FAQs About Medicare

We contract with a large group of doctors, hospitals, labs, and other healthcare providers who agree to provide care to our members at a lower rate. This group is called a network. You may pay less when you use providers in our network. Kelsey-Seybold Clinics and doctors are some of the providers in our network.

If you have a Point-of-Service (HMO-POS) plan, you may choose to see healthcare providers outside of our network. You may pay more out of pocket for covered services when you see an out-of-network provider.

After you sign up for KelseyCare Advantage, make an appointment with any Kelsey-Seybold Clinic doctor. Schedule your appointment online. Or call our 24/7 Contact Center at 713-442-0427.

Once you sign up for a KelseyCare Advantage Plan you stay enrolled as a member of that plan. There is no need to renew during the Annual Enrollment Period. You remain a KelseyCare Advantage member until you switch to another Medicare plan.

All of our plans include preventive dental coverage for routine exams, cleanings, and X-rays. These services help you maintain good oral health. They can also identify possible problems early.

Many of our plans also cover comprehensive dental services. You'll have coverage for the basics and more. These plans have coverage for fillings, extractions, root canals, crowns, and dentures.

Learn more about our dental benefits here.

KelseyCare Advantage plans are available in 13 Texas counties.

If you travel outside the Houston area, you can still get care when you need it.

KelseyCare Advantage benefits include telehealth appointments with Kelsey-Seybold providers. If you're traveling, you can schedule a telehealth session to see a provider who has full access to your medical records or use our Convenience Care benefit at any CVS Minute Clinic. Emergency care is covered worldwide, and urgent care is covered within the United States.

Traveling outside the U.S.? You’re covered for emergency care services worldwide.

KelseyCare Advantage is a Medicare Advantage plan. We are a private insurance company with a federal contract with Medicare. With our plans, you get all the benefits that Original Medicare offers, plus more. We offer coverage for dental, vision, hearing, and more.

You must have Part A and Part B to join. Most of our plans do not have a monthly premium but you must continue paying your monthly Medicare Part B premium to Medicare.

Your specific coverage depends on which KelseyCare Advantage Plan you choose. And all our plans give you access to Kelsey-Seybold Clinics. You'll have a robust network of premier specialists and other providers as your trusted partners in health.

For most people, Medicare Part A costs $0. That’s because they or their spouse paid Medicare taxes long enough while working (usually at least 10 years). Part B has a standard monthly premium determined by Medicare. Both Part A and Part B have deductibles and coinsurance amounts you pay for some services.

Your KelseyCare Advantage monthly premiums will depend on which plan you choose. You must keep paying your Part B monthly premium to Medicare.

You may also have out-of-pocket costs when you receive services. Cost sharing is a payment you make for healthcare or medication. Your copay, coinsurance, and deductible are all types of cost sharing. Using in-network providers will help you save money.

A POS plan is a type of health plan. It provides coverage for both in-network and out-of-network healthcare providers. You may use the POS benefit for the following services:

• Office visits with a specialist
• Doctor services in ambulatory surgery centers and hospitals
• Outpatient surgery and other hospital and ambulatory services
• Bloodwork and testing
• Radiology services like X-rays, CT scans, and MRI
• Inpatient hospital stays

You may pay higher costs for covered services you receive from out-of-network providers.

You can enroll in a Medicare Advantage plan when:

• You are new to Medicare (a seven-month enrollment period – three months before the month you turn 65, the month you turn 65, and three months after your birthday month).
• You retire and lose your group health coverage. You have eight months to enroll in Medicare once you stop working OR your employer coverage ends (whichever happens first).
• It is during a designated Medicare election period (For example, Medicare's Annual Enrollment Period is October 15 through December 7).

You can enroll in KelseyCare Advantage when you:

• Are already enrolled in Medicare Parts A and B. Most of our plans do not have a monthly premium but you must continue paying your monthly Medicare Part B premium to Medicare.
• Live within our geographic service area.
• Are a United States citizen or lawfully present in the United States.

Compare all of our KelseyCare Advantage Plans.

If you have questions about plan benefits, please call our local health plan specialists at 713-442-JOIN (5646).

All of our plans give you access to Kelsey-Seybold Clinics. You'll have a robust network of premier specialists and other providers as your trusted partners in health. We also contract with many specialists and hospitals throughout the Greater Houston area.

• Find a provider

The 2024 KelseyCare Advantage plans that include Medicare Part D prescription drug coverage are:

• Classic (HMO)
• Freedom (HMO-POS)
• Signature (HMO)
• Secure (HMO)
• Thrive (HMO-POS)
• Compare all of our 2024 plans

Our health plan specialists are ready to assist you. They'll help you understand your options and find a coverage solution to meet your needs. Call us at 713-442-JOIN (5646).

You have choices when it comes to your primary care. Your PCP may practice family medicine, internal medicine, or OB-GYN. Find a Kelsey-Seybold doctor online. Or call our 24/7 Contact Center at 713-442-0427.

Schedule your appointment online via MyKelsey Online. Or, call our 24/7 Contact Center at 713-442-0427.

You may see any Kelsey-Seybold doctor without a referral.

You will need a referral from your PCP:

• To see a non-Kelsey-Seybold doctor.
• To get non-emergency services from an out-of-network hospital.
• To receive services outside of the network.

If you have an HMO plan and choose to go to a doctor outside of our network, you must pay for these services yourself. Neither KelseyCare Advantage nor Original Medicare will pay for these services.

If you have an HMO-POS plan, you may see out-of-network providers without a referral. You may pay higher costs out of pocket for out-of-network services. Your provider must be willing to bill KelseyCare Advantage. Please see your Evidence of Coverage for complete details.

A preferred pharmacy has a contract with KelseyCare Advantage. They agree to charge less for covered drugs. Use a preferred pharmacy to help save money on your drug costs. Our preferred pharmacies are Kelsey-Seybold Pharmacy, CVS, and H-E-B.

If you use an out-of-network pharmacy, you will likely have to pay the full price when you fill a prescription. In the following situations, we may cover the cost of prescription drugs filled at an out-of-network pharmacy:

• When a network pharmacy isn’t available.
• When you’re traveling within the U.S. but outside of the network area and are in need of prescription medications.
• When a prescription is written as part of your medical emergency or urgent care treatment.

In these cases, you’ll still have to pay the full cost, but you can request that we reimburse you for our share of the cost.

A formulary is a list of the prescription drugs that we help pay for as part of your plan. We work with a team of healthcare providers to develop this list. These providers agree that these drug therapies are necessary for quality treatment.

Prescription drugs are available as brand-name drugs or generic drugs. Most drugs have a brand-name version and a generic version. Both versions have the same active ingredients. The difference is that you may not know the generic name. The generic is often cheaper than the brand-name version.

If your drug is not on the approved list of drugs or is restricted:

• You can change to another drug.
• You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.
• You may be able to get a temporary (transition) supply of the drug. This will give you and your doctor time to change to another drug or to file an exception. Note: Only members in certain situations can get a temporary supply.

Temporary (transition) supply requirements

Under certain circumstances, your KelseyCare Advantage Plan can offer a temporary supply of a drug you need. Doing this gives you time to talk to your doctor about available alternatives.

To be eligible for a temporary supply, you must meet both requirements:

• The change to your drug coverage must be one of the following types:
  • The drug you have been taking is no longer on the plan's drug list (formulary).
  • The drug you have been taking is now restricted in some way.
• You must be in one of the following situations:
  • For members who were in the plan last year and affected by the drug coverage changes: We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we allow multiple refills to provide up to a maximum of a 30-day supply of medication. You must fill the prescription at a network pharmacy. (Long-term care pharmacies may provide the drug in smaller amounts to prevent waste.)
  • For new members affected by drug coverage changes: We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we allow multiple refills to provide up to a maximum of a 30-day supply of medication. You must fill the prescription at a network pharmacy.
  • For those who have been members of the plan for more than 90 days, reside in a long-term care facility, and need a supply right away: We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.

Download our transition policy

If there’s a change to coverage for a drug you’re taking, we will send you a notice. The FDA may recall a drug if it's found to be unsafe, or for other reasons. If this happens, we will immediately remove the drug from our drug list and let you know of this change. Your doctor will also know about this change and will work with you to find another drug for your condition.

Learn more about prescription drug benefits.

Extra Help is a Medicare program to help people with limited income and resources pay for Medicare prescription drug costs.

If you have limited income, you may be able to get help with your prescription drug costs from Medicare's Extra Help program. If you qualify, Medicare could pay for 75% or more of your:

• Monthly prescription drug premiums
• Annual deductibles
• Prescription copays

Many people qualify and don't know. There's no penalty for applying.

For more information and to apply, visit ssa.gov/medicare/prescriptionhelp/ or call Social Security toll-free at 1-800-772-1213, TTY 1-800-325-0778. You can also call your local Social Security office.

With Extra Help, you won't have a coverage gap or a late enrollment penalty (LEP). Also, as long as you're in the program, you can change plans at any time. If you're notified that you no longer qualify, you'll have two months to change plans.

If you take a lot of medication, you may qualify for a program that helps you manage your prescriptions.

Your participation is voluntary and doesn’t affect your coverage. This program is open to those invited to take part. The program isn’t a benefit for all members.

Learn more about our Medication Therapy Management program.