2022 KelseyCare Advantage Silver Freedom (HMO-POS)

KelseyCare Advantage Silver Freedom (HMO-POS) H0332-003 is a 2022 Medicare Advantage Plan or Part-C by KelseyCare Advantage available to residents in Texas. This plan does not provide additional prescription drug (Part-D) coverage. The KelseyCare Advantage Silver Freedom (HMO-POS) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $3,450 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,450 out-of-pocket. This can be a extremely nice safety net.

KelseyCare Advantage Silver Freedom (HMO-POS) is a Local HMO *. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

KelseyCare Advantage works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for KelseyCare Advantage Silver Freedom (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from KelseyCare Advantage and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from KelseyCare Advantage except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

2022 KelseyCare Advantage Medicare Advantage Plan Costs

2021 KelseyCare Advantage Silver Freedom (HMO-POS) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

Yes

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	20% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$0-150 copay
Diagnostic tests and procedures	$0-25 copay
Diagnostic tests and procedures	20% coinsurance (Out-of-Network)
Lab services	20% coinsurance (Out-of-Network)
Lab services	$0 copay
Outpatient x-rays	$0 copay
Outpatient x-rays	20% coinsurance (Out-of-Network)

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Doctor Visits

Primary	50% coinsurance per visit (Out-of-Network)
Primary	$0 copay
Specialist	20% coinsurance per visit (Out-of-Network)
Specialist	$20 copay per visit

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Emergency care/Urgent Care

Emergency	$120 copay per visit (always covered)
Urgent care	$25 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$20 copay
Foot exams and treatment	20% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$200 copay
50% coinsurance (Out-of-Network)

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Hearing

Fitting/evaluation	$20 copay
Hearing aids	$0 copay
Hearing exam	$20 copay
Hearing exam	20% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

$150 per day for days 1 through 4 $0 per day for days 5 through 90
$1,000 per stay $0 per day for days 1 through 60 $250 per day for days 61 through 90 $500 per day for days 91 through 150 (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	50% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	15-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	50% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	20% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance
Other Part B drugs	20% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	$1,000 per stay $0 per day for days 1 through 60 $250 per day for days 61 through 90 $500 per day for days 91 through 150 (Out-of-Network)
Inpatient hospital - psychiatric	$150 per day for days 1 through 4 $0 per day for days 5 through 90
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit	$20 copay
Outpatient group therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$20 copay
Outpatient individual therapy visit	$20 copay
Outpatient individual therapy visit	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$20 copay
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)

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MOOP

$3,450 In-network $10,000 Out-of-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$250 copay per visit
20% coinsurance per visit (Out-of-Network)

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Package #1

Deductible	$25.00
Monthly Premium	$32.80

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Preventive Care

50% coinsurance (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	Covered under office visit
Dental x-ray(s)	Covered under office visit
Fluoride treatment	Not covered
Office visit	$25.00
Oral exam	Covered under office visit

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Rehabilitation Services

Occupational therapy visit	$10 copay
Occupational therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$10-20 copay
Physical therapy and speech and language therapy visit	50% coinsurance (Out-of-Network)

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Skilled Nursing Facility

$0 per day for days 1 through 20 $125 per day for days 21 through 100
50% per stay (Out-of-Network)

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Transportation

$0 copay

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Vision

Contact lenses	$0 copay
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$0 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for KelseyCare Advantage Silver Freedom (HMO-POS) H0332

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in KelseyCare Advantage Silver Freedom (HMO-POS) Plans Performance

Health Plan Customer Service Rating for KelseyCare Advantage Silver Freedom (HMO-POS)

KelseyCare Advantage Silver Freedom (HMO-POS) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for KelseyCare Advantage Silver Freedom (HMO-POS)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.