UHC Complete Care NC-28 (HMO-POS C-SNP)
UHC Complete Care NC-28 (HMO-POS C-SNP) H5253-189 Plan Details
UHC Complete Care NC-28 (HMO-POS C-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H5253-189
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
UHC Complete Care NC-28 (HMO-POS C-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H5253-189
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
UHC Complete Care NC-28 (HMO-POS C-SNP) H5253-189 Plan Details
UHC Complete Care NC-28 (HMO-POS C-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H5253-189
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
North Carolina Counties Served
Iredell
Alamance
Davidson
Forsyth
Davie
Yadkin
Chatham
Surry
Rowan
Vance
Stokes
Anson
Randolph
Rockingham
Montgomery
Moore
Caswell
Guilford
Harnett
Orange
Lee
Durham
Person
Richmond
Johnston
Wake
Wayne
Wilson
Franklin
Nash
Gaston
Stanly
Catawba
Mecklenburg
Cabarrus
Union
Sampson
Scotland
Hoke
Cumberland
Alexander
Granville
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $255 |
| Out of Pocket Max |
In-Network: $3900 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 to $15 Prior Authorization Required for Doctor Specialty Visit Note: $0 copayment applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services. Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $395 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services 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. Prior authorization required |
| Urgent Care | Copayment for Urgent Care $0 to $65 Note: $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 |
| Emergency Room Visit | Copayment for Emergency Care $140 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 Copayment for Worldwide Emergency Transportation $0 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $195 Air Ambulance: Copayment for Air Ambulance Services $195 Prior Authorization Required for Air Ambulance Prior authorization required |
Health Care Services and Medical Supplies
UHC Complete Care NC-28 (HMO-POS C-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 $20 Prior Authorization Required for Chiropractic Services Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Diagnostic Tests and Procedures: $25 copay Lab Services: $0 copay Diagnostic Radiology Services: $105 copay X-rays: $15 copay |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $395 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services 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. Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 to $25 Copayment for Medicare-covered Group Sessions $15 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $395 Prior Authorization Required for Outpatient Hospital Services Note: $0 copayment for 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 $395 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 $295 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: $0 copayment for outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures. Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $395 Note: $0 copayment for outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures.Note: Benefit category includes both the facility and professional component. Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 to $25 Copayment for Medicare-covered Group Sessions $15 Prior Authorization Required for Outpatient Substance Abuse Services Note: $0 copayment applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services. Prior authorization required |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0 Note: Plan offers a monthly benefit credit that can be used to either purchase items from a catalog and/or a retail card allowing members to receive Over The Counter healthcare items. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $15 Copayment for Routine Foot Care $15
Prior authorization required |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $203 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Coinsurance for Office Visit 20% Prior Authorization Required for Preventive Dental Comprehensive Dental: Copayment for Non-routine Services $0
Prior authorization required |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Routine Eye Exam: $0 copay, 1 per year Routine Eyewear: Plan pays up to $200 every two years for 1 pair of frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full. Home-delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only). |
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 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $199 to $1249
Prior authorization required |
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 |
Prescription Drug Costs and Coverage
The UHC Complete Care NC-28 (HMO-POS C-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $255 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $255 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $255 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $255 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
