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UHC Dual Complete WI-D001 (PPO D-SNP) - H0294-027-000

na* for plan year 2025

$0.00

Monthly Premium

UHC Dual Complete WI-D001 (PPO D-SNP) is a PPO D-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare

Plan ID: H0294-027-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

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.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$9,350.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Coinsurance for Primary Care Office Visit 0% to 20%
Note: $0 copayment applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services.
Specialty doctor visitIn Network
In-Network:

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit 0% to 20%
Prior Authorization Required for Doctor Specialty Visit
Note: $0 copayment applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services.


Out of Network

Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit 0% or 20%
Note: $0 copayment applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services.
Inpatient hospital careIn Network
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0 or $1615
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.


Out of Network

Out-of-Network:

Acute Hospital Services:
Coinsurance for Acute Hospital Services per Stay 0% or 20%
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 $45

Note: $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
Emergency room visit
Emergency Care:
Copayment for Emergency Care $0 or $110
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0
Copayment for Worldwide Emergency Transportation $0
Ambulance transportationIn Network
In-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services 0% or 20%

Air Ambulance:
Coinsurance for Air Ambulance Services 0% or 20%
Prior Authorization Required for Air Ambulance


Out of Network

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 WI-D001 (PPO D-SNP) covers a range of additional benefits. Learn more about UHC Dual Complete WI-D001 (PPO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn Network
In-Network:

Chiropractic Services:
Coinsurance for Medicare-covered Chiropractic Services 0% or 20%
Prior Authorization Required for Chiropractic Services


Out of Network

Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 0% or 20%
Diabetes supplies, training, nutrition therapy and monitoringIn Network
In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 0% or 20%


Out of Network

Out-of-Network:

Medicare Covered 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)In Network
In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% or 20%
Prior Authorization Required for Durable Medical Equipment


Out of Network

Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 0% or 20%
Diagnostic tests, lab and radiology services, and X-raysDiagnostic Tests and Procedures:
$0 - 20% of the cost

Lab Services:
$0 copay

Diagnostic Radiology Services:
$0 - 20% of the cost

X-rays:
$0 - 20% of the cost
Home health careIn Network
In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services


Out of Network

Out-of-Network:

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 0% or 40%
Mental health inpatient careIn Network
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0 or $1615
Prior Authorization Required for Psychiatric Hospital Services
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.


Out of Network

Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 0% or 20%
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 careIn Network
In-Network:

Outpatient Mental Health Services:
Coinsurance for Medicare-covered Individual Sessions 0% to 20%
Coinsurance for Medicare-covered Group Sessions 0% or 20%


Out of Network

Out-of-Network:

Medicare Covered Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 0% or 20%
Coinsurance for Medicare Covered Group Sessions 0% or 20%
Outpatient services/surgeryIn Network
In-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 20%
Prior Authorization Required for Outpatient Hospital Services
Note: $0 copayment for outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures.Note: Benefit category includes both the facility and professional component.

Outpatient Observation Services:
Coinsurance for Medicare Covered Observation Services 0% or 20%
Prior Authorization Required for Outpatient Observation Services
Benefit Details - General 9a2 Note - NOTE ON OBSERVATION SERVICES: Benefit category includes both the facility and professional component.

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 0% to 20%
Prior Authorization Required for Ambulatory Surgical Center Services
Benefit Details - General 9b Note - NOTE ON ASC SERVICES: Benefit category 9b includes both the facility and professional component.Benefit Details - General 9b Note - NOTE ON COST SHARING RANGE FOR ASC Services: $0 copayment for outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures.


Out of Network

Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% or 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 0% or 20%
Note: $0 copayment for 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 careIn Network
In-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare-covered Individual Sessions 0% to 20%
Coinsurance for Medicare-covered Group Sessions 0% or 20%
Prior Authorization Required for Outpatient Substance Abuse Services
Note: $0 copayment applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services.


Out of Network

Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 0% or 20%
Coinsurance for Medicare Covered Group Sessions 0% or 20%
Note: $0 copayment applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services.
Over-the-counter itemsIn Network
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
Note: Plan offers a monthly benefit credit that can be used to either purchase items from a catalog and/or a retail card allowing members to receive Over The Counter healthcare items.


Out of Network

Out-of-Network:

Non-Medicare Covered Over-The-Counter (OTC) Items Services:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0
Podiatry servicesIn Network
In-Network:

Podiatry Services:
Coinsurance for Medicare-Covered Podiatry Services 0% or 20%
Copayment for Routine Foot Care $0
  • Maximum 2 visits every year
Prior Authorization Required for Podiatry Services


Out of Network

Out-of-Network:

Medicare Covered Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 0% or 20%

Non-Medicare Covered Podiatry Services:
Coinsurance for Non-Medicare Covered Podiatry Services 0% or 20%
Skilled Nursing Facility (SNF) careIn-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.

CoverageDetails
Dental care$2,000 per year for covered dental services
$0 copay for covered network preventive services such as oral exams, routine cleanings, X-rays and fluoride
$0 copay for covered network comprehensive services such as fillings, crowns, root canals, extractions, bridges and dentures
You will have access to Medicare Advantage's largest dental network, or you can choose any dentist. Seeing a network dentist may save you money.

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careRoutine Eye Exam:
$0 copay, 1 per year

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn Network
In-Network:

Hearing Exams:
Coinsurance for Medicare Covered Benefits 0% or 20%
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $2,200 every year


Out of Network

Out-of-Network:

Medicare Covered Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 0% or 20%

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.

CoverageDetails
Preventive services and health/wellness education programsIn Network
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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit



    Out of Network

    Out-of-Network:

    Medicare Covered Medicare-covered Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 20%

    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.

    Plan Documents

    Links to plan documents

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

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