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UHC Dual Complete MO-V001 (D-SNP) Plan Details for Jefferson County, MO

This page provides coverage and cost details for UnitedHealthcare’s H0169-008-0 Medicare SNP plan for 2025. Enrollment is subject to eligibility.

CMS 2025 Rating: ☆☆☆☆☆*

*CMS rated this UnitedHealthcare plan (H0169-008-0) 4 (Good) out of 5 stars.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. The UnitedHealthcare logo is a registered trademark.[2] Its use by MedicareWire is strictly for editorial purposes. This is not a solicitation of insurance.

This private health insurance option offers all of the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may include additional benefits that Medicare Part A and Part B do not cover.

Individuals must meet all Dual-Eligible SNP qualification requirements to join this D-SNP plan.

UHC Dual Complete MO-V001 Basic Plan Details

Plan ID
H0169-008-0
Plan Type
HMO-POS D-SNP
Plan Year
2025
Premium
$51.00/mo
Plus your Medicare Part B premium.
Health Plan Deductible
$0.00
Out-of-Pocket Maximum
2,800.00 /yr (in-network)
Part B Reduction
$0.00/mo
Drug Plan Benefit
Basic
$590.00 deductible
Supplemental Benefits
Vision, Hearing
Availability
Jefferson County, MO
Insured By
UnitedHealthcare
Summary of Benefits

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Health Plan Out-of-Pocket Costs

The following table is a summary of the most common out-of-pocket costs you will incur if you join this UnitedHealthcare plan:

Doctor's Office Visits

Primary
$0 Copay
Specialist
$25 Copay
Prior Authorization Required

Emergency, Urgent, and Inpatient Hospital Coverage

Emergency room care
$140 Copay
Urgent care
$60 Copay
Ground ambulance
$290 Copay
Inpatient hospital care
$275.00 per day for days 1 through 8
$0.00 per day for days 9 and beyond
Skilled Nursing Facility
$0.00 per day for days 1 through 20
$203.00 per day for days 21 and beyond

Foot Care

Foot Exams and Treatments (Medicare-covered)
$25 Copay
Prior Authorization Required
Routine Foot Care
$25 Copay
Prior Authorization Required

Chiropractic Care

Medicare-covered chiropractic
$20 Copay
Prior Authorization Required
Routine chiropractic
$20 Copay
Prior Authorization Required

Mental Health Services

Outpatient individual therapy
$25 Copay
Outpatient group therapy
$15 Copay
Inpatient psychiatric hospital care
$275.00 per day for days 1 through 8
$0.00 per day for days 9 and beyond

Rehabilitation Services

Physical therapy and speech and language therapy
$20 Copay
Prior Authorization Required
Occupational therapy
$20 Copay
Prior Authorization Required

Medical Equipment and Supplies

Diabetes supplies
$0 Copay
Prior Authorization Required
Durable medical equipment
20% Coinsurance
Prior Authorization Required
Prosthetics
20% Coinsurance

Diagnostics, Lab Services, and Imaging

Diagnostic radiology services
$200 Copay
Prior Authorization Required
Lab services
$0 Copay
Prior Authorization Required
Outpatient x-rays
$25 Copay
Prior Authorization Required
Diagnostic tests and procedures
$45 Copay
Prior Authorization Required

Medicare Part B Drugs

Chemotherapy
20% Coinsurance
Other Part B drugs (Medicare-covered)
20% Coinsurance

Dental Services

Medicare Covered Preventive Dental
20% Coinsurance
Prior Authorization Required
Oral exam
$0 Copay
Dental x-rays
$0 Copay
Cleaning
$0 Copay
Periodontics
Not Covered
Endodontics
Not Covered
Restorative Services
Not Covered
Maximum dental benefit
$750.00 (Every year)

Hearing Aids and Services

Fitting/evaluation
Covered
Limits may apply
Hearing aids
Covered
Limits may apply
Hearing exam
Not Covered

Vision Services

Medicare-covered eye exam
$0 Copay
Routine eye exam
$0 Copay
1 Every year
Eyewear benefits
Eyeglasses: No
Contact Lenses: No
Eyeglass Lenses: No
Eyeglass Frames: No
Eyewear Upgrades: No
Maximum eyewear benefit:
$2.00
Every three years
If you qualify for Medicare Advantage but don't know where to begin, we have licensed insurance agents[1] at 1-855-728-0510 (TTY 711) who can answer your questions (Mon-Fri 5am-6pm, Sat 6am-5pm PT) and help you get enrolled. There's no obligation.

Prescription Drug Costs & Benefits

UHC Dual Complete MO-V001 includes an basic benefit Medicare Part D plan (PDP). This simply means that the plan covers the minimum amount required by the Centers for Medicare & Medicaid Services, whereas enhanced benefit plans cover more.

Prescription Drug Premium with Extra Help

Extra Help is a Social Security program that helps people with limited income and resources lower or cut Part D costs. The following table outlines premium assistance details with Extra Help.

Low Income Premium Subsidy: ${part_d_lips_amount}
Low Income Premium Subsidy CMS Pays: $51.00
Low Income Subsidy Premium: $0.00

If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.

Prescription Drug Deductible

The Medicare Part D annual deductible with this plan is $590.00. You must pay this amount at the pharmacy before UnitedHealthcare begins paying its share.

Prescription Drug Out-of-Pocket Costs

In addition to the plan's monthly premium and deductible, UHC Dual Complete MO-V001 has out-of-pocket costs you must pay when you pick up your prescriptions.

Drug Tier Retail Mail Order
Cost data not available.
*The Part D deductible does not apply.

How to Qualify to Enroll in
UHC Dual Complete MO-V001

To qualify for enrollment in UHC Dual Complete MO-V001 in Jefferson County, you must be eligible for both Medicare and Medicaid. To be eligible for Medicare, you must be age 65 or older, or have Social Security Disability Insurance for 24 months. To be eligible for Medicaid, your income and assets must be at or below Missouri's state thresholds.

Before enrolling in UHC Dual Complete MO-V001 , or any other dual-eligible SNP, be sure to ask the following questions:

  • What costs should I expect to pay out-of-pocket (premiums, deductibles, copayments)?
  • Will I be able to use my doctors? Are they in the plan's network?
  • Are the plan's in-network providers and facilities in convenient locations?
  • Does the plan provide coverage for services I receive from out-of-network providers?
  • Do I need a referral to see a specialist?
  • Are my medications on the Part D plan's formulary? What if I can't afford my medications?
  • What special accommodations does the plan make for persons with disabilities?
  • Does the plan offer free meal delivery after a stay in the hospital?
  • What help is offered for caregivers? Is adult day care covered?
  • Does the plan offer a prepaid card for over the counter medications and covered groceries?