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KelseyCare Advantage Core (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for KelseyCare Advantage Core (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on KelseyCare Advantage Core (HMO) in 2026, please refer to our full plan details page.
KelseyCare Advantage Core (HMO) is a HMO plan offered by UnitedHealth Group, Inc. available for enrollment in 2025 to people living in Houston metro and nearby outlying areas. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that KelseyCare Advantage Core (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about KelseyCare Advantage Core (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For KelseyCare Advantage Core (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
Prescription drugs are not covered by KelseyCare Advantage Core (HMO).
Additional Benefits
The KelseyCare Advantage Core (HMO) plan offers comprehensive healthcare coverage with no copay for primary care visits and a $20 copay for specialists. For inpatient hospital stays, members pay a $325 daily copay for the first five days and no copay for days six through 90, with no coinsurance required. Emergency room visits carry a $125 copay, while urgent care visits require a $25 copay and outpatient hospital services have a $300 copay. Additional perks include partially covered dental services with no copay up to a $1,500 annual limit, alongside routine vision and hearing exams for a $20 copay. Members also enjoy unlimited round-trip transportation to plan-approved health locations with no copay, as well as a $25 quarterly allowance for over-the-counter items with no copay. Home health services and preventive care are also fully covered with no copay or coinsurance.
Inpatient Hospital See details
KelseyCare Advantage Core (HMO) partially covers inpatient hospital services with no coinsurance and a copay of $325 per day for days 1 through 5, followed by no copay for days 6 through 90. Prior authorization is required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
KelseyCare Advantage Core (HMO) covers outpatient services with no coinsurance, including a $300 copay per stay for outpatient hospital and observation services and a $200 copay (prior authorization required) for ambulatory surgical center services. Outpatient substance abuse sessions incur a $20 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by the KelseyCare Advantage Core (HMO) plan with a $140.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by KelseyCare Advantage Core (HMO), with ground and air ambulance services requiring a $275 copay and no coinsurance. Transportation services are partially covered, offering unlimited round trips with no copay and no coinsurance to plan-approved health-related locations, while transportation to any health-related location is not covered.
Emergency Services See details
KelseyCare Advantage Core (HMO) covers emergency services with a $125 copay and no coinsurance, which is waived if admitted to the hospital within three days, and urgent care with a $25 copay and no coinsurance. Worldwide emergency and transportation services are partially covered up to a $20,000 limit with no copay and a 20% coinsurance, though worldwide urgent care is not covered.
Primary Care See details
KelseyCare Advantage Core (HMO) offers primary care physician services with no copay and no coinsurance, while specialist visits, occupational therapy, and mental health services require a $20 copay and no coinsurance. Physical and speech therapy cost a $15 copay with no coinsurance, whereas podiatry and routine chiropractic services are not covered. Opioid treatment services are covered with a $0 to $20 copay and 20% coinsurance.
Preventive Services See details
Preventive Services are partially covered by KelseyCare Advantage Core (HMO) with no copay and no coinsurance for all covered services, including annual physical exams, kidney disease education, and diabetes self-management training. Although additional benefits like health education, nutritional counseling, and memory fitness are covered, other services such as in-home safety assessments, medical nutrition therapy, and personal emergency response systems are not covered.
Hearing Services See details
KelseyCare Advantage Core (HMO) covers routine hearing exams and fitting evaluations with a $20 copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to a $750 maximum per ear every three years, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by KelseyCare Advantage Core (HMO), offering one routine eye exam yearly for a $20 copay and no coinsurance, and eyewear with no copay, no coinsurance, and a $125 annual limit. Sub-services not covered include other eye exam services, separate eyeglass lenses, separate eyeglass frames, and upgrades.
Dental Services See details
KelseyCare Advantage Core (HMO) provides partially covered dental services with no copay and no coinsurance, subject to a deductible and a $1,500 annual maximum. Covered services include routine exams, cleanings, x-rays, restorative care, and oral surgery, while fluoride, endodontics, periodontics, implants, prosthodontics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by KelseyCare Advantage Core (HMO) with no copay, subject to prior authorization. Medicare Part B chemotherapy and other infusion drugs require no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
KelseyCare Advantage Core (HMO) covers Dialysis Services with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
KelseyCare Advantage Core (HMO) covers medical equipment with no copay, though prior authorization is required and coinsurance applies to most items. Durable medical equipment requires a 15% to 20% coinsurance, while medical supplies, prosthetics, and diabetic therapeutic shoes carry a 20% coinsurance, though diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by KelseyCare Advantage Core (HMO) with no coinsurance, though prior authorization is required. Covered diagnostic procedures and tests require a copay ranging from no copay to $25, diagnostic radiological services require a minimum $25 copay, and therapeutic radiological services require a minimum $50 copay, while lab services and outpatient X-ray services are not covered.
Home Health Services See details
Home Health Services are covered by KelseyCare Advantage Core (HMO) with no copay and no coinsurance, although prior authorization is required for these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by KelseyCare Advantage Core (HMO) with no coinsurance and prior authorization required. While some services are covered, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
KelseyCare Advantage Core (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization is required and a prior three-day hospital stay is not necessary. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, while additional days beyond the Medicare limit are not covered.
Other Services See details
KelseyCare Advantage Core (HMO) provides partial coverage for other services, which includes over-the-counter (OTC) items with no copay and no coinsurance up to a $25 limit every three months, and supplemental surgeries in an ambulatory surgical center for a $200 copay and no coinsurance. Acupuncture and meal benefits are not covered under this plan.
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