UHC Dual Complete HI-S001 (PPO D-SNP)
Health Insurance Company: UnitedHealthcareⓇ
Medicare Advantage Plan Details
Medicare-Medicaid Dual Eligible (D-SNP)
- Rx
- Dental
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: 30% coinsurance per visit
Out-of-network: 30% coinsurance per visit
Out-of-network: 0-30% coinsurance
Emergency Room
$0 copay
Ambulance Coverage
In-network: $0 copay
Out-of-network: 20% coinsurance
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $0 copay
Out-of-network: 30% coinsurance
Medicare-covered lab services: In-network: $0 copay
Out-of-network: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $0 copay
Out-of-network: 30% coinsurance
Medicare-covered x-ray services: In-network: $0 copay
Out-of-network: 30% coinsurance
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $0 copay
Out-of-network: 30% coinsurance per visit
Hospitalization Coverage
Inpatient hospital-acute:
In-network: $0 copay
Out-of-network: 30% per stay
Inpatient hospital psychiatric:
In-network: $0 copay
Out-of-network: 30% per stay
Rehabilitation Coverage
Occupational therapy services:
In-network: $0 copay
Out-of-network: 30% coinsurance
Physical therapy and speech and language therapy services:
In-network: $0 copay
Out-of-network: 30% coinsurance
Urgent Care Coverage
$0 copay
Skilled Nursing Facility (SNF)
In-network: $0 copay
Out-of-network: 30% per stay
Mental Health Coverage
Medicare-covered individual sessions: In-network: $0 copay
Out-of-network: 30% coinsurance
Medicare-covered group sessions: In-network: $0 copay
Out-of-network: 30% coinsurance
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Eye exams:
Routine eye exams: Not covered
Eyewear:
Contact Lenses: Not covered
Eyeglasses: Not covered
Hearing Benefits
Hearing exams:
Routine hearing exams: In-network: $0 copay
Out-of-network: 30% coinsurance
More Additional Benefits
Plan Links
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