UHC Complete Care MO-0001 (PPO C-SNP) H0271-052-000 2024 Plan Details and Costs (2024)

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$0.00
Out-of-pocket maximum	$4,400.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$8,000.00
Primary care doctor visit	In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00
Specialty doctor visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 to $30.00 Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital care	Out-of-Network: Coinsurance for Acute Hospital Services per Stay 40%
Urgent care	Urgent Care: Copayment for Urgent Care $0.00 to $40.00 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	Emergency Care: Copayment for Emergency Care $120.00 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 $225.00 Air Ambulance: Copayment for Air Ambulance Services $225.00 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

Health Care Services and Medical Supplies

UHC Complete Care MO-0001 (PPO C-SNP) covers a range of additional benefits. Learn more about UHC Complete Care MO-0001 (PPO C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $40.00
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable medical equipment (DME)	Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic tests, lab and radiology services, and X-rays	In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $25.00 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 to $150.00 Copayment for Medicare-covered Therapeutic Radiological Services $60.00 Copayment for Medicare-covered X-Ray Services $15.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health care	Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 50%
Mental health inpatient care	Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 40%
Mental health outpatient care	In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0.00 to $25.00 Copayment for Medicare-covered Group Sessions $15.00 Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgery	In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $230.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $230.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $180.00 Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse care	Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual or Group Sessions $30.00 to $40.00
Over-the-counter items	In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $40.00 every month Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry services	Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $40.00 Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $40.00
Skilled Nursing Facility (SNF) care	In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
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 $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Coinsurance for Medicare-covered Benefits 20% 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) Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 0% to 50% Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Prior Authorization Required for Comprehensive Dental

Coverage

Details

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 $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Coinsurance for Medicare-covered Benefits 20%
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)

Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 0% to 50%

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

Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Vision benefits	Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $40.00 Coinsurance for Medicare Covered Eyewear 40% Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $40.00 Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing benefits	Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $40.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $40.00 Copayment for Non-Medicare Covered Hearing Aids $99.00 to $1249.00

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
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: COVID-19 shots Flu shots Hepatitis B shots Pneumococcal shots Tobacco use cessation Yearly "Wellness" visit

Coverage

Details

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:

COVID-19 shots

Flu shots

Hepatitis B shots

Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

When reviewing Missouri Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Missouri that offer similar benefits at similar or lower prices than the plan above. Call 1-855-580-1854 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Summary of benefits
Evidence of coverage
Star ratings

Missouri Counties Served

Adair Andrew Atchison Audrain Barry Barton Bates Benton Bollinger Boone Buchanan Butler Caldwell Callaway Camden Cape Girardeau Carroll Carter Cass Cedar Chariton Christian Clark Clay Clinton Cole Cooper Crawford Dade Dallas Daviess Dekalb Dent Douglas Dunklin Franklin Gasconade Gentry Greene Grundy Harrison Henry Hickory Holt Howard Howell Iron Jackson Jasper Jefferson Johnson Knox Laclede Lafayette Lawrence Lewis Lincoln Linn Livingston Macon Madison Maries Marion Mcdonald Mercer Miller Mississippi Moniteau Monroe Montgomery Morgan New Madrid Newton Nodaway Oregon Osage Ozark Pemiscot Perry Pettis Phelps Pike Platte Polk Pulaski Putnam Ralls Randolph Ray Reynolds Ripley Saint Charles Saint Clair Saint Francois Saint Louis Saint Louis City Sainte Genevieve Saline Schuyler Scotland Scott Shannon Shelby Stoddard Stone Sullivan Taney Texas Vernon Warren Washington Wayne Webster Worth Wright

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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