Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H2228-013-000
Plan Organization UnitedHealthcare
Plan Type Local PPO
Plan Name UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Defined Standard Benefit
Special Needs Plan Yes
Special Needs Plan Type Institutional
Overall Star Rating 4 Stars
Plan Cost Sharing
Premium $25.30
Total Premium (Includes Part B) $160.80
Monthly Part D Basic Premium $25.30
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $25.30
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $6.30
Monthly Part D Premium 50% Assistance $12.60
Monthly Part D Premium 25% Assistance $19.00
Part D Drug Deductible $435.00
Annual Drug Deductible $435.00
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Non-routine services No - - - Not covered
Endodontics Yes Out-of-Network Yes No $0 copay
Extractions Yes Out-of-Network Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No $0 copay
Restorative services Yes In-Network Yes No $0
Periodontics Yes Out-of-Network Yes No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic tests and procedures - Out-of-Network Yes No 30%
Lab services - In-Network Yes No $0
Outpatient x-rays - In-Network Yes No $0
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No 30%
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - Out-of-Network Yes No 30% per visit
Primary - Out-of-Network - - 30% per visit
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - In-Network Yes No 0-20%
Routine foot care Yes In-Network Yes No $0
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 20%
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $1,300 per stay
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - In-Network Yes - 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 30% per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 30% per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - In-Network Yes - 20%
Other Part B drugs - In-Network Yes - 20%
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 30%
Outpatient individual therapy visit with a psychiatrist - In-Network Yes No 0-20%
Outpatient individual therapy visit - In-Network Yes No 0-20%
Inpatient hospital - psychiatric - Out-of-Network Yes No $1,300 per stay
Outpatient group therapy visit - Out-of-Network Yes No 30%
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 30% per visit
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Oral exam Yes Out-of-Network No No $0 copay
Cleaning Yes Out-of-Network No No $0 copay
Dental x-ray(s) Yes Out-of-Network No No $0 copay
Fluoride treatment No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 30%
Occupational therapy visit - In-Network Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes In-Network No No $0 copay
Routine eye exam Yes Out-of-Network Yes No 30%
Upgrades - - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes In-Network No No $0 copay
Eyeglass frames No - - - Not covered
Other No - - - Not covered
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $65 per visit (always covered)
Emergency - - - - $90 per visit (always covered)
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing exam - Out-of-Network Yes No 30%
Hearing aids Yes Out-of-Network Yes No $0 copay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $5,100 In and Out-of-network $1,800 In-network
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network No No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $0 per day for days 1 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes In-Network No No $0 copay
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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