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


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



This chapter explains what you need to know about using the plan to get your medical care covered. It gives definitions of terms and explains the rules you will need to follow to get the medical treatments, services, and other medical care that are covered by the plan.

For the details on what medical care is covered by our plan and how much you pay when you get this care, use the benefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what is covered and what you pay).


Section 1.1 - What are "network providers" and "covered services"?

Here are some definitions that can help you understand how you get the care and services that are covered for you as a member of our plan:

  • "Providers" are doctors and other health care professionals licensed by the state to provide medical services and care. The term "providers" also includes hospitals and other health care facilities.

  • "Network providers" are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and your cost-sharing amount as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The providers in our network bill us directly for care they give you. When you see a network provider, you pay only your share of the cost for their services.

  • "Covered services" include all the medical care, health care services, supplies, and equipment that are covered by our plan. Your covered services for medical care are listed in the benefits chart in Chapter 4.

Section 1.2 - Basic rules for getting your medical care covered by the plan

As a Medicare health plan, KelseyCare Advantage Rx+Choice must cover all services covered by Original Medicare and must follow Original Medicare’s coverage rules.

KelseyCare Advantage Rx+Choice will generally cover your medical care as long as:

  • The care you receive is included in the plan’s Medical Benefits Chart (this chart is in Chapter 4 of this booklet).
  • The care you receive is considered medically necessary. "Medically necessary" means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.
  • You have a network primary care provider (a PCP) who is providing and overseeing your care. As a member of our plan, you must choose a network PCP (for more information about this, see Section 2.1 in this chapter).

    • In most situations, our plan must give you approval in advance before you can use other providers in the plan’s network, such as specialists, hospitals, skilled nursing facilities, or home health care agencies. This is called giving you a "referral." For more information about this, see Section 2.3 of this chapter.

    • Referrals from your PCP are not required for emergency care or urgently needed services. There are also some other kinds of care you can get without having approval in advance from your PCP (for more information about this, see Section 2.2 of this chapter).
  • You must receive your care from a network provider (for more information about this, see Section 2 in this chapter).This plan has a Point-of-Service (POS) benefit, which covers Medicare-covered, medically necessary services you get from out-of-network physicians or from network physicians. Certain Medicare-covered services require prior authorization. For more information see the Medical Benefits Chart in Chapter 4. Some Medicare providers may not be willing to see you or bill our plan for medical services. You may choose to see any willing Medicare provider for the services. Care ordered by a physician you are seeing under you POS benefits, even when provided at a network facility, will be covered under your POS benefits and higher coinsurance or copayments will apply. When you use the POS benefit, you are responsible for more of the cost of care. For services that require prior authorization, see the Medical Benefits Chart in Chapter 4.

    In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. Here are three exceptions:

    • The plan covers emergency care or urgently needed services that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed services means, see Section 3 in this chapter.

    • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. In this situation, you will pay the same as you would pay if you got the care from a network provider. For information about getting approval to see an out-of-network doctor, see Section 2.4 in this chapter.

    • The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

Section 2.1 - You may choose a Primary Care Provider (PCP) to provide and oversee your medical care

What is a "PCP" and what does the PCP do for you?

  • What is a PCP? A PCP is a physician in the network who will provide you with most of your routine health care needs and help you coordinate your other medical needs.
  • What types of providers may act as a PCP? Usually, Family Medicine and Internal Medicine physicians in the network will act as a PCP. Occasionally, another specialist will agree to act as your PCP, if they are managing all of your care.
  • What is the role of a PCP in KelseyCare Advantage? Your PCP will provide care for your routine health care needs and assist in coordinating your care. Your PCP will arrange preventive health care screenings, order laboratory tests and other diagnostic tests. Your PCP will also arrange referrals to other non-Kelsey-Seybold Medical Group Specialists if care cannot be provided by Kelsey-Seybold Medical Group Specialists. Your PCP will coordinate your clinical care with specialists.
  • What is the role of the PCP in coordinating covered services? Your PCP will help you coordinate your health care needs. Coordinating your care includes consulting with our plan providers about your care and monitoring any treatment you are receiving. Your PCP may also help arrange any other covered services or supplies you may need such as home health care or medical equipment. Specialists may also help you arrange other services.
  • What is the role of the PCP in making decisions about or obtaining prior authorization, if applicable? Your PCP may also arrange referrals to other non-Kelsey-Seybold Medical Group Specialists if care cannot be provided by the specialists within Kelsey-Seybold Medical Group.

How do you choose your PCP?

You may choose your PCP by looking at the list of Family Medicine or Internal Medicine physicians listed in the plan’s Provider Directory and calling the provider’s main number to make an appointment. Some PCPs will only see you if you are an existing patient and have seen them in the past.

Primary Care Physician services must be provided by an in-network Family Medicine or Internal Medicine provider, unless you choose to use your POS Benefits to see an out-of-network provider.

Changing your PCP

You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might leave our plan’s network of providers and you would have to find a new PCP.

You can change your PCP at any time by making an appointment to see another PCP within the network, who is accepting new patients. You do not need to notify the plan of the change. Member Services can also help you make an appointment with a new PCP.


Section 2.2 - What kinds of medical care can you get without getting approval in advance from your PCP?

You can get the services listed below without getting approval in advance from your PCP.

  • Routine women’s health care, which includes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
  • Flu shots, Hepatitis B vaccinations, and pneumonia vaccinations as long as you get them from a network provider
  • Emergency services from network providers or from out-of-network providers
  • Urgently needed services from network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible (e.g., when you are temporarily outside of the plan’s service area)
  • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away. Phone numbers for Member Services are printed on the back cover of this booklet.)
  • Most laboratory testing and x-rays ordered by a network physician and performed at Kelsey-Seybold Clinic.

Section 2.3 - How to get care from specialists and other network providers

A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:

  • Oncologists care for patients with cancer.
  • Cardiologists care for patients with heart conditions.
  • Orthopedists care for patients with certain bone, joint, or muscle conditions.

What is the role of the PCP in referring members to specialists and other providers?

You do not need a referral to see most Kelsey-Seybold Medical Group specialists. Just call Kelsey-Seybold Clinic and schedule an appointment. A referral is needed to see a network specialist outside of Kelsey-Seybold Medical Group and this can be requested by either your PCP or another Kelsey-Seybold specialist. Your network physician can refer you to a specialist outside of Kelsey-Seybold Medical Group if the care cannot be provided by one of the Kelsey-Seybold Medical Group specialists. Kelsey-Seybold is your primary network. Generally, you will only be referred to a doctor outside of Kelsey-Seybold Medical Group if the specialists at Kelsey-Seybold cannot provide the care you need. For example, you may request to see a specialist at MD Anderson, but the referral may not be approved if a Kelsey-Seybold oncologist can provide your care. A referral to a certain specialist may be approved if you meet the medical guidelines for the type of treatment the specialist will provide. For example, if you are sent to see a surgeon for possible weight loss (Bariatric) procedures, your referral may be approved only if you meet the Medicare criteria for an office visit and evaluation. Also, if you are requesting a second opinion about your care, your PCP can assist you. Generally, a second opinion will be provided by a specialist within your primary Kelsey-Seybold network. Please refer to Chapter 4, Section 2.1 for information about which services require prior authorization.

Generally, your PCP or a Kelsey-Seybold specialist will request a prior authorization for services and send the request to the Utilization Management department at Kelsey-Seybold Clinic. You can also contact Member Services and request prior authorization.

For what services will the PCP need to get prior authorization from the plan?

  • Home Health Services
  • Durable Medical Equipment such as oxygen or wheelchairs
  • Orthotics and Prosthetics such as braces or mastectomy forms
  • Certain diagnostic tests such as MRIs or PET scans
  • Referrals to non-Kelsey-Seybold Medical Group specialists
  • Elective hospital procedures for surgeries or other treatment
  • Outpatient or ambulatory surgery procedures and treatment
  • Other services listed in this Evidence of Coverage with prior authorization requirements

What if a specialist or another network provider leaves our plan?

We may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan, but if your doctor or specialist does leave your plan you have certain rights and protections that are summarized below:

  • Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists.
  • We will make a good faith effort to provide you with at least 30 days’ notice that your provider is leaving our plan so that you have time to select a new provider.
  • We will assist you in selecting a new qualified provider to continue managing your health care needs.
  • If you are undergoing medical treatment you have the right to request, and we will work with you to ensure that the medically necessary treatment you are receiving is not interrupted.
  • If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision.
  • If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider and managing your care.
  • Please contact our Member Services 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). Member Services has free language interpreter services available for non-English speakers.

Section 2.4 - How to get care from out-of-network providers

You may use your point-of-service benefits to get care from any willing Medicare provider without obtaining a referral for physician office services. Some Medicare providers may not be willing to see you or bill our plan for your care. We pay out-of-network providers you use the Medicare rate for the services they provide. Prior authorization is not needed for office services and you can make the appointment with a physician of your choice. You can also use your POS benefits to make an appointment with a network physician who is not part of the Kelsey-Seybold Medical Group, without obtaining prior authorization. Care ordered by a physician who you are seeing under your POS benefits, even when provided at a network facility will all be covered under your POS benefits and higher coinsurance or copayments will apply. Coinsurance and copayments you pay when using your POS benefits for covered services count toward your $10,000 out-of-network out-of-pocket maximum. Medicare-covered Part A and B services are covered under your POS benefit. Services provided must be covered by Medicare guidelines. See the benefit chart in Chapter 4 for more information about POS benefits.


Section 3.1 - Getting care if you have a medical emergency

What is a "medical emergency" and what should you do if you have one?

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.

If you have a medical emergency:

  • Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.
  • As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours. Call the Member Services telephone number on the back of your membership card or on the back cover of this book.

What is covered if you have a medical emergency?

You may get covered emergency medical care whenever you need it, anywhere in the United States or its territories. Our plan covers ambulance services in situations where getting to the emergency room in any other way could endanger your health. For more information, see the Medical Benefits Chart in Chapter 4 of this booklet.

The KelseyCare Advantage Rx+Choice plan provides worldwide emergency coverage. You can get emergency care outside of the United States. Emergency care includes emergency room visits, emergency hospital admissions and ambulance trips where you are taken to the emergency room. The plan generally does not pay for transportation back to the United States after out-of-the-country emergency care. The plan will pay up to 100% of what Medicare would allow for the services if they had been obtained in the United States, less any copayments and coinsurance. Some providers, such as cruise ships, will charge you significantly more than Medicare, so you may have more out-of-pocket costs. Emergency care providers outside of the United States may require you to pay for care at the time services are provided. You will need to submit receipts and any medical information to the plan for payment. There is no worldwide coverage for care outside of the emergency room or emergency hospital admission. There is also no coverage for medications purchased while outside of the United States. For more information, please refer to Chapter 4 of this booklet.

If you have an emergency, we will talk with the doctors who are giving you emergency care to help manage and follow up on your care. The doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over.

After the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by our plan. If your emergency care is provided by out-of-network providers, we will try to arrange for network providers to take over your care as soon as your medical condition and the circumstances allow.

What if it wasn’t a medical emergency?

Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care – thinking that your health is in serious danger – and the doctor may say that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care.

However, after the doctor has said that it was not an emergency, we will cover additional care only if you get the additional care in one of these two ways:

  • You go to a network provider to get the additional care.
  • – or – The additional care you get is considered "urgently needed services" and you follow the rules for getting this urgently needed services (for more information about this, see Section 3.2 below).

Section 3.2 - Getting care when you have an urgent need for services

What are "urgently needed services"?

"Urgently needed services" are 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. The unforeseen condition could, for example, be an unforeseen flare-up of a known condition that you have.

What if you are in the plan’s service area when you have an urgent need for care?

You should always try to obtain urgently needed services from network providers. However, if providers are temporarily unavailable or inaccessible and it is not reasonable to wait to obtain care from your network provider when the network becomes available, we will cover urgently needed services that you get from an out-of-network provider.

To obtain information on the urgent care centers in the plan’s network, refer to the Provider Directory located at www.kelseycareadvantage.com or contact Member Services. (Phone numbers for Member Services are printed on the back cover of this booklet.) If you have questions about urgent care services after hours, you can call Kelsey-Seybold Clinic’s 24-hour contact center at 713-442-0000 to speak with a registered nurse or have a doctor paged.

What if you are outside the plan’s service area when you have an urgent need for care?

When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed services that you get from any provider.

Our plan does not cover urgently needed services or any other non-emergency services if you receive the care outside of the United States.


Section 3.3 - Getting care during a disaster

If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan.

Please visit the following website: www.kelseycareadvantage.com/emergency for information on how to obtain needed care during a disaster.

Generally, if you cannot use a network provider during a disaster, your plan will allow you to obtain care from out-of-network providers at in-network cost-sharing. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy. Please see Chapter 5, Section 2.4 for more information.


Section 4.1 - You can ask us to pay our share of the cost of covered services

If you have paid more than your share for covered services, or if you have received a bill for the full cost of covered medical services, go to Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs) for information about what to do.


Section 4.2 - If services are not covered by our plan, you must pay the full cost

KelseyCare Advantage Rx+Choice covers all medical services that are medically necessary, are listed in the plan’s Medical Benefits Chart (this chart is in Chapter 4 of this booklet), and are obtained consistent with plan rules. You are responsible for paying the full cost of services that aren’t covered by our plan, either because they are not plan covered services, or they were obtained out-of-network and were not authorized.

If you have any questions about whether we will pay for any medical service or care that you are considering, you have the right to ask us whether we will cover it before you get it. You also have the right to ask for this in writing. If we say we will not cover your services, you have the right to appeal our decision not to cover your care.

Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has more information about what to do if you want a coverage decision from us or want to appeal a decision we have already made. You may also call Member Services to get more information (phone numbers are printed on the back cover of this booklet).

For covered services that have a benefit limitation, you pay the full cost of any services you get after you have used up your benefit for that type of covered service. Costs you pay after your benefit limit has been reached will not count toward your out-of-pocket maximum. You can call Member Services when you want to know how much of your benefit limit you have already used.


Section 5.1 - What is a "clinical research study"?

A clinical research study (also called a "clinical trial") is a way that doctors and scientists test new types of medical care, like how well a new cancer drug works. They test new medical care procedures or drugs by asking for volunteers to help with the study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a new approach works and if it is safe.

Not all clinical research studies are open to members of our plan. Medicare first needs to approve the research study. If you participate in a study that Medicare has not approved, you will be responsible for paying all costs for your participation in the study.

Once Medicare approves the study, someone who works on the study will contact you to explain more about the study and see if you meet the requirements set by the scientists who are running the study. You can participate in the study as long as you meet the requirements for the study and you have a full understanding and acceptance of what is involved if you participate in the study.

If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the covered services you receive as part of the study. When you are in a clinical research study, you may stay enrolled in our plan and continue to get the rest of your care (the care that is not related to the study) through our plan.

If you want to participate in a Medicare-approved clinical research study, you do not need to get approval from us or your PCP. The providers that deliver your care as part of the clinical research study do not need to be part of our plan’s network of providers.

Although you do not need to get our plan’s permission to be in a clinical research study, you do need to tell us before you start participating in a clinical research study.

If you plan on participating in a clinical research study, contact Member Services (phone numbers are printed on the back cover of this booklet) to let them know that you will be participating in a clinical trial and to find out more specific details about what your plan will pay.


Section 5.2 - When you participate in a clinical research study, who pays for what?

Once you join a Medicare-approved clinical research study, you are covered for routine items and services you receive as part of the study, including:

  • Room and board for a hospital stay that Medicare would pay for even if you weren’t in a study.
  • An operation or other medical procedure if it is part of the research study.
  • Treatment of side effects and complications of the new care.

Original Medicare pays most of the cost of the covered services you receive as part of the study. After Medicare has paid its share of the cost for these services, our plan will also pay for part of the costs. We will pay the difference between the cost-sharing in Original Medicare and your cost-sharing as a member of our plan. This means you will pay the same amount for the services you receive as part of the study as you would if you received these services from our plan.

    Here’s an example of how the cost-sharing works: Let’s say that you have a lab test that costs $100 as part of the research study. Let’s also say that your share of the costs for this test is $20 under Original Medicare, but the test would be $10 under our plan’s benefits. In this case, Original Medicare would pay $80 for the test and we would pay another $10. This means that you would pay $10, which is the same amount you would pay under our plan’s benefits.

In order for us to pay for our share of the costs, you will need to submit a request for payment. With your request, you will need to send us a copy of your Medicare Summary Notices or other documentation that shows what services you received as part of the study and how much you owe. Please see Chapter 7 for more information about submitting requests for payment.

When you are part of a clinical research study, neither Medicare nor our plan will pay for any of the following:

  • Generally, Medicare will not pay for the new item or service that the study is testing unless Medicare would cover the item or service even if you were not in a study.
  • Items and services the study gives you or any participant for free.
  • Items or services provided only to collect data, and not used in your direct health care. For example, Medicare would not pay for monthly CT scans done as part of the study if your medical condition would normally require only one CT scan.

Do you want to know more?

You can get more information about joining a clinical research study by reading the publication "Medicare and Clinical Research Studies" on the Medicare website (https://www.medicare.gov). You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.


Section 6.1 - What is a religious non-medical health care institution?

A religious non-medical health care institution is a facility that provides care for a condition that would ordinarily be treated in a hospital or skilled nursing facility. If getting care in a hospital or a skilled nursing facility is against a member’s religious beliefs, we will instead provide coverage for care in a religious non-medical health care institution. You may choose to pursue medical care at any time for any reason. This benefit is provided only for Part A inpatient services (non-medical health care services). Medicare will only pay for non-medical health care services provided by religious non-medical health care institutions.


Section 6.2 - What care from a religious non-medical health care institution is covered by our plan?

To get care from a religious non-medical health care institution, you must sign a legal document that says you are conscientiously opposed to getting medical treatment that is "non-excepted."

  • "Non-excepted" medical care or treatment is any medical care or treatment that is voluntary and not required by any federal, state, or local law.
  • "Excepted" medical treatment is medical care or treatment that you get that is not voluntary or is required under federal, state, or local law.

To be covered by our plan, the care you get from a religious non-medical health care institution must meet the following conditions:

  • The facility providing the care must be certified by Medicare.
  • Our plan’s coverage of services you receive is limited to non-religious aspects of care.
  • If you get services from this institution that are provided to you in a facility, the following conditions apply:

    • You must have a medical condition that would allow you to receive covered services for inpatient hospital care or skilled nursing facility care.

    • – and – you must get approval in advance from our plan before you are admitted to the facility or your stay will not be covered.

    • There is a 150 day coverage limit per benefit period for care which would normally be provided in an inpatient acute care hospital. If care would normally be provided in a Skilled Nursing Facility there is a limit of 100 days per benefit period. See benefit chart in Chapter 4 for more information.

Section 7.1 - Will you own the durable medical equipment after making a certain number of payments under our plan?

Durable medical equipment (DME) includes items such as oxygen equipment and supplies, wheelchairs, walkers, powered mattress systems, crutches, diabetic supplies, speech generating devices, IV infusion pumps, nebulizers, and hospital beds ordered by a provider for use in the home. The member always owns certain items, such as prosthetics. In this section, we discuss other types of DME that you must rent.

In Original Medicare, people who rent certain types of DME own the equipment after paying copayments for the item for 13 months. As a member of KelseyCare Advantage Rx+Choice, however, you usually will not acquire ownership of rented DME items no matter how many copayments you make for the item while a member of our plan. Under certain limited circumstances we will transfer ownership of the DME item to you. Call Member Services (phone numbers are printed on the back cover of this booklet) to find out about the requirements you must meet and the documentation you need to provide.


What happens to payments you made for durable medical equipment if you switch to Original Medicare?

If you did not acquire ownership of the DME item while in our plan, you will have to make 13 new consecutive payments after you switch to Original Medicare in order to own the item. Payments you made while in our plan do not count toward these 13 consecutive payments.

If you made fewer than 13 payments for the DME item under Original Medicare before you joined our plan, your previous payments also do not count toward the 13 consecutive payments. You will have to make 13 new consecutive payments after you return to Original Medicare in order to own the item. There are no exceptions to this case when you return to Original Medicare.