UHC Dual Advantage MS-V2 (PPO D-SNP)

Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $0 or $20

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0 to $40
Prior Authorization Required for Doctor Specialty Visit
Note: The lower cost share applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services.

Out-of-Network:

Acute Hospital Services:
$455 per day for days 1 to 6
$0 per day for days 7 to 999
Note: All inpatient substance abuse and mental health care (including both care received in an acute care facility and a Medicare-certified psychiatric facility) are included in category 1b.

Urgent Care:
Copayment for Urgent Care $0 to $50

Note: The lower cost share applies to Medicare covered telehealth. The higher cost share applies to all other Medicare covered services.

Emergency Care:
Copayment for Emergency Care $0 or $130
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $0 or $350

Air Ambulance:
Copayment for Air Ambulance Services $0 or $350
Prior Authorization Required for Air Ambulance

In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0 or $15
Prior Authorization Required for Chiropractic Services

Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $0 or $15

In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 0% or 20%

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 0% or 50%

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 or $50
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $320
Coinsurance for Medicare-covered Therapeutic Radiological Services 0% or 20%
Copayment for Medicare-covered X-Ray Services $0 or $30

Out-of-Network:

Home Health Services:
Copayment for Medicare Covered Home Health $0

Out-of-Network:

Psychiatric Hospital Services:
$455 per day for days 1 to 5
$0 per day for days 6 to 90
Benefit Details - General Note - NOTE ON INPATIENT SUBSTANCE ABUSE: All inpatient substance abuse and mental health care (including both care received in an acute care facility and a Medicare-certified psychiatric facility) are included in category 1b.

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0 to $25
Copayment for Medicare-covered Group Sessions $0 or $15

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $455
Prior Authorization Required for Outpatient Hospital Services
Note: The lower cost share applies to outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures.Note: Benefit category includes both the facility and professional component.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $0 or $455
Prior Authorization Required for Outpatient Observation Services
Benefit Details - General 9a2 Note - NOTE ON OBSERVATION SERVICES: Benefit category includes both the facility and professional component.

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $405
Prior Authorization Required for Ambulatory Surgical Center Services
Benefit Details - General 9b Note - NOTE ON ASC SERVICES: Benefit category 9b includes both the facility and professional component.Benefit Details - General 9b Note - NOTE ON COST SHARING RANGE FOR ASC Services: The lower cost share applies to outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures.

Out-of-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $0 or $40
Copayment for Medicare Covered Group Sessions $0 or $30
Note: The lower cost share applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services.
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0 to $25
Copayment for Medicare-covered Group Sessions $0 or $15
Prior Authorization Required for Outpatient Substance Abuse Services
Note: The lower cost share applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services.

Out-of-Network:

Over-The-Counter (OTC) Items Services:
Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 0% or 90%

In-Network
$40 copay 6 visits per year
Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $0 or $60

In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$221 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

$1,000 allowance per year toward covered preventive and comprehensive services.
$0 copay for covered preventive services such as oral exams, routine cleanings, X-rays and fluoride
50% of the cost for all covered comprehensive services, such as fillings, crowns, root canals, extractions, bridges and dentures
You will have access to one of Medicare Advantage's largest dental networks, or you can choose any dentist.

In-Network

Routine Eye Exam: $0 copay 1 exam per year
Routine Eyewear: $0 copay for standard prescription lenses
$200 allowance every 2 years for 1 pair of lenses/frames or contacts.

Out-of-Network: Routine Eye Exam:$60 copayRoutine Eyewear: 90% coinsurance up to allowance

In-Network

Routine Hearing Exam: $0 copay 1 exam per year
Routine Hearing Aids: $700 allowance up to 2 hearing aids per year
Choose from a broad selection of brand-name prescription hearing aids through UnitedHealthcare Hearing. Access to one of the largest national networks with thousands of hearing professionals.
Out-of-Network Routine Hearing Exam:$60 copay
Routine Hearing Aids:90% coinsurance up to allowance

Out-of-Network:

Medicare-covered Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 40%