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UHC Dual Complete RI-Q1 (PPO D-SNP) - H0764-001-000
$3.40
Monthly Premium
UHC Dual Complete RI-Q1 (PPO D-SNP) is a PPO D-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0764-001-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$3.40
Monthly Premium
Rhode Island 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 additional benefits Original Medicare doesn’t cover.
Learn more about Rhode Island Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $3.40 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $700.00 |
| Out-of-pocket maximum | $9,850.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit 0% or 30% Note: The lower cost share applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services. |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit 0% to 20% Prior Authorization Required for Doctor Specialty Visit Note: The lower cost share applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services. |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0 or $1640 Prior Authorization Required for Acute Hospital Services Note: All inpatient substance abuse and mental health care (including both care received in an acute care facility and a Medicare-certified psychiatric facility) are included in category 1b. |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 to $40 Note: The lower cost share applies to Medicare covered telehealth. The higher cost share applies to all other Medicare covered services. |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $0 or $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours |
| Ambulance transportation | Out-of-Network: Ambulance Services: Coinsurance for Medicare Covered Ambulance Services - Ground 0% or 20% Coinsurance for Medicare Covered Ambulance Services - Air 0% or 20% |
Health Care Services and Medical Supplies
UHC Dual Complete RI-Q1 (PPO D-SNP) covers a range of additional benefits. Learn more about UHC Dual Complete RI-Q1 (PPO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 0% or 30% |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 0% or 20% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 0% or 20% |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 0% or 20% |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 0% or 40% Copayment for Medicare Covered Lab Services $0 Coinsurance for Medicare Covered Diagnostic Radiological Services 0% or 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 0% or 20% Coinsurance for Medicare Covered Outpatient X-Ray Services 0% or 40% |
| Home health care | Out-of-Network: Home Health Services: Copayment for Medicare Covered Home Health $0 |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital per Stay $0 or $1640 Benefit Details - General Note - NOTE ON INPATIENT SUBSTANCE ABUSE: All inpatient substance abuse and mental health care (including both care received in an acute care facility and a Medicare-certified psychiatric facility) are included in category 1b. |
| 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 0% or 20% |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 0% or 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 0% or 40% Note: The lower cost share applies to outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures.Note: Benefit category includes both the facility and professional component. |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 0% or 30% Coinsurance for Medicare Covered Group Sessions 0% or 30% Note: The lower cost share applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services. |
| Over-the-counter items | Out-of-Network: Over-The-Counter (OTC) Items Services: Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 0% or 90% |
| Podiatry services | In-Network $0 copay 4 visits per year |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: Copayment for Skilled Nursing Facility Services per Stay $0 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: Preventive Dental Services: Coinsurance for Medicare Covered Preventive Dental 0% or 40% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 0% or 30% Coinsurance for Medicare Covered Eyewear 0% or 40% |
Hearing Benefits
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 Routine Hearing Exam: $0 copay 1 exam per year Routine Hearing Aids: $2,200 allowance up to 2 hearing aids every 2 years Choose from a broad selection of brand-name prescription hearing aids through UnitedHealthcare Hearing. Access to one of the largest national networks with thousands of hearing professionals. Out-of-Network Routine Hearing Exam:30% of the cost Routine Hearing Aids:90% coinsurance up to allowance |
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 | 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 |
When reviewing Rhode Island 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 Rhode Island 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.
Plan Documents
| Links to plan documents |
Rhode Island Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.