UHC Dual Complete SC-S001 (PPO D-SNP) H0271-016 2024 Plan Details and Costs (2024)

UHC Dual Complete SC-S001 (PPO D-SNP) H0271-016 2024 Plan Details and Costs (1)

UHC Dual Complete SC-S001 (PPO D-SNP) H0271-016 Plan Details

4 out of 5 stars

UHC Dual Complete SC-S001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0271-016

$0.00

Monthly Premium

UHC Dual Complete SC-S001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0271-016

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UHC Dual Complete SC-S001 (PPO D-SNP) H0271-016 2024 Plan Details and Costs (2)

UHC Dual Complete SC-S001 (PPO D-SNP) H0271-016 Plan Details

4 out of 5 stars

UHC Dual Complete SC-S001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0271-016

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help

$0.00

Monthly Premium

South Carolina Counties Served

York Fairfield Spartanburg Union Pickens Chester Kershaw Cherokee Greenville Anderson Lancaster Bamberg Clarendon Abbeville Edgefield Hampton Chesterfield Charleston Marlboro Lexington Greenwood Newberry Florence Darlington Calhoun Allendale Colleton Lee Oconee Williamsburg Saluda Beaufort Berkeley Laurens Jasper Georgetown Mccormick Orangeburg Horry Marion Richland Aiken Dillon Dorchester Sumter Barnwell

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8850
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:
Coinsurance for Medicare Covered Primary Care Office Visit 20%

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:
Coinsurance for Medicare Covered Physician Specialist Office Visit 20%

Inpatient Hospital Care

In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Prior authorization required

Out-of-Network:
Copayment for Acute Hospital Services per Stay $0.00

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:
Coinsurance for Medicare Covered Ambulance Services - Ground 20%
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

UHC Dual Complete SC-S001 (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:
Coinsurance for Medicare Covered Chiropractic Services 20%

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 20%

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 20%

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:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20%
Copayment for Medicare Covered Lab Services $0.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 0% to 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
Prior Authorization Required for Home Health Services
Prior authorization required

Out-of-Network:
Copayment for Medicare Covered Home Health $0.00

Mental Health Inpatient Care

In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required

Out-of-Network:
Copayment for Psychiatric Hospital Services per Stay $0.00

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 $0.00
Copayment for Medicare Covered Group Sessions $0.00

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

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 $0.00

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 $236.00 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 $236.00

Podiatry Services

In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00

  • Maximum 6 visits every year

Prior Authorization Required for Podiatry Services
Prior authorization required

Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 20% Copayment for Non-Medicare Covered Podiatry Services $0.00

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:
Copayment for Skilled Nursing Facility Services per Stay $0.00

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 2 visits every year

Copayment for Prophylaxis (Cleaning) $0.00

  • Maximum 3 visits every year

Copayment for Fluoride Treatment $0.00

  • Maximum 2 visits every year

Copayment for Dental X-Rays $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $4000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Non-routine Services $0.00
Copayment for Diagnostic Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Restorative Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Endodontics $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Extractions $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $4000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental
Prior authorization required

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
Copayment for Routine Eye Exams $0.00

  • Maximum 1 Routine Eye Exam every year

Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglasses (lenses and frames) $0.00

  • Maximum 1 Pair every year

Maximum Plan Benefit of $400.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior authorization required

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:
Coinsurance for Non-Medicare Covered Eye Exams 20%
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

  • Maximum 1 visit every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00

  • Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $2500.00 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:
Coinsurance for Medicare Covered Hearing Exams 20%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 20%
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 & vagin*l 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

    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 UHC Dual Complete SC-S001 (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
    • Standard retail $0.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Generic
    • Standard retail $0.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Preferred Brand
    • Standard retail $0.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Non-Preferred Drug
    • Standard retail $0.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Specialty Tier
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Generic
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Preferred Brand
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Non-Preferred Drug
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Specialty Tier
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Preferred Brand
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Non-Preferred Drug
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Specialty Tier
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A

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    UHC Dual Complete SC-S001 (PPO D-SNP) H0271-016 2024 Plan Details and Costs (2024)

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