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. In 2010, you will pay up to $461.00 each month if you do not get premium-free Part A. If you pay a late enrollment penalty, this amount is higher.
Part B Monthly Premiums
Most people enrolled in Medicare Part B will pay $110.50 a month for Part B in 2010.
KelseyCare Advantage Monthly Premiums
The only KelseyCare Advantage plan for which there is a monthly premium is Rx + Choice. Your monthly plan premium for KelseyCare Advantage Rx + Choice is $49.00 in addition to your monthly Medicare Part B premium
Other costs associated with KelseyCare Advantage Plans can be found in the Summary of Benefits and/or Evidence of Coverage documents for each plan.
KelseyCare Advantage Essential
- Summary of Benefits
PDF 2010
- Evidence of Coverage PDF 2010
KelseyCare Advantage Essential+Choice
- Summary of Benefits PDF 2010
- Evidence of Coverage PDF 2010
KelseyCare Advantage Rx
- Summary of Benefits PDF 2010
- Evidence of Coverage PDF 2010
KelseyCare Advantage Rx+Choice
- Summary of Benefits PDF 2010
- Evidence of Coverage PDF 2010
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:
o The plan covers emergency care or urgently needed care that you get from a non-network provider.
o 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, click here to download a PDF of our 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 866-535-8405. You may also schedule a future appointment online at www.kelsey-seybold.com.
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-CARE (2273) option 1 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)
Our business hours are from 8:00 a.m. – 8:00 p.m., seven days a week.
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 as well. 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.
How do KelseyCare Advantage plans work?
KelseyCare Advantage is a health plan option 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.
How is my KelseyCare Advantage health plan going to be impacted by health care reform?
KelseyCare Advantage continues to carefully follow all of the details regarding health care reform, and we will notify you of any plan changes that occur as a result of the new legislation.
Our commitment to providing you with the highest standards of health care remains steadfast. We are proud to have Kelsey-Seybold Clinic as the cornerstone of our provider network. The medical care provided to KelseyCare Advantage members is based on Kelsey-Seybold Clinic’s unique model of care which includes physician collaboration, electronic medical records management and nationally recognized disease management programs. Kelsey-Seybold Clinic and KelseyCare Advantage are well-poised to meet the future demands and challenges of health care in America.
What hospitals do I have access to under the plan?
The KelseyCare Advantage network hospitals include:
Fort Bend County
Memorial Hermann Sugar Land Hospital
Sugar Land Surgical Hospital
Harris County
Christus St. Catherine Hospital
Christus St. John Hospital
M. D. Anderson Cancer Center
Memorial Hermann Hospital
Memorial Hermann Katy Hospital
Memorial Hermann Memorial City Hospital
Memorial Hermann Northeast Hospital
Memorial Hermann Northwest Hospital
Memorial Hermann Southeast Hospital
Memorial Hermann Specialty Hospital Kingwood
Memorial Hermann TOPS Surgical Specialty Hospital
St. Luke’s Episcopal Hospital
Woman’s Hospital of Texas
Montgomery County
Memorial Hermann – The Woodlands Hospital
SLEH Community Medical Center – The Woodlands
Tomball Regional Medical Center
For hospital contact information, please refer to the KelseyCare Advantage Provider Directory.
- 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 20% coinsurance for all services provided outside of the KelseyCare Advantage network.