Tools & Resources

Evidences of Coverage

Download the KelseyCare Advantage Essential Evidence of Coverage PDF  2010. This document gives the details about your Medicare health coverage through KelseyCare Advantage Essential.

Download the KelseyCare Advantage Essential+Choice Evidence of Coverage PDF 2010. This document gives the details about your Medicare health coverage through KelseyCare Advantage Essential+Choice.

Download the KelseyCare Advantage Rx Evidence of Coverage PDF 2010. This document gives the details about your Medicare health and prescription drug coverage through KelseyCare Advantage Rx.

Download the KelseyCare Advantage Rx+Choice Evidence of Coverage PDF 2010. This document gives the details about your Medicare health and prescription drug coverage through KelseyCare Advantage Rx+Choice.

Summaries of Benefits

• Download the Summary of Benefits for KelseyCare Advantage Essential PDF 2010
• Download the Summary of Benefits for KelseyCare Advantage Essential+Choice PDF 2010
• Download the Summary of Benefits for KelseyCare Advantage Rx PDF 2010
• Download the Summary of Benefits for KelseyCare Advantage Rx+Choice PDF 2010

Appointment of Representative Form

If you need someone to file a grievance, coverage determination or appeal on your behalf, you can name a relative, friend, advocate, doctor or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

If you want to appoint a representative, you should complete the Appointment of Representative form  PDF and mail it to:

KelseyCare Advantage
ATTN: Member Services
P. O. Box 300427
Houston, Texas 77230

Health Risk Assessment Form

After you enroll, you can complete our Health Risk Assessment Form. The information you provide will help us determine what special programs, if any, are right for you. Download the Health Risk Assessment form  PDF.

Coordination of Benefits Form

If you have more than one medical plan, you could save on your medical costs by coordinating your benefits. Contact a KelseyCare Advantage Member Services representative for more details at the number below.

Order New or Replacement ID Card

Your ID card shows information important to your health insurance coverage. You don’t need a new ID card every year. If you change plans, we will send you a new ID card.

For a new or replacement ID card, contact a KelseyCare Advantage Member Services representative at one of the phone numbers below and a new ID card will be sent to the address on file for you.

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

How Do I Change Plans?

To make a change in the Medicare Advantage plan you have with KelseyCare Advantage, print and complete the Change of Plan form  PDF. Select the plan you want, and sign the form. Then mail the completed form back to 8900 Lakes at 610 Drive, Suite 1100, Houston, Texas 77054.

Please be aware that you can change health plans only at certain times during the year. Between November 15th and December 31st each year, anyone can join our plan. In addition, you can switch plans between January 1st and March 31st, as long as you do not change your prescription drug coverage. Generally, you may not make changes at other times unless you meet certain special exceptions, such as if you move out of the plan’s service area.

When and how to submit a paper claim form for Drugs covered by Part D

Below is a brief description of some of the situations you may submit a paper claim for reimbursement for your Part D drug expenses. For a full description and a complete listing of all situations refer to the Evidence of Coverage, Chapter 7, Asking the plan to pay its share of a bill you have received for covered services or drugs. Some of the situations you may submit a paper claim include:

• When you use an out-of-network pharmacy to get a prescription filled
• When you pay the full cost for a prescription because you don't have your plan membership card with you
• When you pay the full cost for a prescription drug that is not on the plan's List of Covered Drugs (Formulary); or the drug has a requirement or restriction that you didn't know about or don't think should apply to you.

When you send us your request for payment, along with your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records. Make sure you are giving us all the information we need to make a decision. You don't have to use our form, but it's helpful for our plan to process the information faster. Either download a copy of our KelseyCare Advantage/Catalyst Rx Direct Member Reimbursement Form PDF (click here) or call Member Services and ask for the KelseyCare Advantage /Catalyst Rx Direct Member Reimbursement Form.

Mail your request for payment and the KelseyCare Advantage/Catalyst Rx Direct Member Reimbursement Form together with any bills or receipts to this address:

Catalyst Rx
Direct Member Reimbursement
PO Box 1069
Rockville, MD 20849-1069

Newsletters

As a KelseyCare Advantage member, you can access the monthly newsletter, House Call, which offers additional convenience by bringing health news directly to your mailbox. Read past newsletters here:

Ask an Expert

For more information about your KelseyCare Advantage benefits, contact us at:

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

Or, click here to request a phone call from KelseyCare Advantage.

You may also contact Medicare at 1-800-MEDICARE 1-800-633-4277 (TTY/TDD 877-486-2048, 24 hours a day, seven days a week.