UHC Complete Care GS-0002 (Regional PPO C-SNP)
UHC Complete Care GS-0002 (Regional PPO C-SNP) R2604-003 Plan Details
UHC Complete Care GS-0002 (Regional PPO C-SNP) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: R2604-003
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.
$28.00
Monthly Premium
UHC Complete Care GS-0002 (Regional PPO C-SNP) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: R2604-003
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 GS-0002 (Regional PPO C-SNP) R2604-003 Plan Details
UHC Complete Care GS-0002 (Regional PPO C-SNP) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: R2604-003
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.
$28.00
Monthly Premium
Georgia Counties Served
Jeff Davis
Carroll
Oconee
Appling
Hancock
Barrow
Catoosa
Decatur
Douglas
Morgan
Newton
Lincoln
Haralson
Taliaferro
Columbia
Mitchell
Sumter
Bacon
Lamar
Pulaski
Washington
Webster
Wilcox
Bibb
Macon
Wilkinson
Telfair
Walker
Liberty
Hart
Terrell
Lee
Dawson
Chattooga
Randolph
Gilmer
Troup
Early
Cherokee
Crawford
Forsyth
Irwin
Lumpkin
White
Dekalb
Treutlen
Brooks
Wheeler
Coweta
Baldwin
Turner
Tattnall
Peach
Candler
Clinch
Dodge
Berrien
Clarke
Johnson
Elbert
Spalding
Muscogee
Ben Hill
Towns
Paulding
Echols
Baker
Polk
Oglethorpe
Effingham
Houston
Chattahoochee
Chatham
Miller
Franklin
Thomas
Screven
Tift
Russell
Whitfield
Cook
Mcduffie
Pierce
Gwinnett
Brantley
Dooly
Seminole
Clayton
Rabun
Meriwether
Bulloch
Evans
Coffee
Calhoun
Emanuel
Butts
Lanier
Upson
Cobb
Bleckley
Schley
Taylor
Clay
Floyd
Richmond
Stewart
Dougherty
Murray
Worth
Bartow
Long
Rockdale
Charlton
Jasper
Wilkes
Union
Marion
Henry
Jenkins
Greene
Glascock
Glynn
Colquitt
Grady
Toombs
Quitman
Laurens
Crisp
Ware
Jones
Gordon
Fulton
Stephens
Pickens
Wayne
Montgomery
Putnam
Madison
Warren
Habersham
Heard
Harris
Atkinson
Bryan
Jackson
Jefferson
Pike
Mcintosh
Dade
Gadsden
Hall
Monroe
Fannin
Walton
Banks
Twiggs
Burke
Lowndes
Talbot
South Carolina Counties Served
Bamberg
Clarendon
Edgefield
Abbeville
Cherokee
Hampton
Chesterfield
Greenwood
Marlboro
Lexington
Charleston
Newberry
Florence
York
Calhoun
Darlington
Union
Pickens
Allendale
Greenville
Lee
Chester
Oconee
Fairfield
Williamsburg
Anderson
Saluda
Beaufort
Berkeley
Laurens
Jasper
Georgetown
Mccormick
Spartanburg
Colleton
Orangeburg
Horry
Lancaster
Marion
Richland
Aiken
Dillon
Dorchester
Sumter
Barnwell
Kershaw
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $7500 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $20.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 to $40.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $40.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $335.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: $335.00 per day for days 1 to 5 $0.00 per day for days 6 to 999 |
| 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 | Copayment for Emergency Care $100.00 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 $275.00 Air Ambulance: Copayment for Air Ambulance Services $275.00 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 Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $275.00 Copayment for Medicare Covered Ambulance Services - Air $275.00 |
Health Care Services and Medical Supplies
UHC Complete Care GS-0002 (Regional PPO 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 $15.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Chiropractic Services $15.00 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 50% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: 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 $35.00 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 $200.00 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 Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $35.00 Copayment for Medicare Covered Lab Services $0.00 Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $200.00 Copayment for Medicare Covered Therapeutic Radiological Services $60.00 Copayment for Medicare Covered Outpatient X-Ray Services $15.00 |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Home Health 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $335.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: $335.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 |
| Mental Health Outpatient Care | In-Network: 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 Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual Sessions $15.00 to $25.00 Copayment for Medicare Covered Group Sessions $15.00 to $25.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $335.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $335.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $335.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $335.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $335.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 to $25.00 Copayment for Medicare-covered Group Sessions $15.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $15.00 to $25.00 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 Copayment for Routine Foot Care $0.00
Prior authorization required Out-of-Network: Copayment for Medicare Covered Podiatry Services $0.00 Copayment for Non-Medicare Covered Podiatry Services $0.00 |
| Skilled Nursing Facility 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 Prior authorization required Out-of-Network: $225.00 per day for days 1 to 34 $0.00 per day for days 35 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Comprehensive Dental: Coinsurance for Medicare-covered Benefits 20% Prior Authorization Required for Comprehensive Dental Prior authorization required Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 20% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 50% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Copayment for Eyeglasses (lenses and frames) $0.00
Prior authorization required Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 Copayment for Medicare Covered Eyewear $0.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 Copayment for Non-Medicare Covered Eyewear $0.00 |
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 $0.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $99.00 to $1249.00
Prior authorization required 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 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 Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
