UHC Dual Complete PA-V001 D-SNP: H3113-014-0
What is Plan H3113-014-0 from UnitedHealthcare?
UHC Dual Complete PA-V001, is a 2024 D-SNP Special Needs Plan, with a HMO-POS provider network. This UnitedHealthcare HMO-POS plan is required to provide all of the same benefits as Original Medicare, and includes some additional benefits, but out-of-pocket costs may be different.
You must meet all qualification requirements to join this D-SNP plan.
| Plan Basics | |
|---|---|
| Plan ID: | H3113-014-0 |
| Plan Type: | HMO-POS |
| Plan Year: | 2024 |
| Premium: | $29.50/mo Plus your Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Basic $545.00 deductible |
| Rx Gap Coverage: | {gap} |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Lebanon County, PA |
| Insured By: | UnitedHealthcare |
| Summary of Benefits |
|---|
Health Plan Costs & Benefits
UHC Dual Complete PA-V001 is an HMO-POS (point-of-sale) plan. HMO-POS plans offer the same features as a Health Maintenance Organization (HMO) plan, however, there is one major difference. HMO-POS plans allow members to access healthcare providers outside the plan's network to receive some or all of their services. In most cases, a member will need to get a referral from their physician to go out of the plan's network. Plus, there are separate deductibles for in-network and out-of-network services.
The following table is a summary of the most common out-of-pocket costs you will incur if you join this UnitedHealthcare plan:
| Healthcare Service | Member Cost |
|---|---|
| Doctor Visits (In-Network) | |
| Primary: | $0 Copay |
| Specialist: | $25 Copay Authorization Required |
| Wellness programs (e.g., fitness, nursing hotline): | |
| Preventive care: | $0 Copay |
| Foot Care (In-Network) | |
| Foot exams and treatment (Medicare-covered): | $25 Copay Authorization Required |
| Routine foot care: | $25 Copay Authorization Required |
| Chiropractic Care (In-Network) | |
| Medicare-covered chiropractic care: | $15 Copay Authorization Required |
| Routine chiropractic care: | $15 Copay Authorization Required |
| Emergency Care / Urgent Care | |
| Emergency room care: | $100 Copay |
| Urgent care: | $40 Copay |
| Ground ambulance: | $290 Copay |
| Inpatient hospital coverage: | $250.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
| Outpatient hospital coverage: | $150 Copay Authorization Required |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 and beyond |
| Optional supplemental benefits: | Not Covered |
| Mental Health Services (In-Network) | |
| Outpatient individual therapy visit with a psychiatrist: | $25 Copay |
| Outpatient group therapy visit with a psychiatrist: | $15 Copay |
| Inpatient hospital - psychiatric: | $250.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
| Outpatient group therapy visit: | $15 Copay |
| Outpatient individual therapy visit: | $0 |
| Rehabilitation Services (In-Network) | |
| Physical therapy and speech and language therapy visit: | $25 Copay Authorization Required |
| Occupational therapy visit: | $25 Copay Authorization Required |
| Medical Equipment / Supplies (In-Network) | |
| Diabetes supplies: | $0 Copay Authorization Required |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Authorization Required |
| Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
| Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
| Diagnostic radiology services (e.g., MRI): | $250 Copay Authorization Required |
| Lab services: | $0 Copay Authorization Required |
| Outpatient x-rays: | $25 Copay Authorization Required |
| Diagnostic tests and procedures: | $20 Copay Authorization Required |
| Medicare Part B Drugs (In-Network) | |
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our UHC Dual Complete PA-V001 Summary of Benefits information.
Supplemental Health Plan Benefits (H3113-014-0)
The following is a summary of the supplemental benefits UnitedHealthcare includes with this plan:
| Supplemental Healthcare Service | Member Cost |
|---|---|
| Preventive Dental | |
| Oral exam (In-Network) | Not Covered |
| Fluoride treatment (In-Network) | Not Covered |
| Dental x-ray(s) (In-Network) | Not Covered |
| Cleaning (In-Network) | Not Covered |
| Comprehensive Dental | |
| Periodontics (In-Network) | Not Covered |
| Non-routine services (In-Network) | Not Covered |
| Diagnostic services (In-Network) | Not Covered |
| Extractions (In-Network) | Not Covered |
| Endodontics (In-Network) | Not Covered |
| Restorative services (In-Network) | Not Covered |
| Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
| Hearing | |
| Fitting/evaluation (In-Network) | Covered Limits may apply |
| Hearing aids (In-Network) | Covered Limits may apply |
| Hearing exam (In-Network) | Not Covered |
| Vision | Maximum vision benefit: | $250.00 Every year |
| Eyeglasses (frames and lenses) (In-Network) | Not Covered |
| Routine eye exam (In-Network) | $0 Copay Authorization Required |
| Contact lenses (In-Network) | $0 Copay |
Additional Supplemental Benefits
None specified.
Prescription Drug Plan Costs & Benefits
UHC Dual Complete PA-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 Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. The following table outlines the prescription drug plan premium details of this plan.
| Basic Part D Premium: | $29.50 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $29.50 |
| Part D Premium with Full LIS Assistance: | $0.00 |
For more information about the Low-Income Subsidy (aka, "Extra Help") program, refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $545.00. This is the amount you must pay at the pharmacy before UnitedHealthcare begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, UHC Dual Complete PA-V001 has out-of-pocket costs that you must pay when you pick up your prescriptions. The following table shows you those costs.
| Drug Tier | Preferred | Standard |
|---|---|---|
| $0 copay on all covered generic and brand-name prescriptions. | ||
5-Star Rating Marks
Each year Medicare rates D-SNP plans, using a 5-star rating system, in nine major categories. These ratings are designed to help you understand the quality of care and service you can expect if you qualify and choose to join UHC Dual Complete PA-V001.
| CMS Measure | Star Rating |
|---|---|
| 2024 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
How to Qualify to Enroll in
UHC Dual Complete PA-V001
To qualify for enrollment in UHC Dual Complete PA-V001 in Lebanon 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 Pennsylvania's state thresholds.
Before enrolling in UHC Dual Complete PA-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?
Additional D-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
- Aetna Medicare Advantra Cares
- UPMC for Life Complete Care
- Geisinger Gold Secure Rx
- Highmark Wholecare Medicare Assured Diamond
- Highmark Wholecare Medicare Assured Ruby
Contact UnitedHealthcare
| Plan Website: | http://UHC.com/Medicare |
|---|---|
| Formulay Information: | http://UHC.com/Medicare |
| Pharmacy Information: | UnitedHealthcare Pharmacy Page |
| Prospective Members: | (888)834-3721 |
| TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- UnitedHealthcare, http://UHC.com/Medicare, Last Accessed October 13, 2022
- Medicaid.gov, "Medicaid & CHIP in Pennsylvania", Last Accessed January 20, 2023
- CMS.gov, "Dual Eligible Special Needs Plans (D-SNPs)", Last Accessed January 20, 2023
- CMS.gov, Landscape Source Files, Last Accessed January 21, 2023
- CMS.gov, Medicare Part C & D Performance, Last Accessed January 21, 2023
- CMS.gov, Plan Benefits Package, Last Accessed January 21, 2023