Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5322-030-000
Plan Organization UnitedHealthcare
Plan Type Local HMO
Plan Name UnitedHealthcare Dual Complete (HMO-POS D-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors Only (some exceptions)
Benefit Type Defined Standard Benefit
Special Needs Plan Yes
Special Needs Plan Type Dual-Eligible
Overall Star Rating 3.5
Plan Cost Sharing
Premium $29.80
Total Premium (Includes Part B) $165.30
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $29.80
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $29.80
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.40
Monthly Part D Premium 50% Assistance $14.90
Monthly Part D Premium 25% Assistance $22.30
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

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 In-Network Yes No $0 copay
Endodontics Yes In-Network Yes No $0 copay
Extractions Yes In-Network Yes No $0 copay
Non-routine services Yes In-Network Yes No $0 copay
Periodontics Yes In-Network Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes In-Network Yes No $0 copay
Restorative services Yes In-Network Yes No $0 copay
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% or 0-20% coinsurance
Diagnostic tests and procedures - In-Network Yes No 0% or 20% coinsurance
Lab services - In-Network Yes No $0 copay
Outpatient x-rays - In-Network Yes No 0% or 20% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - In-Network - - 0% or 20% coinsurance per visit
Specialist - In-Network Yes No 0% or 20% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $0 or $90 copay per visit (always covered)
Urgent care - - - - $0 or $65 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 0% or 20% coinsurance
Routine foot care Yes In-Network Yes No $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 20% coinsurance
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 or $198 In and Out-of-network
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing aids Yes In-Network Yes No $0 copay
Hearing exam - In-Network Yes No 0% or 20% coinsurance
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
- - - - $7,550 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 - 0% or 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - In-Network Yes - 0% or 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - In-Network Yes - 0% or 20% coinsurance
Other Part B drugs - In-Network Yes - 0% or 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No 40% per stay
Outpatient group therapy visit - Out-of-Network Yes No 40% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 40% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 40% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 40% coinsurance
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% or 0-20% coinsurance 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 In-Network No No $0 copay
Dental x-ray(s) Yes In-Network No No $0 copay
Fluoride treatment Yes In-Network No No $0 copay
Oral exam Yes In-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - In-Network Yes No 0% or 20% coinsurance
Physical therapy and speech and language therapy visit - In-Network Yes No 0% or 20% coinsurance
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
Appling County, Georgia, Atkinson County, Georgia, Barrow County, Georgia, Bartow County, Georgia, Ben Hill County, Georgia, Berrien County, Georgia, Brooks County, Georgia, Bryan County, Georgia, Bulloch County, Georgia, Burke County, Georgia, Butts County, Georgia, Catoosa County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Chattooga County, Georgia, Clarke County, Georgia, Columbia County, Georgia, Crisp County, Georgia, Dade County, Georgia, Decatur County, Georgia, Dooly County, Georgia, Douglas County, Georgia, Echols County, Georgia, Effingham County, Georgia, Elbert County, Georgia, Fayette County, Georgia, Floyd County, Georgia, Grady County, Georgia, Greene County, Georgia, Hall County, Georgia, Hancock County, Georgia, Haralson County, Georgia, Harris County, Georgia, Hart County, Georgia, Henry County, Georgia, Houston County, Georgia, Jackson County, Georgia, Jeff Davis County, Georgia, Jefferson County, Georgia, Johnson County, Georgia, Macon County, Georgia, Madison County, Georgia, Mcduffie County, Georgia, Meriwether County, Georgia, Mitchell County, Georgia, Montgomery County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Paulding County, Georgia, Peach County, Georgia, Richmond County, Georgia, Rockdale County, Georgia, Spalding County, Georgia, Talbot County, Georgia, Taliaferro County, Georgia, Tattnall County, Georgia, Thomas County, Georgia, Tift County, Georgia, Toombs County, Georgia, Treutlen County, Georgia, Turner County, Georgia, Upson County, Georgia, Walker County, Georgia, Walton County, Georgia, Warren County, Georgia, Washington County, Georgia, Wilcox County, Georgia

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