UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) By UnitedHealthcare

UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) H2272 001 0 is a 2023 Medicare Advantage Special Needs Plan plan by UnitedHealthcare. This plan from UnitedHealthcare works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from UnitedHealthcare and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) H2272-001 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.

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Overview.
Monthly Costs
Premium Assistance
Formulary and Drugs
Plan Benefits
Coverage Area

2023 Medicare Special Needs Plan Details

Plan Name:	UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)
Plan ID:	H2272 001 0
Special Needs Type:	Dual-Eligible
Provider:	UnitedHealthcare
Plan Year:	2023
Plan Type:	Local HMO
Monthly Premium C+D:	$30.30
Part C Premium:	$0
Part D (Drug) Premium:	$30.30
Part D Supplemental Premium	$0
Total Part D Premium:	$30.30
Drug Deductible:	$505.00
Tiers with No Deductible:	0
Benchmark:	below the regional benchmark
Type of Medicare Health Plan:	Defined Standard Benefit
Drug Benefit Type:	Basic
Gap Coverage:	No
Similar Plan:	H2272-001

The UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) H2272-001 is available to residents to Medicare eligible seniors in Rhode Island. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.

How much does UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. UnitedHealthcare charges a $0 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) has a monthly drug premium of $30.30 and a $505.00 drug deductible. This UnitedHealthcare plan offers a $30.30 Part-D Basic Premium that is below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by UnitedHealthcare above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $30.30. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

UnitedHealthcare Gap Coverage

In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This UnitedHealthcare plan does not offer additional coverage through the gap.

Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $7.60 for 75% low-income subsidy $15.10 for 50% and $22.70 for 25%.

Full Assistance Premium:	$0
75% Assistance Premium:	$7.60
50% Assistance Premium:	$15.10
25% Assistance Premium:	$22.70

H2272-001 Formulary and Drug Coverage

UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	15%
Tier 2	NA	15%
Tier 3	NA	15%
Tier 4	NA	15%
Tier 5	NA	15%

The complete UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) H2272-001 Formulary
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from UnitedHealthcare helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

Contact lenses

In-Network Vision	$0 copay

Eyeglass frames

Vision	Not covered

Eyeglass lenses

Vision	Not covered

Eyeglasses (frames and lenses)

In-Network Vision	$0 copay

Other

Vision	Not covered

Routine eye exam

In-Network Vision	$0 copay

Upgrades

Vision	Not covered

In-Network Transportation	$0 copay
Out-of-Network Skilled Nursing Facility	Not Applicable
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $0 or $196 per day for days 21 through 43 $0 per day for days 44 through 100

Occupational therapy visit

In-Network Rehabilitation services	$0 or $10 copay

Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$0 or $10 copay

Cleaning

Out-of-Network Preventive dental	$0 copay
In-Network Preventive dental	$0 copay

Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

Fluoride treatment

Out-of-Network Preventive dental	$0 copay
In-Network Preventive dental	$0 copay

Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

In-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$0 or $0-310 copay per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

Inpatient hospital - psychiatric

Out-of-Network Mental health services	Not Applicable
In-Network Mental health services	$0 or $310 per day for days 1 through 5 $0 per day for days 6 through 90

Outpatient group therapy visit

In-Network Mental health services	$0 or $5 copay

Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$0 or $5 copay

Outpatient individual therapy visit

In-Network Mental health services	$0 or $10 copay

Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$0 or $10 copay

Chemotherapy

In-Network Medicare Part B drugs	0% or 20% coinsurance

Other Part B drugs

In-Network Medicare Part B drugs	0% or 20% coinsurance

Diabetes supplies

In-Network Medical equipment/supplies	$0 copay per item

Durable medical equipment (e.g., wheelchairs, oxygen)

In-Network Medical equipment/supplies	0% or 20% coinsurance per item

Prosthetics (e.g., braces, artificial limbs)

In-Network Medical equipment/supplies	0% or 20% coinsurance per item

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$4,500 In-network
In-Network Inpatient hospital coverage	$0 or $310 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond
Out-of-Network Inpatient hospital coverage	Not Applicable

Fitting/evaluation

Hearing	Not covered

Hearing aids

In-Network Hearing	$0 copay

Hearing exam

In-Network Hearing	$0 copay

Health plan deductible	$0
In-Network Ground ambulance	$0 or $250 copay

Foot exams and treatment

In-Network Foot care (podiatry services)	$0 or $10 copay

Routine foot care

In-Network Foot care (podiatry services)	$10 copay

Emergency

Emergency care/Urgent care	$0 or $90 copay per visit (always covered)

Urgent care

Emergency care/Urgent care	$0 or $40 copay per visit (always covered)

Primary

In-Network Doctor visits	$0 copay

Specialist

In-Network Doctor visits	$0 or $10 copay per visit

Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0 or $0-135 copay

Diagnostic tests and procedures

In-Network Diagnostic procedures/lab services/imaging	$0 or $30 copay

Lab services

In-Network Diagnostic procedures/lab services/imaging	$0 copay

Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	$0 or $15 copay

Diagnostic services

Out-of-Network Comprehensive dental	$0 copay
In-Network Comprehensive dental	$0 copay

Endodontics

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

Extractions

Out-of-Network Comprehensive dental	$0 copay
In-Network Comprehensive dental	$0 copay

Non-routine services

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

Periodontics

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

Prosthodontics, other oral/maxillofacial surgery, other services

Out-of-Network Comprehensive dental	$0 copay
In-Network Comprehensive dental	$0 copay

Restorative services

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	Yes, contact plan for further details

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) requires you to live in that plan’s service area. The service area is listed below:

State:	Medicare Rhode Island
County:	SNP in Bristol SNP in Kent SNP in Newport SNP in Providence SNP in Washington

Source: CMS.

Plans as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.