UHC Complete Care Support FG-5 (PPO C-SNP)
UHC Complete Care Support FG-5 (PPO C-SNP) H2001-135 Plan Details
UHC Complete Care Support FG-5 (PPO C-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H2001-135
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.
$36.60
Monthly Premium
UHC Complete Care Support FG-5 (PPO C-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H2001-135
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 Support FG-5 (PPO C-SNP) H2001-135 Plan Details
UHC Complete Care Support FG-5 (PPO C-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H2001-135
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.
$36.60
Monthly Premium
Minnesota Counties Served
North Dakota Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $590 |
| Out of Pocket Max |
In-Network: $6700 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 In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 to $45 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. Out of Network Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $65 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 In-Network: Acute Hospital Services: $495 per day for days 1 to 5 $0 per day for days 6 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. Out of Network Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 40% 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 $55 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 $125 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 In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $290 Air Ambulance: Copayment for Air Ambulance Services $290 Prior Authorization Required for Air Ambulance Out of Network Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $290 Copayment for Medicare Covered Ambulance Services - Air $290 Prior authorization required |
Health Care Services and Medical Supplies
UHC Complete Care Support FG-5 (PPO 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 In-Network: Copayment for Medicare-covered Chiropractic Services $20 Prior Authorization Required for Chiropractic Services Out of Network Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $65 Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In Network In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 Out of Network Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 50% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50% |
| Durable Medical Eqipment (DME) | In Network In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Out of Network Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50% Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Diagnostic Tests and Procedures: $40 copay Lab Services: $0 copay Diagnostic Radiology Services: $250 copay X-rays: $25 copay |
| Home Health Care | In Network In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Out of Network Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50% Prior authorization required |
| Mental Health Inpatient Care | In Network In-Network: Psychiatric Hospital Services: $495 per day for days 1 to 4 $0 per day for days 5 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. Out of Network Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 40% 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 In-Network: Copayment for Medicare-covered Individual Sessions $0 to $15 Copayment for Medicare-covered Group Sessions $15 Out of Network Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $15 Copayment for Medicare Covered Group Sessions $15 |
| Outpatient Services / Surgery | In Network In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $495 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 $495 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 $445 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 Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $595 Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $595 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 In-Network: Copayment for Medicare-covered Individual Sessions $0 to $15 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. Out of Network Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $15 Copayment for Medicare Covered Group Sessions $15 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 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. Out of Network Out-of-Network: Non-Medicare Covered Over-The-Counter (OTC) Items Services: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0 |
| Podiatry Services | In Network In-Network: Copayment for Medicare-Covered Podiatry Services $40 Copayment for Routine Foot Care $40
Out of Network Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $65 Non-Medicare Covered Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $65 Prior authorization required |
| Skilled Nursing Facility Care | In Network 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 Out of Network Out-of-Network: Skilled Nursing Facility Services: $225 per day for days 1 to 100 Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In Network In-Network: Preventive Dental: Coinsurance for Office Visit 20% Prior Authorization Required for Preventive Dental Comprehensive Dental: Copayment for Non-routine Services $0
Out of Network Out-of-Network: Medicare Covered Preventive Dental Services: Coinsurance for Medicare Covered Preventive Dental 20% 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 $250 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 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
Out of Network Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $65 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 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 Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
