KelseyCare Advantage Gold Freedom (HMO-POS)

KelseyCare Advantage Gold Freedom (HMO-POS) H0332-004 Plan Details
5 out of 5 stars

KelseyCare Advantage Gold Freedom (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Kelsey-Seybold Medical Group, PLLC.
Plan ID: H0332-004.

$0.00
Monthly Premium

KelseyCare Advantage Gold Freedom (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Kelsey-Seybold Medical Group, PLLC.
Plan ID: H0332-004.

KelseyCare Advantage Gold Freedom (HMO-POS) H0332-004 Plan Details
5 out of 5 stars

KelseyCare Advantage Gold Freedom (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Kelsey-Seybold Medical Group, PLLC.
Plan ID: H0332-004.

$0.00
Monthly Premium

Texas Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $100
Out of Pocket Max In-Network: $3450
Out-of-Network: 10000
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
POS (Out-of-Network):

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $10.00 to $250.00
Coinsurance for Medicare Covered Primary Care Office Visit 0% to 50%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $25.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
POS (Out-of-Network):

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $10.00 to $250.00
Coinsurance for Medicare Covered Physician Specialist Office Visit 0% to 50%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $375.00
Maximum out of Pocket $375.00
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 40%
Urgent Care
Copayment for Urgent Care $25.00
Emergency Room Visit
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Copayment for Worldwide Emergency Transportation $200.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $225.00

Air Ambulance:
Copayment for Air Ambulance Services $225.00

Non emergency ambulance trips must be scheduled 5 days in advance of appointment.
Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
POS (Out-of-Network):

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $10.00 to $250.00
Coinsurance for Medicare Covered Ambulance Services - Ground 0% to 50%
Coinsurance for Medicare Covered Ambulance Services - Air 50%

Health Care Services and Medical Supplies

KelseyCare Advantage Gold Freedom (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
POS (Out-of-Network):
Copayment for Medicare Covered Chiropractic Services $10.00 to $250.00
Coinsurance for Medicare Covered Chiropractic Services 0% to 50%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 15% to 20%
Prior Authorization Required for Durable Medical Equipment
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $25.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $150.00
Copayment for Medicare-covered Therapeutic Radiological Services $50.00
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Referral Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20%
Copayment for Medicare Covered Lab Services $10.00 to $250.00
Coinsurance for Medicare Covered Lab Services 0% to 50%
Coinsurance for Medicare Covered Diagnostic Radiological Services 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $10.00 to $250.00
Coinsurance for Medicare Covered Outpatient X-Ray Services 0% to 50%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $10.00
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Home Health 50%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $375.00
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 40%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
Prior Authorization Required for Outpatient Mental Health Services
Referral Required for Outpatient Mental Health Services
Prior authorization required
POS (Out-of-Network):
Copayment for Medicare Covered Individual Sessions $10.00 to $250.00
Coinsurance for Medicare Covered Individual Sessions 0% to 50%
Copayment for Medicare Covered Group Sessions $10.00 to $250.00
Coinsurance for Medicare Covered Group Sessions 0% to 50%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $300.00
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $300.00
Prior Authorization Required for Outpatient Observation Services
Referral Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $225.00
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Prior authorization required
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services
Prior authorization required
POS (Out-of-Network):
Copayment for Medicare Covered Individual or Group Sessions $10.00 to $250.00
Coinsurance for Medicare Covered Individual or Group Sessions 0% to 50%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $25.00 every month
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $25.00
Prior Authorization Required for Podiatry Services
Prior authorization required
POS (Out-of-Network):
Copayment for Medicare Covered Podiatry Services $10.00 to $250.00
Coinsurance for Medicare Covered Podiatry Services 0% to 50%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$125.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 50%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Office Visit $25.00
Office Vists include:
  • Oral Exams(Max 1(Please see Evidence of Coverage for details))
  • Prophylaxis (Cleaning)(Max 1 every six months)
  • Dental X-Rays(Max 1(Please see Evidence of Coverage for details))<
    • Maximum 1 visit (Please see Evidence of Coverage for details)
    Maximum Plan Benefit of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

    Comprehensive Dental:
    Copayment for Medicare-covered Benefits $25.00
    Coinsurance for Non-routine Services 50%
    • Maximum 1 visit (Please see Evidence of Coverage for details)
    Coinsurance for Restorative Services 50%
    Coinsurance for Periodontics 50%
    • Maximum 1 visit (Please see Evidence of Coverage for details)
    Coinsurance for Extractions 50%
    Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 50%
    Maximum Plan Benefit of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $25.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $125.00 every year for all Non-Medicare covered eyewear
POS (Out-of-Network):

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 20%
Coinsurance for Medicare Covered Eyewear 50%

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $25.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $25.00
  • Maximum 1 visit every year
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 1 Hearing Aids every three years
Maximum Plan Benefit of $750.00 every three years per ear
A maximinum allowance of $750 per ear towards the cost of non-implantable hearing aid(s) every three years. Replacement batteries not covered.
Prior authorization required
POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 20%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    POS (Out-of-Network):

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 50%

    Prescription Drug Costs and Coverage

    The KelseyCare Advantage Gold Freedom (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $100 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $100 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $3.00
    • Preferred mail order $0.00
    • Standard mail order $3.00
    Generic
    • Preferred retail $0.00
    • Standard retail $15.00
    • Preferred mail order $0.00
    • Standard mail order $15.00
    Annual Drug Deductible $100 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $6.00
    • Preferred mail order $0.00
    • Standard mail order $6.00
    Generic
    • Preferred retail $0.00
    • Standard retail $30.00
    • Preferred mail order $0.00
    • Standard mail order $30.00
    Annual Drug Deductible $100 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $9.00
    • Preferred mail order $0.00
    • Standard mail order $9.00
    Generic
    • Preferred retail $0.00
    • Standard retail $45.00
    • Preferred mail order $0.00
    • Standard mail order $45.00