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2019 Evidence of Coverage Essential+Choice (HMO-POS)

Your Medicare Health Benefits and Services as a Member of KelseyCare Advantage Essential+Choice (HMO-POS)

Medicare health care coverage from January 1 – December 31, 2019.


Chapter 1 - Getting started as a member

Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date.


Chapter 2 - Important phone numbers and resources

Tells you how to get in touch with our plan (KelseyCare Advantage Essential+Choice) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), and the Railroad Retirement Board.


Chapter 3 - Using the plan’s coverage for your medical services

Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan’s network and how to get care when you have an emergency.


Chapter 4 - Medical Benefits Chart (what is covered and what you pay)

Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Explains how much you will pay as your share of the cost for your covered medical care.


Chapter 5 - Asking us to pay our share of a bill you have received for covered medical services

Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services.


Chapter 6 - Your rights and responsibilities

Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected.


Chapter 7 - What to do if you have a problem or complaint (coverage decisions, appeals, complaints)

Tells you step-by-step what to do if you are having problems or concerns as a member of our plan.

  • Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care you think is covered by our plan. This includes asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon.
  • Explains how to make complaints about quality of care, waiting times, customer service, and other concerns.

Chapter 8 - Ending your membership in the plan

Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership.


Chapter 9 - Legal notices

Includes notices about governing law and about non-discrimination.


Chapter 10 - Definitions of important words

Explains key terms used in this booklet.

KelseyCare Advantage Essential+Choice (HMO-POS)

January 1 – December 31, 2019

Evidence of Coverage:

Your Medicare Health Benefits and Services as a Member of KelseyCare Advantage Essential+Choice (HMO-POS)

This booklet gives you the details about your Medicare health care coverage from January 1 – December 31, 2019. It explains how to get coverage for the health care services you need. This is an important legal document. Please keep it in a safe place.

This plan, KelseyCare Advantage Essential+Choice, is offered by KS Plan Administrators LLC. (When this Evidence of Coverage says “we,” “us,” or “our,” it means KS Plan Administrators LLC. When it says “plan” or “our plan,” it means KelseyCare Advantage Essential+Choice.)

KelseyCare Advantage is offered by KS Plan Administrators LLC, a Medicare Advantage HMO-POS with a Medicare contract.

This document is available for free in Spanish.

Please contact our Member Services number at 713-442-CARE (2273) or toll free at 1-866-535-8343 for additional information. From October 1 through March 31, hours are 8:00 a.m. to 8:00 p.m., seven days a week. During this period on Thanksgiving Day and Christmas Day, calls are handled by our voicemail system. From April 1 through September 30, hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. During this period on Saturdays, Sundays and holidays, calls are handled by our voicemail system. (TTY users should call 1-866-302-9336.)

Esta información está disponible gratis en otros idiomas. Por favor póngase en contacto con nuestro número de Servicios para Miembros al 713-442-CARE (2273) o al número gratuito 1-866-535-8343 para obtener información adicional. Del 1 de octubre al 31 de marzo, el horario es de 8:00 a.m. a 8:00 p.m., siete días a la semana. Durante este período, en el Día de Acción de Gracias y en el Día de Navidad, las llamadas son manejadas por nuestro sistema de buzón de voz. Del 1 de abril al 30 de septiembre, el horario es de 8:00 a.m. a 8:00 p.m., de lunes a viernes. Durante este período, los sábados, domingos y días festivos, las llamadas son manejadas por nuestro sistema de buzón de voz. (Los usuarios de TTY deben llamar al 1-866-302-9336). Servicios para Miembros tiene disponible servicios gratuitos de intérpretes para las personas que no hablan inglés (Los números de teléfono están impresos en la portada posterior de este folleto).

We can also give you information in Braille, in large print or other alternate formats, upon request.

Benefits, deductible, and/or copayments/coinsurance may change on January 1, 2020.

The provider network may change at any time. You will receive notice when necessary.


H0332_003EOC19_C
OMB Approval 0938-1051 (Pending OMB Approval)

2019 Evidence of Coverage Essential+Choice (HMO-POS)

Your Medicare Health Benefits and Services as a Member of KelseyCare Advantage Essential+Choice (HMO-POS)

Medicare health care coverage from January 1 – December 31, 2019.


Chapter 1 - Getting started as a member

Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date.


Chapter 2 - Important phone numbers and resources

Tells you how to get in touch with our plan (KelseyCare Advantage Essential+Choice) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), and the Railroad Retirement Board.


Chapter 3 - Using the plan’s coverage for your medical services

Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan’s network and how to get care when you have an emergency.


Chapter 4 - Medical Benefits Chart (what is covered and what you pay)

Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Explains how much you will pay as your share of the cost for your covered medical care.


Chapter 5 - Asking us to pay our share of a bill you have received for covered medical services

Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services.


Chapter 6 - Your rights and responsibilities

Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected.


Chapter 7 - What to do if you have a problem or complaint (coverage decisions, appeals, complaints)

Tells you step-by-step what to do if you are having problems or concerns as a member of our plan.

  • Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care you think is covered by our plan. This includes asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon.
  • Explains how to make complaints about quality of care, waiting times, customer service, and other concerns.

Chapter 8 - Ending your membership in the plan

Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership.


Chapter 9 - Legal notices

Includes notices about governing law and about non-discrimination.


Chapter 10 - Definitions of important words

Explains key terms used in this booklet.

KelseyCare Advantage Essential+Choice (HMO-POS)

January 1 – December 31, 2019

Evidence of Coverage:

Your Medicare Health Benefits and Services as a Member of KelseyCare Advantage Essential+Choice (HMO-POS)

This booklet gives you the details about your Medicare health care coverage from January 1 – December 31, 2019. It explains how to get coverage for the health care services you need. This is an important legal document. Please keep it in a safe place.

This plan, KelseyCare Advantage Essential+Choice, is offered by KS Plan Administrators LLC. (When this Evidence of Coverage says “we,” “us,” or “our,” it means KS Plan Administrators LLC. When it says “plan” or “our plan,” it means KelseyCare Advantage Essential+Choice.)

KelseyCare Advantage is offered by KS Plan Administrators LLC, a Medicare Advantage HMO-POS with a Medicare contract.

This document is available for free in Spanish.

Please contact our Member Services number at 713-442-CARE (2273) or toll free at 1-866-535-8343 for additional information. From October 1 through March 31, hours are 8:00 a.m. to 8:00 p.m., seven days a week. During this period on Thanksgiving Day and Christmas Day, calls are handled by our voicemail system. From April 1 through September 30, hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. During this period on Saturdays, Sundays and holidays, calls are handled by our voicemail system. (TTY users should call 1-866-302-9336.)

Esta información está disponible gratis en otros idiomas. Por favor póngase en contacto con nuestro número de Servicios para Miembros al 713-442-CARE (2273) o al número gratuito 1-866-535-8343 para obtener información adicional. Del 1 de octubre al 31 de marzo, el horario es de 8:00 a.m. a 8:00 p.m., siete días a la semana. Durante este período, en el Día de Acción de Gracias y en el Día de Navidad, las llamadas son manejadas por nuestro sistema de buzón de voz. Del 1 de abril al 30 de septiembre, el horario es de 8:00 a.m. a 8:00 p.m., de lunes a viernes. Durante este período, los sábados, domingos y días festivos, las llamadas son manejadas por nuestro sistema de buzón de voz. (Los usuarios de TTY deben llamar al 1-866-302-9336). Servicios para Miembros tiene disponible servicios gratuitos de intérpretes para las personas que no hablan inglés (Los números de teléfono están impresos en la portada posterior de este folleto).

We can also give you information in Braille, in large print or other alternate formats, upon request.

Benefits, deductible, and/or copayments/coinsurance may change on January 1, 2020.

The provider network may change at any time. You will receive notice when necessary.


H0332_003EOC19_C
OMB Approval 0938-1051 (Pending OMB Approval)