UHC Complete Care IL-001A (PPO C-SNP) H0271-027-000 2024 Plan Details and Costs (2024)

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$23.50
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$545.00
Out-of-pocket maximum	$8,850.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$8,000.00
Primary care doctor visit	Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 40%
Specialty doctor visit	In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit 0% to 20% Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital care	In-Network: Acute Hospital Services: $250.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services
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 $90.00 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	Out-of-Network: Ambulance Services: Coinsurance for Medicare Covered Ambulance Services - Ground 20% Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

UHC Complete Care IL-001A (PPO C-SNP) covers a range of additional benefits. Learn more about UHC Complete Care IL-001A (PPO C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	In-Network: Chiropractic Services: Coinsurance for Medicare-covered Chiropractic Services 20% Prior Authorization Required for Chiropractic Services
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)	In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-rays	In-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 0% to 20% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Coinsurance for Medicare-covered X-Ray Services 20% Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health care	In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services
Mental health inpatient care	In-Network: Psychiatric Hospital Services: $250.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care	In-Network: Outpatient Mental Health Services: Coinsurance for Medicare-covered Individual Sessions 0% to 20% Coinsurance for Medicare-covered Group Sessions 20% Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgery	Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
Outpatient substance abuse care	Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 40%
Over-the-counter items	Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $148.00
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0.00 Copayment for Routine Foot Care $0.00 Maximum 4 visits every year Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care	In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $200.00 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	Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 40% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Copayment for Non-Medicare Covered Comprehensive Dental $0.00

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: Coinsurance for Medicare Covered Eye Exams 40% Coinsurance for Medicare Covered Eyewear 40% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 40% 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	In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 20% Copayment for Routine Hearing Exams $0.00 Maximum 1 visit every year Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0.00 Maximum 2 Hearing Aids every year Maximum Plan Benefit of $2500.00 every year both ears combined for in and out of network services combined Prior Authorization Required for Hearing Aids

Coverage

Details

Hearing benefits

In-Network:

Hearing Exams:
Coinsurance for Medicare Covered Benefits 20%
Copayment for Routine Hearing Exams $0.00

Maximum 1 visit every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00

Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $2500.00 every year both ears combined for in and out of network services combined
Prior Authorization Required for Hearing Aids

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	Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 40%

Prescription Drug Costs and Coverage

The UHC Complete Care IL-001A (PPO C-SNP) offers prescription drug coverage, with an annual drug deductible of $545.00

When reviewing Illinois 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 Illinois 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

Illinois Counties Served

Boone Brown Bureau Carroll Cass Christian Clark Clay Coles Cook Crawford Cumberland Dekalb Dewitt Douglas Dupage Edgar Edwards Ford Franklin Fulton Grundy Hamilton Hanco*ck Henderson Henry Iroquois Jasper Jefferson Jo Daviess Kane Kankakee Kendall Knox La Salle Lake Lawrence Lee Livingston Logan Macon Marshall Mason Mcdonough Mchenry Mclean Menard Mercer Morgan Moultrie Ogle Peoria Piatt Putnam Richland Rock Island Sangamon Schuyler Scott Shelby Stark Stephenson Tazewell Vermilion Wabash Warren Wayne White Whiteside Will Winnebago Woodford

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

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