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UHC Nursing Home Plan IN-F001 (PPO I-SNP)

5 out of 5 stars* for plan year 2024
$23.80 Monthly Premium

UHC Nursing Home Plan IN-F001 (PPO I-SNP) is a PPO I-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare

Plan ID: H0710-013-000

$23.80 Monthly Premium

Indiana 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 Indiana 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$23.80
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$545.00
Out-of-pocket maximum$2,300.00
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 30%
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit 0% to 20%
Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital care
Out-of-Network:
Copayment for Acute Hospital Services per Stay $1628.00
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.
Emergency room visit
Emergency Care:
Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours
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 Nursing Home Plan IN-F001 (PPO I-SNP) covers a range of additional benefits. Learn more about UHC Nursing Home Plan IN-F001 (PPO I-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 30%
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
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
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 careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1628.00
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Coinsurance for Medicare-covered Individual Sessions 0% to 20%
Coinsurance for Medicare-covered Group Sessions 0% to 20%
Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 20%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Coinsurance for Medicare Covered Observation Services 20%
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 0% to 20%
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare-covered Individual Sessions 0% to 20%
Coinsurance for Medicare-covered Group Sessions 0% to 20%
Prior Authorization Required for Outpatient Substance Abuse Services
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 $270.00
Podiatry services
Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 30%
Podiatry Services:
Coinsurance for Non-Medicare Covered Podiatry Services 30%
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 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 30%
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 30%
Copayment for Medicare Covered Eyewear $0.00
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 30%
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 benefitsIn-Network:

Hearing Exams:
Coinsurance for Medicare Covered Benefits 0% to 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 $2000.00 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 30%

Prescription Drug Costs and Coverage

The UHC Nursing Home Plan IN-F001 (PPO I-SNP) offers prescription drug coverage, with an annual drug deductible of $545.00 (excludes Tiers 1 and 2)

Coverage
Cost
Coverage & Cost
Annual drug deductible$545.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail 25%
  • Preferred mail order N/A
  • Standard mail order N/A
  • Tier 2
  • Standard retail 25%
  • Preferred mail order N/A
  • Standard mail order N/A
  • Annual drug deductible$545.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
  • Tier 2
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
  • Annual drug deductible$545.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail 25%
  • Preferred mail order 25%
  • Standard mail order 25%
  • Tier 2
  • Standard retail 25%
  • Preferred mail order 25%
  • Standard mail order 25%
  • When reviewing Indiana 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 Indiana 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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