UHC Dual Complete SC-S001 (PPO D-SNP) H0271-016-000 2024 Plan Details and Costs (2024)

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$0.00
Out-of-pocket maximum	$8,850.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$8,000.00
Primary care doctor visit	Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 20%
Specialty doctor visit	Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 20%
Inpatient hospital care	In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services
Urgent care	Urgent Care: Copayment for Urgent Care $0.00 Benefit Details - General 4b Note - NOTE ON COST SHARING RANGE FOR URGENTLY NEEDED SERVICES: $0 copayment applies to Medicare covered telehealth. The higher cost share applies to all other Medicare covered services. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00
Emergency room visit	Emergency Care: Copayment for Emergency Care $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00 Copayment for Worldwide Emergency Transportation $0.00
Ambulance transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 Benefit Details - General 10a Note - NOTE ON AUTHORIZATION: Authorization is required for Non-emergency Medicare-covered ambulance ground and air transportation. Emergency Ambulance does not require authorization. Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

UHC Dual Complete SC-S001 (PPO D-SNP) covers a range of additional benefits. Learn more about UHC Dual Complete SC-S001 (PPO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 20%
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 20%
Durable medical equipment (DME)	Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 20%
Diagnostic tests, lab and radiology services, and X-rays	In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health care	Out-of-Network: Home Health Services: Copayment for Medicare Covered Home Health $0.00
Mental health inpatient care	Out-of-Network: Copayment for Psychiatric Hospital Services per Stay $0.00
Mental health outpatient care	Out-of-Network: Outpatient Mental Health Services: Copayment for Medicare Covered Individual Sessions $0.00 Copayment for Medicare Covered Group Sessions $0.00
Outpatient services/surgery	In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse care	Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual or Group Sessions $0.00
Over-the-counter items	In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $236.00 every month Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry services	Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 20% Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $0.00
Skilled Nursing Facility (SNF) care	Out-of-Network: Copayment for Skilled Nursing Facility Services per Stay $0.00

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Dental care	In-Network: Preventive Dental: Copayment for Oral Exams $0.00 Maximum 2 visits every year Copayment for Prophylaxis (Cleaning) $0.00 Maximum 3 visits every year Copayment for Fluoride Treatment $0.00 Maximum 2 visits every year Copayment for Dental X-Rays $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $4000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Copayment for Non-routine Services $0.00 Copayment for Diagnostic Services $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Restorative Services $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Endodontics $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Periodontics $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Extractions $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $4000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Prior Authorization Required for Comprehensive Dental

Coverage

Details

Dental care

In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00

Maximum 2 visits every year

Copayment for Prophylaxis (Cleaning) $0.00

Maximum 3 visits every year

Copayment for Fluoride Treatment $0.00

Maximum 2 visits every year

Copayment for Dental X-Rays $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $4000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Non-routine Services $0.00
Copayment for Diagnostic Services $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Restorative Services $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Endodontics $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Extractions $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $4000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Vision benefits	Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 20% Coinsurance for Medicare Covered Eyewear 20% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 20% Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing benefits	Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 20% Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 20% Copayment for Non-Medicare Covered Hearing Aids $0.00

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Preventive services and health/wellness education programs	In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vagin*l cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots: COVID-19 shots Flu shots Hepatitis B shots Pneumococcal shots Tobacco use cessation Yearly "Wellness" visit

Coverage

Details

Preventive services and health/wellness education programs

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vagin*l cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

COVID-19 shots

Flu shots

Hepatitis B shots

Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

When reviewing South Carolina Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of South Carolina that offer similar benefits at similar or lower prices than the plan above. Call 1-855-580-1854 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Summary of benefits
Evidence of coverage
Star ratings

South Carolina Counties Served

Abbeville Aiken Allendale Anderson Bamberg Barnwell Beaufort Berkeley Calhoun Charleston Cherokee Chester Chesterfield Clarendon Colleton Darlington Dillon Dorchester Edgefield Fairfield Florence Georgetown Greenville Greenwood Hampton Horry Jasper Kershaw Lancaster Laurens Lee Lexington Marion Marlboro Mccormick Newberry Oconee Orangeburg Pickens Richland Saluda Spartanburg Sumter Union Williamsburg York

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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