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KelseyCare Advantage Signature (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for KelseyCare Advantage Signature (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on KelseyCare Advantage Signature (HMO) in 2025, please refer to our full plan details page.
KelseyCare Advantage Signature (HMO) is a HMO plan offered by UnitedHealth Group, Inc. available for enrollment in 2025 to people living in Houston metro area. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that KelseyCare Advantage Signature (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about KelseyCare Advantage Signature (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 Signature (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.
This plan has a $100.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
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
The KelseyCare Advantage Signature (HMO) plan has a $100 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, the copay is $5 at a preferred pharmacy and $15 at a standard pharmacy. Specialty tier drugs have no copay.
Additional Benefits
The KelseyCare Advantage Signature (HMO) plan offers a range of benefits beyond standard Medicare coverage. Inpatient hospital stays have a $325 copay for days 1-5, with no copay for days 6-90, while outpatient services, like hospital and ASC services, have a $300 copay. The plan also covers services like primary care, hearing, and vision, with copays ranging from $15 to $20 for many services, and offers coverage for dental, home infusion, and durable medical equipment.
Inpatient Hospital See details
Inpatient Hospital coverage includes both acute and psychiatric care, each with a $325 copay for days 1-5, and no copay for days 6-90. Additional days and non-Medicare covered stays for inpatient hospital are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services. Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center (ASC) Services have a $300 copay, and Individual and Group Sessions for Outpatient Substance Abuse have a copay between $20 and $20. Outpatient Blood Services has an enhanced benefit with a waived three-pint deductible.
Partial Hospitalization See details
KelseyCare Advantage Signature (HMO) covers partial hospitalization with a $25 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $275 copay for both ground and air ambulance services. Transportation Services to a plan-approved health-related location are covered for up to 10 one-way trips per year via bus/subway or other modes of transportation, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, with a $125 copay and no coinsurance, and the copay is waived if admitted to the hospital within 3 days. Urgently Needed Services are also covered, with a $25 copay and no coinsurance. Worldwide Emergency Services are covered, with a 20% coinsurance for Worldwide Emergency Coverage and Worldwide Emergency Transportation, while Worldwide Urgent Coverage is not covered.
Primary Care See details
The KelseyCare Advantage Signature (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $20 copay, and physician specialist services with a $20 copay. Mental health specialty services and psychiatric services individual and group sessions have a $20 copay. Physical therapy and speech-language pathology services have a $15 copay, and additional telehealth benefits have a copay between $0 and $15. Opioid treatment program services are covered with a coinsurance and copay, with more information available. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, health education, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit. Additional services like in-home safety assessments, personal emergency response systems, and others are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $20 copay, and routine hearing exams and fitting/evaluation for hearing aids with an annual limit of one visit each. Prescription hearing aids are covered up to $750 per ear every three years, while OTC hearing aids are also covered.
Vision Services See details
Vision Services include eye exams with a $20 copay, and eyewear, including contact lenses and eyeglasses. Eyeglasses (lenses and frames) and contact lenses are limited to one pair per year, and eyewear has a combined maximum plan benefit coverage amount of $125 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include a $20 copay for Medicare dental services. Other dental services include oral exams, dental x-rays, and prophylaxis (cleaning), which are covered, but fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. Additionally, there is a $2,500 maximum plan benefit per year. Orthodontic services are covered under Diagnostic and Preventive Dental.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by KelseyCare Advantage Signature (HMO), including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by the KelseyCare Advantage Signature (HMO) plan, but require prior authorization. The plan has a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 15-20% coinsurance and no copay, Prosthetic Devices with a 20% coinsurance and no copay, and Medical Supplies with a 20% coinsurance and no copay. Diabetic Equipment is covered, but Diabetic Supplies are not covered, and Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the KelseyCare Advantage Signature (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $25, while Diagnostic Radiological Services have a copay between $25 and $200, and Therapeutic Radiological Services have a copay of $50. Lab Services and Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by KelseyCare Advantage Signature (HMO) with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, SET for PAD, and Additional Cardiac Rehabilitation Services are not covered. A copay applies to some services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by KelseyCare Advantage Signature (HMO). There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for over-the-counter items, with the plan offering nicotine replacement therapy and Naloxone as a Part C OTC benefit. Acupuncture, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. The plan also covers Other 2, with a copay of $300.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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