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

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 20%

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required

Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 20%

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
Prior authorization required

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

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

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
Prior authorization required

Out-of-Network:

Ambulance Services:
Coinsurance for Medicare Covered Ambulance Services - Ground 20%
Coinsurance for Medicare Covered Ambulance Services - Air 20%

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
Prior authorization required

Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20%
Copayment for Medicare Covered Lab Services $0.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 0% to 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Coinsurance for Medicare Covered Outpatient X-Ray Services 20%

In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required

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
Prior authorization required

Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 0% to 20%

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

Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $236.00

In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00

• Maximum 6 visits every year

Prior Authorization Required for Podiatry Services
Prior authorization required

In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$0.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

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
Prior authorization required

Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 20%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $0.00

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00

• Maximum 1 Routine Eye Exam every year

Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglasses (lenses and frames) $0.00

• Maximum 1 Pair every year

Maximum Plan Benefit of $400.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior authorization required

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

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00

• Maximum 1 visit every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00

• Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $2500.00 every year both ears combined for in and out of network services combined
Prior Authorization Required for Hearing Aids
Prior authorization required

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

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

Tobacco use cessation
Yearly "Wellness" visit

Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00