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Monthly Premium
UHC Care Advantage WI-E001 (HMO-POS I-SNP) is a HMO-POS I-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H5253-064-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
Monthly Premium
Wisconsin Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Wisconsin Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Coverage | Details |
---|---|
Monthly plan premium | $48.10 |
Vision coverage | |
Dental coverage | |
Hearing coverage | |
Prescription drugs | |
Medical deductible | $0.00 |
Out-of-pocket maximum | $500.00 |
Initial drug coverage limit | $0.00 |
Catastrophic drug coverage limit | $8,000.00 |
Primary care doctor visit | POS (Out-of-Network): Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 30% |
Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit |
Inpatient hospital care | Out-of-Network: Coinsurance for Acute Hospital Services per Stay 30% |
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 | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $100.00 Air Ambulance: Copayment for Air Ambulance Services $100.00 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 |
UHC Care Advantage WI-E001 (HMO-POS I-SNP) covers a range of additional benefits. Learn more about UHC Care Advantage WI-E001 (HMO-POS I-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: Copayment for Medicare-covered Chiropractic Services $0.00 Prior Authorization Required for Chiropractic Services |
Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) |
Durable medical equipment (DME) | POS (Out-of-Network): Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 30% |
Diagnostic tests, lab and radiology services, and X-rays | POS (Out-of-Network): Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30% Copayment for Medicare Covered Lab Services $0.00 Coinsurance for Medicare Covered Diagnostic Radiological Services 30% Coinsurance for Medicare Covered Therapeutic Radiological Services 30% Coinsurance for Medicare Covered Outpatient X-Ray Services 30% |
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 | Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 30% |
Mental health outpatient care | POS (Out-of-Network): Outpatient Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 30% Coinsurance for Medicare Covered Group Sessions 30% |
Outpatient services/surgery | POS (Out-of-Network): Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 30% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30% |
Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: 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 |
Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $375.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0.00 Copayment for Routine Foot Care $0.00
|
Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Dental care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Coinsurance for Medicare-covered Benefits 20% Copayment for Non-routine Services $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
Prior Authorization Required for Comprehensive Dental |
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
Coverage | Details |
---|---|
Vision care | 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
|
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Maximum Plan Allowance of $2000.00 every year both ears combined Prior Authorization Required for Hearing Aids |
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 | POS (Out-of-Network): Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 30% |
When reviewing Wisconsin 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 Wisconsin that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Links to plan documents |
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
Every minute we help someone compare their Medicare Advantage plan options.2