UHC Complete Care TX-19 (HMO-POS C-SNP)
UHC Complete Care TX-19 (HMO-POS C-SNP) H4527-042 Plan Details
UHC Complete Care TX-19 (HMO-POS C-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H4527-042
HelpAdvisor Editorial Team analysis of data from the 2024 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 TX-19 (HMO-POS C-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H4527-042
HelpAdvisor Editorial Team analysis of data from the 2024 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 TX-19 (HMO-POS C-SNP) H4527-042 Plan Details
UHC Complete Care TX-19 (HMO-POS C-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H4527-042
HelpAdvisor Editorial Team analysis of data from the 2024 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
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $340 |
| Out of Pocket Max |
In-Network: $3600 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 $10 Prior Authorization Required for Doctor Specialty Visit Referral 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: $195 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Referral 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 $175 Air Ambulance: Copayment for Air Ambulance Services $175 Prior Authorization Required for Air Ambulance Prior authorization required |
Health Care Services and Medical Supplies
UHC Complete Care TX-19 (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 Referral 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: $0 copay Lab Services: $0 copay Diagnostic Radiology Services: $200 copay X-rays: $0 copay |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Referral Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $195 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Referral 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 $195 Prior Authorization Required for Outpatient Hospital Services Referral 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 $195 Prior Authorization Required for Outpatient Observation Services Referral 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 $145 Prior Authorization Required for Ambulatory Surgical Center Services Referral 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. 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 Referral 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 $10 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services 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 Referral 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 Referral 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 $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: Hearing Exams: Copayment for Medicare Covered Benefits $0 Copayment for Routine Hearing Exams $0
Referral Required for Hearing Exams 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 TX-19 (HMO-POS C-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $340 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $340 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $340 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $340 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
