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UHC Dual Complete VA-Y4 (PPO D-SNP) - H0421-001-000
$0.00
Monthly Premium
UHC Dual Complete VA-Y4 (PPO D-SNP) is a PPO D-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0421-001-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Virginia Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Virginia Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
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 | $9,350.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Note: $0 copayment applies to Medicare covered telehealth, Medicare covered remote monitoring, and visits conducted in the member's home. The higher cost share applies to all other Medicare covered services. |
| Specialty doctor visit | In Network In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 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: Coinsurance for Medicare Covered Physician Specialist Office Visit 0% or 40% Note: $0 copayment applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services. |
| Inpatient hospital care | In Network In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0 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: Copayment for Acute Hospital Services per Stay $0 or $1565 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. |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 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 | Emergency Care: Copayment for Emergency Care $0 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 $0 Air Ambulance: Copayment for Air Ambulance Services $0 Prior Authorization Required for Air Ambulance Out of Network Out-of-Network: Ambulance Services: Coinsurance for Medicare Covered Ambulance Services - Ground 0% or 20% Coinsurance for Medicare Covered Ambulance Services - Air 0% or 20% |
Health Care Services and Medical Supplies
UHC Dual Complete VA-Y4 (PPO D-SNP) covers a range of additional benefits. Learn more about UHC Dual Complete VA-Y4 (PPO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In Network In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $0 Prior Authorization Required for Chiropractic Services Out of Network Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 0% or 40% |
| Diabetes supplies, training, nutrition therapy and monitoring | In Network In-Network: Diabetic Supplies and Services: 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 0% or 40% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 0% or 40% |
| Durable medical equipment (DME) | In Network In-Network: Durable Medical Equipment: Copayment for Medicare-covered Durable Medical Equipment $0 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 0% or 40% |
| Diagnostic tests, lab and radiology services, and X-rays | Diagnostic Tests and Procedures: $0 copay Lab Services: $0 copay Diagnostic Radiology Services: $0 copay X-rays: $0 copay |
| Home health care | In Network In-Network: Home Health Services: 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 0% or 40% |
| Mental health inpatient care | In Network In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0 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: Copayment for Psychiatric Hospital per Stay $0 or $1565 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. |
| Mental health outpatient care | In Network In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 Out of Network Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 0% or 40% Coinsurance for Medicare Covered Group Sessions 0% or 40% |
| Outpatient services/surgery | In Network In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 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 $0 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 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: Coinsurance for Medicare Covered Outpatient Hospital Services 0% or 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 0% or 40% 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 substance abuse care | In Network In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 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: Coinsurance for Medicare Covered Individual Sessions 0% or 40% Coinsurance for Medicare Covered Group Sessions 0% or 40% Note: $0 copayment applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services. |
| Over-the-counter 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: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0 Copayment for Routine Foot Care $0
Out of Network Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 0% or 40% Non-Medicare Covered Podiatry Services: Coinsurance for Non-Medicare Covered Podiatry Services 0% or 40% |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: Copayment for Skilled Nursing Facility Services per Stay $0 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 | $2,500 per year for covered dental services $0 copay for covered network preventive services such as oral exams, routine cleanings, X-rays and fluoride $0 copay for covered network comprehensive services such as fillings, crowns, root canals, extractions, bridges and dentures You will have access to Medicare Advantage's largest dental network, or you can choose any dentist. Seeing a network dentist may save you money. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Routine Eye Exam: $0 copay, 1 per year |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In Network In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $0
Out of Network Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 0% or 40% |
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 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: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 40% |
When reviewing Virginia 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 Virginia that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Virginia Counties Served
- Accomack
- Albemarle
- Alexandria City
- Alleghany
- Amelia
- Amherst
- Appomattox
- Arlington
- Augusta
- Bath
- Bedford
- Bland
- Botetourt
- Bristol City
- Brunswick
- Buchanan
- Buckingham
- Buena Vista City
- Campbell
- Caroline
- Carroll
- Charles City
- Charlotte
- Charlottesville City
- Chesapeake City
- Chesterfield
- Clarke
- Colonial Heights City
- Covington City
- Craig
- Culpeper
- Cumberland
- Danville City
- Dickenson
- Dinwiddie
- Emporia City
- Essex
- Fairfax
- Fairfax City
- Falls Church City
- Fauquier
- Floyd
- Fluvanna
- Franklin
- Franklin City
- Frederick
- Fredericksburg City
- Galax City
- Giles
- Gloucester
- Goochland
- Grayson
- Greene
- Greensville
- Halifax
- Hampton City
- Hanover
- Harrisonburg City
- Henrico
- Henry
- Highland
- Hopewell City
- Isle Of Wight
- James City
- Jefferson
- King And Queen
- King George
- King William
- Lancaster
- Lee
- Lexington City
- Loudoun
- Louisa
- Lunenburg
- Lynchburg City
- Madison
- Manassas City
- Manassas Park City
- Martinsville City
- Mathews
- Mecklenburg
- Middlesex
- Montgomery
- Nelson
- New Kent
- Newport News City
- Norfolk City
- Northampton
- Northumberland
- Norton City
- Nottoway
- Orange
- Page
- Patrick
- Petersburg City
- Pittsylvania
- Poquoson City
- Portsmouth City
- Powhatan
- Prince Edward
- Prince George
- Prince William
- Pulaski
- Radford
- Rappahannock
- Richmond
- Richmond City
- Roanoke
- Roanoke City
- Rockbridge
- Russell
- Salem
- Scott
- Shenandoah
- Smyth
- Southampton
- Spotsylvania
- Stafford
- Staunton City
- Suffolk City
- Surry
- Sussex
- Tazewell
- Virginia Beach City
- Warren
- Washington
- Waynesboro City
- Westmoreland
- Williamsburg City
- Winchester City
- Wise
- Wythe
- York
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.