UHC Dual Complete AR-V001 (PPO D-SNP)
UHC Dual Complete AR-V001 (PPO D-SNP) H0271-024 Plan Details
UHC Dual Complete AR-V001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0271-024
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$0.00
Monthly Premium
UHC Dual Complete AR-V001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0271-024
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
UHC Dual Complete AR-V001 (PPO D-SNP) H0271-024 Plan Details
UHC Dual Complete AR-V001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0271-024
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
Arkansas Counties Served
Hempstead
Sevier
Pike
Union
Little River
Nevada
Clark
Miller
Columbia
Scott
Pulaski
Crawford
Van Buren
Mccurtain
Hot Spring
Faulkner
Poinsett
Prairie
Perry
Washington
Lawrence
Cleburne
Randolph
Craighead
Ashley
Baxter
Dallas
Madison
Ouachita
Grant
Johnson
Searcy
Greene
Fulton
Izard
Pope
Newton
Logan
Saline
Montgomery
Boone
Independence
Sharp
Carroll
Jefferson
Conway
Franklin
Sebastian
Arkansas
Garland
Benton
Saint Francis
Mississippi
Lonoke
Lee
Phillips
Clay
Stone
Cleveland
Jackson
Woodruff
Lafayette
Calhoun
Le Flore
Chicot
Bradley
Crittenden
Desha
Howard
Cross
White
Drew
Yell
Monroe
Polk
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5400 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $20.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $55.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $0.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: $0.00 per day for days 1 to 10 $0.00 per day for days 11 to 999 |
| Urgent Care | Copayment for Urgent Care $0.00 Benefit Details - General 4b Note - NOTE ON COST SHARING RANGE FOR URGENTLY NEEDED SERVICES: $0 copayment applies to Medicare covered telehealth. The higher cost share applies to all other Medicare covered services. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00 |
| Emergency Room Visit | Copayment for Emergency Care $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00 Copayment for Worldwide Emergency Transportation $0.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 Benefit Details - General 10a Note - NOTE ON AUTHORIZATION: Authorization is required for Non-emergency Medicare-covered ambulance ground and air transportation. Emergency Ambulance does not require authorization. Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $290.00 Copayment for Medicare Covered Ambulance Services - Air $290.00 |
Health Care Services and Medical Supplies
UHC Dual Complete AR-V001 (PPO D-SNP) 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 $0.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Chiropractic Services $55.00 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 50% |
| Durable Medical Eqipment (DME) | In-Network: Copayment for Medicare-covered Durable Medical Equipment $0.00 Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 50% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $40.00 Copayment for Medicare Covered Lab Services $0.00 Copayment for Medicare Covered Diagnostic Radiological Services $325.00 Copayment for Medicare Covered Therapeutic Radiological Services $150.00 Copayment for Medicare Covered Outpatient X-Ray Services $20.00 |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Home Health 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $0.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: $0.00 per day for days 1 to 10 $0.00 per day for days 11 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual Sessions $30.00 to $40.00 Copayment for Medicare Covered Group Sessions $30.00 to $40.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $0.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $495.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $495.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $30.00 to $40.00 |
| 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 $58.00 every month Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $58.00 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 Copayment for Routine Foot Care $15.00
Prior authorization required Out-of-Network: Copayment for Medicare Covered Podiatry Services $55.00 Copayment for Non-Medicare Covered Podiatry Services $55.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $0.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: $0.00 per day for days 1 to 43 $0.00 per day for days 44 to 100 |
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
Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Copayment for Non-routine Services $0.00 Copayment for Diagnostic Services $0.00
Prior Authorization Required for Comprehensive Dental Prior authorization required Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 40% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 50% |
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 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Copayment for Eyeglasses (lenses and frames) $0.00
Prior authorization required Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $55.00 Copayment for Medicare Covered Eyewear $55.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $55.00 Copayment for Non-Medicare Covered Eyewear $0.00 |
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 $0.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Maximum Plan Allowance of $1100.00 every year both ears combined for in and out of network services combined Prior Authorization Required for Hearing Aids Prior authorization required Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $55.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $55.00 Copayment for Non-Medicare Covered Hearing Aids $0.00 |
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:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 40% |
Prescription Drug Costs and Coverage
The UHC Dual Complete AR-V001 (PPO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $0 |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $0 |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $0 |
| Preferred Generic |
|
| Generic |
|
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