Chapter 12 - Definitions of important words

Chapter 12 - Definitions of important words

Ambulatory Surgical Center – An Ambulatory Surgical Center is an entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the center does not exceed 24 hours.

Annual Enrollment Period – A set time each fall when members can change their health or drug plans or switch to Original Medicare. The Annual Enrollment Period is from October 15 until December 7

Appeal – An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving. For example, you may ask for an appeal if we don’t pay for a drug, item, or service you think you should be able to receive. Chapter 9 explains appeals, including the process involved in making an appeal.

Balance Billing – When a provider (such as a doctor or hospital) bills a patient more than the plan’s allowed cost-sharing amount. As a member of KelseyCare Advantage Rx+Choice, you only have to pay our plan’s cost-sharing amounts when you get services covered by our plan. We do not allow providers to "balance bill" or otherwise charge you more than the amount of cost-sharing your plan says you must pay.

Benefit Period – The way that both our plan and Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods.

Brand Name Drug – A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.

Catastrophic Coverage Stage – The stage in the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $5,100 in covered drugs during the covered year.

Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers Medicare. Chapter 2 explains how to contact CMS.

Coinsurance – An amount you may be required to pay as your share of the cost for services or prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

Complaint – The formal name for "making a complaint" is "filing a grievance." The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. See also "Grievance," in this list of definitions.

Compound Medication/Compounding – In general, compounding is a practice in which a licensed pharmacist, a licensed physician, or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist, combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.

Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physical therapy, social or psychological services, respiratory therapy, occupational therapy and speech-language pathology services, and home environment evaluation services.

Copayment (or "copay") – An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.

Cost-sharing – Cost-sharing refers to amounts that a member has to pay when services or drugs are received. (This is in addition to the plan’s monthly premium.) Cost-sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed "copayment" amount that a plan requires when a specific service or drug is received; or (3) any "coinsurance" amount, a percentage of the total amount paid for a service or drug, that a plan requires when a specific service or drug is received. A "daily cost-sharing rate" may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment.

Cost-Sharing Tier – Every drug on the list of covered drugs is in one of five cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug.

Coverage Determination – A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are called "coverage decisions" in this booklet. Chapter 9 explains how to ask us for a coverage decision.

Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan.

Covered Services – The general term we use to mean all of the health care services and supplies that are covered by our plan.

Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

Custodial Care – Custodial care is personal care provided in a nursing home, hospice, or other facility setting when you do not need skilled medical care or skilled nursing care. Custodial care is personal care that can be provided by people who don’t have professional skills or training, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. Medicare doesn’t pay for custodial care.

Daily cost-sharing rate – A "daily cost-sharing rate" may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply. Here is an example: If your copayment for a one-month supply of a drug is $30, and a one-month’s supply in your plan is 30 days, then your "daily cost-sharing rate" is $1 per day. This means you pay $1 for each day’s supply when you fill your prescription.

Deductible – The amount you must pay for health care or prescriptions before our plan begins to pay.

Disenroll or Disenrollment – The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).

Dispensing Fee – A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription. The dispensing fee covers costs such as the pharmacist’s time to prepare and package the prescription.

Durable Medical Equipment (DME) – Certain medical equipment that is ordered by your doctor for medical reasons. Examples include walkers, wheelchairs, crutches, powered mattress systems, diabetic supplies, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, or hospital beds ordered by a provider for use in the home.

Emergency – A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

Emergency Care – Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical condition.

Evidence of Coverage (EOC) and Disclosure Information – This document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan.

Exception – A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Extra Help – A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.

Generic Drug – A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a "generic" drug works the same as a brand name drug and usually costs less.

Grievance – A type of complaint you make about us or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

Home Health Aide – A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

Hospice – A member who has 6 months or less to live has the right to elect hospice. We, your plan, must provide you with a list of hospices in your geographic area. If you elect hospice and continue to pay premiums you are still a member of our plan. You can still obtain all medically necessary services as well as the supplemental benefits we offer. The hospice will provide special treatment for your state.

Hospital Inpatient Stay – A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an "outpatient."

Income Related Monthly Adjustment Amount (IRMAA) – If your income is above a certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium. For example, individuals with income greater than $85,000 and married couples with income greater than $170,000 must pay a higher Medicare Part B (medical insurance) and Medicare prescription drug coverage premium amount. This additional amount is called the income-related monthly adjustment amount. Less than 5% of people with Medicare are affected, so most people will not pay a higher premium.

Initial Coverage Limit – The maximum limit of coverage under the Initial Coverage Stage.

Initial Coverage Stage – This is the stage before your total drug costs including amounts you have paid and what your plan has paid on your behalf for the year have reached $3,820.

Initial Enrollment Period – When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you’re eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

Institutional Equivalent Special Needs Plan (SNP) – An institutional Special Needs Plan that enrolls eligible individuals living in the community but requiring an institutional level of care based on the State assessment. The assessment must be performed using the same respective State level of care assessment tool and administered by an entity other than the organization offering the plan. This type of Special Needs Plan may restrict enrollment to individuals that reside in a contracted assisted living facility (ALF) if necessary to ensure uniform delivery of specialized care.

Institutional Special Needs Plan (SNP) – A Special Needs Plan that enrolls eligible individuals who continuously reside or are expected to continuously reside for 90 days or longer in a long-term care (LTC) facility. These LTC facilities may include a skilled nursing facility (SNF), nursing facility (NF), (SNF/NF), an intermediate care facility for the mentally retarded (ICF/MR), and/or an inpatient psychiatric facility. An institutional Special Needs Plan to serve Medicare residents of LTC facilities must have a contractual arrangement with (or own and operate) the specific LTC facility(ies).

List of Covered Drugs (Formulary or "Drug List") – A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.

Low Income Subsidy (LIS) – See "Extra Help."

Maximum Charge – Maximum amount a non-participating Medicare provider may charge a beneficiary for services. Charge generally limited to 115 percent of the Medicare fee schedule for covered services.

Maximum Out-of-Pocket Amount – The most that you pay out-of-pocket during the calendar year for in-network covered Part A and Part B services. Amounts you pay for Medicare Part A and Part B premiums and prescription drugs do not count toward the maximum out-of-pocket amount. See Chapter 4, Section 1.2, for information about your maximum out-of-pocket amount.

Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state.

Medically Accepted Indication – A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5, Section 3 for more information about a medically accepted indication.

Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.

Medicare – The Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare or a Medicare Advantage Plan.

Medicare Advantage Open Enrollment Period – A set time each year when members in a Medicare Advantage plan can cancel their plan enrollment and switch to Original Medicare or make changes to your Part D coverage. The Open Enrollment Period is from January 1 until March 31, 2019.

Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

Medicare Coverage Gap Discount Program – A program that provides discounts on most covered Part D brand name drugs to Part D members who have reached the Coverage Gap Stage and who are not already receiving "Extra Help." Discounts are based on agreements between the Federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted.

Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.

Medicare Health Plan – A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).

Medicare Prescription Drug Coverage (Medicare Part D) – Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.

"Medigap" (Medicare Supplement Insurance) Policy – Medicare supplement insurance sold by private insurance companies to fill "gaps" in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)

Member (Member of our Plan, or "Plan Member") – A person with Medicare who is eligible to get covered services, who has enrolled in our plan, and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Member Services – A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals. See Chapter 2 for information about how to contact Member Services.

National Compound Credentialing Program (NCCP) – The National Compound Credentialing Program (NCCP) is a process used to ensure that the same standards required for manufacturing traditional prescriptions are being followed by pharmacy providers creating compound medications.

Network Pharmacy – A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them "network pharmacies" because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

Network Provider – "Provider" is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. We call them "network providers" when they have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Our plan pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as "plan providers."

Organization Determination – The Medicare Advantage plan has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called "coverage decisions" in this booklet. Chapter 9 explains how to ask us for a coverage decision.

Original Medicare ("Traditional Medicare" or "Fee-for-service" Medicare) – Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States.

Out-of-Network Pharmacy – A pharmacy that doesn’t have a contract with our plan to coordinate or provide covered drugs to members of our plan. As explained in this Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.

Out-of-Network Provider or Out-of-Network Facility – A provider or facility with which we have not arranged to coordinate or provide covered services to members of our plan. Out-of-network providers are providers that are not employed, owned, or operated by our plan or are not under contract to deliver covered services to you. Using out-of-network providers or facilities is explained in this booklet in Chapter 3

Out-of-Pocket Costs – See the definition for "cost-sharing" above. A member’s cost-sharing requirement to pay for a portion of services or drugs received is also referred to as the member’s "out-of-pocket" cost requirement.

Part C – see "Medicare Advantage (MA) Plan."

Part D – The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)

Part D Drugs – Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.

Part D Late Enrollment Penalty – An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions. For example, if you receive "Extra Help" from Medicare to pay your prescription drug plan costs, you will not pay a late enrollment penalty.

Point of Service – A benefit that allows you to use providers outside the plan’s network for an additional cost. (See Chapter 1, Section 3.2)

Preferred Cost-sharing – Preferred cost-sharing means lower cost-sharing for certain covered Part D drugs at certain network pharmacies.

Preferred Provider Organization (PPO) Plan – A Preferred Provider Organization plan is a Medicare Advantage Plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they are received from network or out-of-network providers. Member cost-sharing will generally be higher when plan benefits are received from out-of-network providers. PPO plans have an annual limit on your out-of-pocket costs for services received from network (preferred) providers and a higher limit on your total combined out-of-pocket costs for services from both network (preferred) and out-of-network (non-preferred) providers.

Premium – The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Prescription Drug Benefit Manager – A Prescription Drug Benefit Manager (PBM) is a company that administers, or handles, the prescription drug (Part D) benefit.

Primary Care Physician (PCP) – Your primary care provider is the doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare health plans, you must see your primary care provider before you see any other health care provider. See Chapter 3, Section 2.1 for information about Primary Care Physicians.

Prior Authorization – Approval in advance to get services or certain drugs that may or may not be on our formulary. Some in-network medical services are covered only if your doctor or other network provider gets "prior authorization" from our plan. Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4. Some drugs are covered only if your doctor or other network provider gets "prior authorization" from us. Covered drugs that need prior authorization are marked in the formulary.

Prosthetics and Orthotics – These are medical devices ordered by your doctor or other health care provider. Covered items include, but are not limited to, arm, back and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function, including ostomy supplies and enteral and parenteral nutrition therapy.

Quality Improvement Organization (QIO) – A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state.

Quantity Limits – A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.

Rehabilitation Services – These services include physical therapy, speech and language therapy, and occupational therapy.

Service Area – A geographic area where a health plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you permanently move out of the plan’s service area.

Skilled Nursing Facility (SNF) Care – Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

Special Enrollment Period – A set time when members can change their health or drug plan or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting "Extra Help" with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you.

Special Needs Plan – A special type of Medicare Advantage Plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.

Standard Cost-sharing – Standard cost-sharing is cost-sharing other than preferred cost-sharing offered at a network pharmacy.

Step Therapy – A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.

Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits.

Urgently Needed Services – Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.

KelseyCare Advantage’s Notice of Privacy Practices

KS Plan Administrators LLC is committed to ensuring the privacy and confidentiality of our members’ Protected Health Information (PHI) and fully supports the provisions of the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

KS Plan Administrators LLC is committed to safeguarding the confidentiality of your personal health information. In order to effectively provide and administer services and benefits to you, KS Plan Administrators LLC must collect and disclose certain protected health information. This is only done, however, in accordance with KS Plan Administrators LLC’s privacy policies. In addition, Federal and state laws require that we guard the privacy of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

This Notice of Privacy Practices describes how KS Plan Administrators LLC may collect, use and disclose your protected health information, and your rights concerning your protected health information. Protected health information is information about you or your dependents, including demographic information, that can reasonably be used to identify you and that relates to your past, present, or future physical or mental health or condition, the provision of health care service to you or our payment for that care. We are required to safeguard your protected health information and to provide you with this notice about our legal duties and privacy practices. We must follow the privacy practices described in this notice while it is in effect.

This notice takes effect April 1, 2007 and will remain in effect until we replace or modify it.

What is Protected Health Information (PHI)?

Whether based on our confidentiality policy or pertinent law, KS Plan Administrators LLC safeguards the privacy of your protected health information ("PHI"). PHI is information that alone, or in conjunction with other data that we collect from or about you, would allow you to be identified. For example, medical information used to help members get needed care, or information about payments for services you have received, as well as descriptive information about those services, is PHI.

How we may use and disclose your PHI

In order to provide coverage for treatment and pay for those services, we need to use and disclose your PHI in a number of different ways. KS Plan Administrators LLC staff is trained in the appropriate handling of your PHI and execute their specific responsibilities using only that information required for their role. KS Plan Administrators LLC maintains and enforces policies governing the use of PHI by workforce members to ensure their proper handling. Procedures to afford these internal protections against mishandling of PHI throughout the workforce include provisions pertinent to physical and technical safeguards taken in order to protect verbal, written and electronic PHI from being mishandled by workforce members as they execute their responsibilities. The following are examples of the types of uses and disclosures of your PHI that we are permitted to make without your authorization:


KS Plan Administrators LLC will use and disclose your PHI to administer your health benefits policy or contract, which may involve the determination of eligibility; claims payment; utilization review activities; medical necessity review; coordination of benefits and responding to complaints, appeals, and external review requests. Examples include:

  • Using PHI in order to pay claims that have been submitted to us by physicians and hospitals for payment.
  • Transmitting PHI to a third party to facilitate administration of a Flexible Spending Account, a Health Savings Account, a Health Reimbursement Account or a dental benefits plan, if you have one
  • Additional PHI of dependents may be shared with subscriber when administering a family membership contract (e.g., the current status of co-payments and deductible amounts for dependents)


KS Plan Administrators LLC may use and disclose your PHI for operational purposes. For example, your PHI may be disclosed to staff members within KS Plan Administrators LLC, such as medical-management, risk-management or quality-improvement personnel, and others to:

  • Assess the quality of care and outcomes in your cases and similar cases
  • Learn how to improve our services and facilities through the use of internal and external surveys
  • Determine how to continuously improve the quality and effectiveness of health care services our members receive
  • Evaluate the performance of our staff, for example, to review our member service representatives’ call documentation

In addition, your PHI may be used for the following purposes, each of which is also considered health care operations:

  • Sharing of data used for enrollment, disenrollment, and premium billing, as well as summary renewal data with your Plan Sponsor (your employer and/or their representatives, if you are enrolled through an employer)
  • Other information beyond what is listed above may be shared only after KS Plan Administrators LLC receives appropriate certifications that the PHI will not be used by your employer for employment decisions or other non-intended purposes.
  • If you have a primary care physician who manages your care, we may furnish his or her name to your Plan Sponsor in order to permit your Sponsor to evaluate the effects of changes to the network available to you.
  • Providing contact information to an external surveyor selected by the Federal government to conduct routine satisfaction surveys with our KelseyCare Advantage beneficiaries.
  • Quality assessment and improvement activities, such as peer review and credentialing of our affiliated providers.
  • Accreditation by independent organizations such as the National Committee for Quality Assurance
  • Performance measurement and outcomes assessment, health claims analysis and health services research.
  • Preventive health, early detection, disease management, case management and coordination of care programs, including sending preventive health service reminders.
  • Underwriting, rate making and determining cost sharing amounts, as well as administration of reinsurance policies.
  • Risk management, auditing and detection of unlawful conduct.
  • Transfer of policies or contracts from and to other insurers, health plans or third party administrators.
  • Facilitation of any potential sale, transfer, merger or consolidation of all or part of a "covered entity" like KS Plan Administrators LLC, with another covered entity, and due diligence related to that activity.
  • Other general administrative activities, including data and information systems management, customer service and collecting premiums.


KS Plan Administrators LLC may disclose your PHI to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers) who request it in connection with your treatment. For example, for your safety, we may provide a list of medications you've received through your KS Plan Administrators LLC coverage to emergency room clinicians treating you in an effort to minimize the potential for adverse drug interactions. This information will only be furnished to emergency room clinicians with your consent, unless you are unable to provide consent. We may also disclose your PHI to health care providers in connection with preventive health initiatives, early detection programs, and disease management programs. For example, KS Plan Administrators LLC may disclose information to physicians involved in your care that includes a list of medications you've filled using your KS Plan Administrators LLC coverage (this will alert those physicians treating you to those medications prescribed for you by others and will help minimize potential adverse drug interactions). KS Plan Administrators LLC may also disclose information to your primary care physician to suggest a disease management or wellness program that could help improve your health.

At times, KS Plan Administrators LLC may contract with other organizations to provide services on our behalf. As these services are performed, PHI is accessed or disclosed. In these cases, KS Plan Administrators LLC will enter into an agreement explicitly outlining the requirements associated with the protection, use and disclosure of your PHI.

Examples of such "business associates" include behavioral health management companies and pharmacy benefit managers.


Other permitted or required uses and disclosures of PHI that do not require your authorization include the following:

  • Parents as Personal Representatives of Minors – In most cases, your minor child’s PHI may be disclosed to you. However, we may be required by law to deny a parent’s access to a minor’s PHI for certain diagnoses or treatment such as sexually transmitted diseases, family planning services, etc.
  • Worker's Compensation – Your PHI may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation.
  • Public Health Activities – Your PHI may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury or disability, tracking of prescription drug or medical device problems, or for other health oversight activities.
  • Research – KS Plan Administrators LLC may use your PHI for research purposes when our Quality Improvement Committee has reviewed the research proposal and approved the research based on established protocols to ensure the privacy of your PHI.
  • Legal Proceedings – Your PHI may be disclosed in the course of any legal proceeding, in response to an order of a court or an administrative tribunal and, in certain cases, in response to a subpoena, discovery request or other lawful process.
  • If You Are Enrolled in a Group Health Plan – If you are enrolled in KS Plan Administrators LLC through your work or through a family member’s policy, you are enrolled in a "Group Health Plan." If your employer has established procedures to safeguard your PHI as required by federal law, and the Group Health Plan elects to receive PHI from KS Plan Administrators LLC, we may disclose this information to your sponsoring employer and/or their representative. Talk to your sponsoring employer to get more details.
  • Health Oversight – Your PHI may be disclosed to a government agency authorized to oversee the health care system or government programs or its contractors, [e.g., the U.S. Department of Health and Human Services (HHS), a state insurance department or the US Department of Labor] for activities authorized by law, such as audits, examinations, investigations, inspections and licensure activity. Although we do not anticipate the following situations will occur frequently, these potential uses and disclosures can occur without your written authorization:
  • As Required by Law – KS Plan Administrators LLC may use and disclose information about you as required by law. For example, KS Plan Administrators LLC may disclose information for the following purposes:
    • To report information related to victims of abuse, neglect or domestic violence;
    • To assist law enforcement officials in performing their duties.
  • Government Functions – Your PHI may be disclosed to prevent serious threat to your health or safety or that of any person pursuant to applicable law. We may also disclose your protected health information to authorized federal officials for national security purposes. In addition, under certain conditions, we may disclose your PHI if you are, or were a member of the Armed Forces, for those activities deemed necessary by appropriate military authorities.
  • Inmates – If you are an inmate, your PHI may be disclosed to a correctional institution or a law enforcement official having lawful custody, if the provision of such information is necessary to provide you with health care, protect your health and safety, and that of others, or maintain the safety and security of the correctional institution.
  • Decedents – PHI may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.
  • Organ/Tissue Donation – Your PHI may be used or disclosed to organ procurement organizations to facilitate cadaveric organ, eye or tissue donation/transplantation purposes only subsequent to your prior authorization.


Uses and disclosures of PHI other than those listed above in Section II will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke such an authorization, at any time in writing, except to the extent that we have already taken an action based on a previously executed authorization.

If a written authorization is obtained from you, your PHI may be disclosed to your personal representative, a person (an adult or an emancipated minor) that KS Plan Administrators LLC recognizes as having the authority to act on behalf of another individual in making decisions related to health care. Many members ask us to disclose their PHI to third parties for reasons not described in this notice. For example, elderly members often ask us to make their records available to family members or caregivers. To authorize us to disclose any of your PHI to a person or organization for reasons other than those described in this notice, please call the toll free number on your ID card and you will be provided with the appropriate authorization form. You should send the completed form to our Member Services Department. You may revoke the authorization at any time by sending a letter to our Member Services Department at 11511 Shadow Creek Parkway, Pearland, TX 77584.

It is important for you to note that once you give us authorization to release your health information, the PHI that we release is out of KS Plan Administrators LLC’s control. KS Plan Administrators LLC is unable to safeguard such PHI from redisclosure by the person(s) that you have authorized us to release it to. Finally, KS Plan Administrators LLC will not use your PHI to offer you services or products unrelated to your health care coverage or your health status without your authorization.


The following are your rights with respect to your PHI.


You have the right to access or receive a copy of your PHI. We may ask you to request access or copies of your records in writing and to provide us with the specific information we need to fulfill your request. We reserve the right to charge a reasonable, cost-based fee for the cost of producing and mailing the copies of such information. We will endeavor to provide you the requested PHI within fifteen (15) business days of receipt of a complete written request and related fees. If we are using an electronic health records system capable of fulfilling the request, Texas law requires us to provide the requested records no later than the fifteenth (15th) business day after the date we receive your written request, and we must provide those records to you in electronic form unless you have agreed to accept the records in another form. There are certain cases in which we are not permitted to fulfill your request to access or receive your PHI.

You may not inspect or copy:

  • Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding;
  • Psychotherapy notes that may be submitted to KS Plan Administrators LLC incidental to a member complaint or appeal. (These confidential notes are never requested by KS Plan Administrators LLC.);
  • PHI that is subject to the Clinical Laboratory Improvements Amendments of 1988;
  • Information created or obtained by KS Plan Administrators LLC in the course of research that includes treatment. Access to these records may be temporarily suspended for as long as the research is in progress;
  • PHI that was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.


If you believe that your protected health information is incorrect or incomplete, you have the right to ask us to amend your PHI. All requests for amendment must be in writing. In certain cases, we may deny your request. For example, we may deny a request if we did not create the information, as is often the case for medical information that is generated by a provider and stored in our records, or if we believe the current information is correct. All denials will be made in writing within sixty (60) days of the original request. You may respond by filing a written statement of disagreement with KS Plan Administrators LLC and we would have the right to rebut that statement.

If you believe someone has received un-amended PHI from us, you should inform us at the time of the request if you want him or her to be informed of any amendment we may subsequently agree to execute.


KS Plan Administrators LLC recognizes that members have the right to receive communications regarding their PHI in a manner and at a location that the individual feels is safe from unauthorized use or disclosure. To support this commitment, KS Plan Administrators LLC will permit individuals to request that they receive PHI by alternative means or at alternative locations. We will consider and attempt to accommodate all reasonable requests, and we must agree to a request if you tell us you would be in danger if we do not. All requests must be in writing.


You have the right to request an accounting of those instances in which we have disclosed your PHI for six (6) years prior to the date of your request, who we shared it with, and why. All requests must be made in writing. KS Plan Administrators LLC will require you to provide us with the specific information we need to fulfill your request. We will provide one such accounting free of charge every twelve (12) months, but we may charge you a reasonable, cost-based fee for any additional accountings you request within that twelve-month period. We will include all disclosures except for the following:

  • Disclosures made for treatment, payment or health care operations;
  • Disclosures made to others involved in your health care;
  • Disclosures that you or your designated personal representative have authorized;
  • Certain other disclosures, such as disclosures for national security purposes;
  • Information disclosed to correctional institutions, law enforcement agencies, or health oversight agencies;
  • Information that was disclosed or used as part of a limited data set for research, public health or health care operations purposes.


You have the right to ask us to place restrictions on the way we use or disclose your PHI for treatment, payment, or health care operations, or as described in the section of this notice entitled "Other Permitted or Required Uses and Disclosures of PHI." We are not, however, required by law to agree to these requested restrictions, and we may deny your request for a restriction if it would affect your care. If we do agree to a restriction, we may not use or disclose your PHI in violation of that restriction, unless it is related to an emergency. We may ask that you request these limits in writing.


You have a right to receive a paper copy of the Notice of Privacy Practices upon request at any time, even if you have agreed to receive the notice electronically. You may be entitled to additional rights under state law.


To request a copy of this Notice of Privacy Practices at any time, or obtain additional information about this notice, you may contact:

KS Plan Administrators LLC
Member Services Department
11511 Shadow Creek Parkway
Pearland, TX 77584
or visit our website at www.kelseycareadvantage.com.

If you believe your privacy rights have been violated, you may file a written complaint with:

Director of Compliance,
KS Plan Administrators LLC
11511 Shadow Creek Parkway
Pearland, TX 77584
or by contacting this office at 713-442-CARE (2273).

You may also notify the Secretary of the Department of Health and Human Services (HHS).

Send your complaint to:

Medical Privacy, Complaint Division, Office for Civil Rights (OCR)
United States Department of Health and Human Services,
200 Independence Avenue, S.W.Room 509F HHH Building
Washington D.C., 20201

You may also contact OCR’s Voice Hotline Number at (800) 368-1019 or send the information to their Internet address www.hhs.gov/ocr/privacy/hipaa/complaints/.

KS Plan Administrators LLC will not take retaliatory action against you if you file a complaint about our privacy practices either with OCR or KS Plan Administrators LLC.


We may make a change to this notice and our privacy practices at any time, as long as the change is consistent with our current privacy policies or state or federal law. If we make an important change to our policies, we will promptly provide you with the new notice by mail and post it on our web site


The effective date of this notice is April 1, 2007. Non-English speaking members may also call KS Plan Administrators LLC’s Member Services Department at 1-866-535-8343 to have their questions answered.

Discrimination is Against the Law

KelseyCare Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. KelseyCare Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

KelseyCare Advantage:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact KelseyCare Advantage Member Services. If you believe that KelseyCare Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: KelseyCare Advantage, Attn: Grievance Department, 11511 Shadow Creek Parkway, Pearland, TX 77584, 1-866-535-8343, TTY 1-866-302-9336, Fax 713-442-9536 You can file a grievance in person, by phone, by mail, or fax. If you need help filing a grievance, KelseyCare Advantage Member Services is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

multi-language interpreter services insert

ATTENTION: If you speak any non-English language, language assistance services, free of charge, are available to you. Call 1-866-535-8343 (TTY: 1-866-302-9936).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-535-8343 (TTY: 1-866-302-9936).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-866-535-8343 (TTY: 1-866-302-9936).

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-866-535-8343(TTY:1-866-302-9936)。

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-866-535-8343 (TTY: 1-866-302-9936)번으로 전화해 주십시오.

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1 - 8343-535-866 )رقم هاتف الصم والبكم:
1 - 9936-302-866 .)
خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کريں
1-866-535-8343 (TTY: 1-866-302-9936).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-866-535-8343 (TTY: 1-866-302-9936).

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-866-535-8343 (ATS : 1-866-302-9936).

ध्यान दें: यदद आप ह िंदी बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-866-535-8343 (TTY: 1-866-302-9936) पर कॉल करें।

توجه: اگر به زبان فارسی گفتگو می کنید، تسهیلات زبانی بصورت رايگان برای شما فراهم می باشد. با
1-866-535-8343 (TTY: 1-866-302-9936) تماس بگیريد.

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-866-535-8343 (TTY: 1-866-302-9936).

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નન:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-866-535-8343 (TTY: 1-866-302-9936).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-866-535-8343 (телетайп: 1-866-302-9936).


ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-866-535-8343 (TTY: 1-866-302-9936).


METHOD KelseyCare Advantage Member Services - Contact Information
CALL 1-866-535-8343

Calls to this number are free.
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. Member Services also has free language interpreter services available for non- English speakers.
TTY 1-866-302-9336 (This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.)

Calls to this number are free. 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.
FAX 713-442-5450
WRITE KelseyCare Advantage
ATTN: Member Services
11511 Shadow Creek Parkway
Pearland, TX 77584
– OR –

PO Box 841569
Pearland, TX 77584-9832
WEBSITE www.kelseycareadvantage.com

Health Information Counseling and Advocacy Program (HICAP)

Health Information Counseling and Advocacy Program (HICAP) is a state program that gets money from the Federal Government to give free local health insurance counseling to people with Medicare.

METHOD The Texas Department of Health and Human Services - Contact Information
CALL 1-800-252-9240 or 512-424-6500 – Monday through Friday 8:00 a.m. – 5:00 p.m.
TTY Texas Relay 1-800-735-2989
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
WRITE The Texas Department of Health and Human Services
P.O. Box 13247
Austin, TX 78711-3247
Website www.hhs.texas.gov

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1051. If you have comments or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.