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

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of KelseyCare Advantage Rx+Choice (HMO-POS)

Medicare health care and prescription drug 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, the Part D late enrollment penalty, 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 Rx+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), programs that help people pay for their prescription drugs, 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 - Using the plan’s coverage for your Part D prescription drugs

Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan’s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan’s programs for drug safety and managing medications.


Chapter 6 - What you pay for your Part D prescription drugs

Tells about the four (4) stages of drug coverage (Deductible Stage, Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the five (5) cost-sharing tiers for your Part D drugs and tells what you must pay for a drug in each cost-sharing tier.


Chapter 7 - Asking us to pay our share of a bill you have received for covered medical services or drugs

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 or drugs.


Chapter 8. - 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 9 - 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 or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and 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 10 - 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 11 - Legal notices

Includes notices about governing law and about non-discrimination.


Chapter 12 - Definitions of important words

Explains key terms used in this booklet.

KelseyCare Advantage Rx+Choice (HMO-POS)

January 1 – December 31, 2019

Evidence of Coverage:

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of KelseyCare Advantage Rx+Choice (HMO-POS)

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

This plan, KelseyCare Advantage Rx+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 Rx+Choice.)

KelseyCare Advantage is offered by KS Plan Administrators LLC, a Medicare Advantage HMO 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. Póngase en contacto con nuestro número de Servicios para Miembros al 713-442-CARE (2273) para obtener información adicional. Desde el 1 de Octubre hasta el 31 de marzo, el horario es de 8:00 a.m. a 8:00 pm., siete días a la semana. Durante este período de tiempo en el Día de Acción de Gracias y Día de Navidad, las llamadas son manejadas por nuestro Sistema de contestador. Desde el 1 de abril hasta el 30 de Septiembre, el horario es de 8:00 a.m. a 8:00 pm., lunes a viernes. Durante este período de tiempo los Sábados, Domingos, y festivos, las llamadas son manejadas por nuestro Sistema de contestador. (Los usuarios de TTY deben llamar al 1-866-302-9336). Servicios para Miembros también tiene servicios de intérprete de lengua libre disponibles para las personas que no hablan inglés. 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, premium, deductible, and/or copayments/coinsurance may change on January 1, 2020.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.


H0332_004EOC19_C
OMB Approval 0938-1051 (Pending OMB Approval)

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

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of KelseyCare Advantage Rx+Choice (HMO-POS)

Medicare health care and prescription drug 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, the Part D late enrollment penalty, 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 Rx+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), programs that help people pay for their prescription drugs, 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 - Using the plan’s coverage for your Part D prescription drugs

Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan’s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan’s programs for drug safety and managing medications.


Chapter 6 - What you pay for your Part D prescription drugs

Tells about the four (4) stages of drug coverage (Deductible Stage, Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the five (5) cost-sharing tiers for your Part D drugs and tells what you must pay for a drug in each cost-sharing tier.


Chapter 7 - Asking us to pay our share of a bill you have received for covered medical services or drugs

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 or drugs.


Chapter 8. - 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 9 - 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 or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and 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 10 - 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 11 - Legal notices

Includes notices about governing law and about non-discrimination.


Chapter 12 - Definitions of important words

Explains key terms used in this booklet.

KelseyCare Advantage Rx+Choice (HMO-POS)

January 1 – December 31, 2019

Evidence of Coverage:

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of KelseyCare Advantage Rx+Choice (HMO-POS)

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

This plan, KelseyCare Advantage Rx+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 Rx+Choice.)

KelseyCare Advantage is offered by KS Plan Administrators LLC, a Medicare Advantage HMO 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. Póngase en contacto con nuestro número de Servicios para Miembros al 713-442-CARE (2273) para obtener información adicional. Desde el 1 de Octubre hasta el 31 de marzo, el horario es de 8:00 a.m. a 8:00 pm., siete días a la semana. Durante este período de tiempo en el Día de Acción de Gracias y Día de Navidad, las llamadas son manejadas por nuestro Sistema de contestador. Desde el 1 de abril hasta el 30 de Septiembre, el horario es de 8:00 a.m. a 8:00 pm., lunes a viernes. Durante este período de tiempo los Sábados, Domingos, y festivos, las llamadas son manejadas por nuestro Sistema de contestador. (Los usuarios de TTY deben llamar al 1-866-302-9336). Servicios para Miembros también tiene servicios de intérprete de lengua libre disponibles para las personas que no hablan inglés. 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, premium, deductible, and/or copayments/coinsurance may change on January 1, 2020.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.


H0332_004EOC19_C
OMB Approval 0938-1051 (Pending OMB Approval)