Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5253-040-000
Plan Organization UnitedHealthcare
Plan Type Local HMO *
Plan Name AARP Medicare Advantage Patriot (HMO-POS)
Drugs Covered No
Doctors Choice Plan Doctors Only (some exceptions)
Overall Star Rating 4
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $90.50
Monthly Part C Premium $0.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $3600.00

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 Yes Out-of-Network Yes No 0-50% coinsurance
Endodontics Yes Out-of-Network Yes No 0-50% coinsurance
Extractions Yes Out-of-Network Yes No 0-50% coinsurance
Non-routine services Yes Out-of-Network Yes No 0-50% coinsurance
Periodontics Yes Out-of-Network Yes No 0-50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No 0-50% coinsurance
Restorative services Yes Out-of-Network Yes No 0-50% coinsurance
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - In-Network Yes No $0-110 copay
Diagnostic tests and procedures - In-Network Yes No $20 copay
Lab services - In-Network Yes No $0 copay
Outpatient x-rays - In-Network Yes No $15 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - In-Network - - $0 copay
Specialist - In-Network Yes No $25 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $25-40 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - In-Network Yes No $25 copay
Routine foot care Yes In-Network Yes No $25 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - $250 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing aids Yes In-Network Yes No $375-2,075 copay
Hearing exam - In-Network Yes No $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No Not Applicable
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $3,600 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - In-Network Yes - $0 copay per item
Durable medical equipment (e.g., wheelchairs, oxygen) - In-Network Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - In-Network Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - In-Network Yes - 20% coinsurance
Other Part B drugs - In-Network Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No Not Applicable
Outpatient group therapy visit - In-Network Yes No $15 copay
Outpatient group therapy visit with a psychiatrist - In-Network Yes No $15 copay
Outpatient individual therapy visit - In-Network Yes No $25 copay
Outpatient individual therapy visit with a psychiatrist - In-Network Yes No $25 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
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
- In-Network Yes No $0-295 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No $0 copay
Dental x-ray(s) Yes Out-of-Network No No $0 copay
Fluoride treatment Yes Out-of-Network No No $0 copay
Oral exam Yes Out-of-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - In-Network Yes No $25 copay
Physical therapy and speech and language therapy visit - In-Network Yes No $25 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No Not Applicable
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes In-Network No No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes In-Network No No $0 copay
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes In-Network No No $0 copay
Other No - - - Not covered
Routine eye exam Yes In-Network Yes No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Alamance County, North Carolina, Alexander County, North Carolina, Avery County, North Carolina, Buncombe County, North Carolina, Burke County, North Carolina, Cabarrus County, North Carolina, Caldwell County, North Carolina, Caswell County, North Carolina, Catawba County, North Carolina, Chatham County, North Carolina, Cherokee County, North Carolina, Clay County, North Carolina, Cleveland County, North Carolina, Cumberland County, North Carolina, Davidson County, North Carolina, Davie County, North Carolina, Durham County, North Carolina, Forsyth County, North Carolina, Franklin County, North Carolina, Gaston County, North Carolina, Graham County, North Carolina, Granville County, North Carolina, Guilford County, North Carolina, Harnett County, North Carolina, Haywood County, North Carolina, Henderson County, North Carolina, Iredell County, North Carolina, Jackson County, North Carolina, Johnston County, North Carolina, Lee County, North Carolina, Lincoln County, North Carolina, Macon County, North Carolina, Madison County, North Carolina, Mcdowell County, North Carolina, Mecklenburg County, North Carolina, Mitchell County, North Carolina, Nash County, North Carolina, Orange County, North Carolina, Person County, North Carolina, Polk County, North Carolina, Randolph County, North Carolina, Richmond County, North Carolina, Rockingham County, North Carolina, Rowan County, North Carolina, Rutherford County, North Carolina, Sampson County, North Carolina, Stokes County, North Carolina, Surry County, North Carolina, Swain County, North Carolina, Transylvania County, North Carolina, Union County, North Carolina, Vance County, North Carolina, Wake County, North Carolina, Wayne County, North Carolina, Wilkes County, North Carolina, Wilson County, North Carolina, Yadkin County, North Carolina, Yancey County, North Carolina

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