UHC Medicare Advantage NH-001A (PPO)

Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit $30%
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.

In-Network:

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit $0% to $20%
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:
Coinsurance for Acute Hospital Services per Stay 30%
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 $40

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 $115
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

In-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services $20%

Air Ambulance:
Coinsurance for Air Ambulance Services $20%
Prior Authorization Required for Air Ambulance

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 30%
In-Network:

Chiropractic Services:
Coinsurance for Medicare-covered Chiropractic Services 20%
Prior Authorization Required for Chiropractic Services

Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 30%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 30%

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 30%

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

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

Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 40%

Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 30%
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.

Out-of-Network:

Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%

In-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 20%
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:
Coinsurance for Medicare Covered Observation Services 20%
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:
Coinsurance for Ambulatory Surgical Center Services 0% to 20%
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.

In-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare-covered Individual Sessions 0% to 20%
Coinsurance for Medicare-covered Group Sessions 20%
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:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 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.

Out-of-Network:

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

In-Network
$0 copay 4 visits per year
Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 30%

Out-of-Network:

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 30%

$0 copay for covered preventive services such as oral exams, routine cleanings, X-rays and fluoride
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
$250 allowance every year for 1 pair of lenses/frames or contacts.

Out-of-Network: Routine Eye Exam:30% of the costRoutine Eyewear: 90% coinsurance up to allowance

Out-of-Network:

Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 30%

Out-of-Network:

Medicare-covered Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 30%