Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H2459-030-000
Plan Organization UCare
Plan Type Local HMO *
Plan Name UCare Value Plus (HMO-POS)
Drugs Covered No
Doctors Choice Plan Doctors Only (some exceptions)
Overall Star Rating 4.5
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $115.50
Monthly Part C Premium $0.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $5500.00

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 No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics Yes Out-of-Network No No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network No No 20% coinsurance
Diagnostic tests and procedures - Out-of-Network No No 20% coinsurance
Lab services - Out-of-Network No No $0 copay
Outpatient x-rays - Out-of-Network No No 20% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $0 copay
Specialist - Out-of-Network No No $45 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 - - - - $50 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No $45 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $200 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 Yes In-Network No No $0 copay
Hearing aids Yes In-Network No No $699-999 copay
Hearing exam - Out-of-Network No No 20% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 20% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $5,500 In-network$7,500 Out-of-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network No - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - In-Network No - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network No - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network No - 20% coinsurance
Other Part B drugs - Out-of-Network No - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network No No 20% per stay
Outpatient group therapy visit - Out-of-Network No No $40 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network No No $40 copay
Outpatient individual therapy visit - Out-of-Network No No $40 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network No No $40 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
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 No No 20% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-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 No 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 - Out-of-Network No No $40 copay
Physical therapy and speech and language therapy visit - Out-of-Network No No $40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 20% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes Out-of-Network No No $0 copay
Eyeglass frames Yes Out-of-Network No No $0 copay
Eyeglass lenses Yes Out-of-Network No No $0 copay
Eyeglasses (frames and lenses) No - - - Not covered
Other No - - - Not covered
Routine eye exam Yes In-Network No No $0 copay
Upgrades Yes Out-of-Network No No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $25.00
Preventive dental Monthly Premium $25.00
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
Aitkin County, Minnesota, Anoka County, Minnesota, Becker County, Minnesota, Beltrami County, Minnesota, Benton County, Minnesota, Big Stone County, Minnesota, Blue Earth County, Minnesota, Brown County, Minnesota, Carlton County, Minnesota, Carver County, Minnesota, Cass County, Minnesota, Chippewa County, Minnesota, Chisago County, Minnesota, Clay County, Minnesota, Clearwater County, Minnesota, Cook County, Minnesota, Cottonwood County, Minnesota, Crow Wing County, Minnesota, Dakota County, Minnesota, Dodge County, Minnesota, Douglas County, Minnesota, Faribault County, Minnesota, Fillmore County, Minnesota, Freeborn County, Minnesota, Goodhue County, Minnesota, Grant County, Minnesota, Hennepin County, Minnesota, Houston County, Minnesota, Hubbard County, Minnesota, Isanti County, Minnesota, Itasca County, Minnesota, Jackson County, Minnesota, Kanabec County, Minnesota, Kandiyohi County, Minnesota, Kittson County, Minnesota, Koochiching County, Minnesota, Lac Qui Parle County, Minnesota, Lake County, Minnesota, Lake Of The Woods County, Minnesota, Le Sueur County, Minnesota, Lincoln County, Minnesota, Lyon County, Minnesota, Mahnomen County, Minnesota, Marshall County, Minnesota, Martin County, Minnesota, Mcleod County, Minnesota, Meeker County, Minnesota, Mille Lacs County, Minnesota, Morrison County, Minnesota, Mower County, Minnesota, Murray County, Minnesota, Nicollet County, Minnesota, Nobles County, Minnesota, Norman County, Minnesota, Olmsted County, Minnesota, Otter Tail County, Minnesota, Pennington County, Minnesota, Pine County, Minnesota, Pipestone County, Minnesota, Polk County, Minnesota, Pope County, Minnesota, Ramsey County, Minnesota, Red Lake County, Minnesota, Redwood County, Minnesota, Renville County, Minnesota, Rice County, Minnesota, Rock County, Minnesota, Roseau County, Minnesota, Saint Louis County, Minnesota, Scott County, Minnesota, Sherburne County, Minnesota, Sibley County, Minnesota, Stearns County, Minnesota, Steele County, Minnesota, Stevens County, Minnesota, Swift County, Minnesota, Todd County, Minnesota, Traverse County, Minnesota, Wabasha County, Minnesota, Wadena County, Minnesota, Waseca County, Minnesota, Washington County, Minnesota, Watonwan County, Minnesota, Wilkin County, Minnesota, Winona County, Minnesota, Wright County, Minnesota, Yellow Medicine County, Minnesota

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