plan are available here:
Once your employees have reviewed these policies please return our Attestation Packet by email to Medicarefraudhotline@kelseycareadvantage.com
 

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