UCare Standard (HMO-POS)

UCare Standard (HMO-POS) H2459-024 Plan Details
4.5 out of 5 stars

UCare Standard (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UCare Minnesota.
Plan ID: H2459-024.

$0.00
Monthly Premium

UCare Standard (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UCare Minnesota.
Plan ID: H2459-024.

UCare Standard (HMO-POS) H2459-024 Plan Details
4.5 out of 5 stars

UCare Standard (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UCare Minnesota.
Plan ID: H2459-024.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $480
Out of Pocket Max In-Network: $-1
Out-of-Network: 7500
Initial Coverage Limit $0
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
POS (Out-of-Network):

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
POS (Out-of-Network):

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $40.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$500.00 per day for days 1 to 3
$0.00 per day for days 4 to the end of your stay
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 20%
Urgent Care
Copayment for Urgent Care $40.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $90.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $375.00

Air Ambulance:
Copayment for Air Ambulance Services $375.00
POS (Out-of-Network):

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $375.00
Copayment for Medicare Covered Ambulance Services - Air $375.00

Health Care Services and Medical Supplies

UCare Standard (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
POS (Out-of-Network):
Coinsurance for Medicare Covered Diabetic Supplies and Services 20%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 10%
Copayment for Medicare-covered Lab Services $0.00
Maximum out of Pocket $100.00 (Please see Evidence of Coverage)

Outpatient Diag/Therapeutic Rad Services:
Coinsurance for Medicare-covered Diagnostic Radiological Services 10%
Coinsurance for Medicare-covered Therapeutic Radiological Services 10%
Coinsurance for Medicare-covered X-Ray Services 10%
Maximum out of Pocket $100.00 (Please see Evidence of Coverage)
POS (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 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Coinsurance for Medicare Covered Outpatient X-Ray Services 20%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
POS (Out-of-Network):
Coinsurance for Medicare Covered Home Health 20%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$500.00 per day for days 1 to 3
$0.00 per day for days 4 to 90
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 20%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
POS (Out-of-Network):
Copayment for Medicare Covered Individual Sessions $40.00
Copayment for Medicare Covered Group Sessions $40.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $300.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $300.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $275.00
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual or Group Sessions 20%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $75.00 every six months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $40.00
POS (Out-of-Network):
Copayment for Medicare Covered Podiatry Services $40.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 20%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 1 visit every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 1 visit every year
Copayment for Fluoride Treatment $0.00
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit every year

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Periodontics $0.00
  • Maximum 1 visit every year
POS (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

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $40.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglass Lenses $0.00
Copayment for Eyeglass Frames $0.00
Copayment for Upgrades $0.00
Maximum Plan Benefit of $100.00 every year for all Non-Medicare covered eyewear
POS (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:
Copayment for Non-Medicare Covered Eyewear $0.00
Maximum Plan Benefit of $100.00 every year

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $40.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 3 visits every year

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
Coverage is limited to TruHearing's Advanced and Premium hearing aids. Minimum copay applies to the Advanced hearing aid and the maximum copay applies to the Premium hearing aid.
POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 20%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
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 & vaginal 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
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    POS (Out-of-Network):

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

    Prescription Drug Costs and Coverage

    The UCare Standard (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $480 (excludes Tier 1) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $480 (excludes Tier 1)
    Preferred Generic
    • Preferred retail $3.00
    • Standard retail $12.00
    • Preferred mail order $3.00
    • Standard mail order $12.00
    Annual Drug Deductible $480 (excludes Tier 1)
    Preferred Generic
    • Preferred retail $6.00
    • Standard retail $24.00
    • Preferred mail order $6.00
    • Standard mail order $24.00
    Annual Drug Deductible $480 (excludes Tier 1)
    Preferred Generic
    • Preferred retail $9.00
    • Standard retail $36.00
    • Preferred mail order $6.00
    • Standard mail order $36.00