UnitedHealthcare Medicare Advantage Assure (PPO) H0271-004-000 2022 Plan Details and Costs (2024)

Table of Contents
Basic Costs and Coverage Health Care Services and Medical Supplies Dental Benefits Vision Benefits Hearing Benefits Preventive Services and Health/Wellness Education Programs Prescription Drug Costs and Coverage Plan Documents Illinois Counties Served References

UnitedHealthcare Medicare Advantage Assure (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare

Plan ID: H0271-004-000

$29.10 Monthly Premium

Illinois 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 Illinois 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$29.10
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$480.00
Out-of-pocket maximum$7,550.00
Initial drug coverage limit$4,430.00
Catastrophic drug coverage limit$7,050.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%

Inpatient hospital careIn-Network:

Acute Hospital Services:
$275.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services

Urgent care
Urgent Care:
Copayment for Urgent Care $65.00

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 transportationIn-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services 20%

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Section B - 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

Health Care Services and Medical Supplies

UnitedHealthcare Medicare Advantage Assure (PPO) covers a range of additional benefits. Learn more about UnitedHealthcare Medicare Advantage Assure (PPO) 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 50%

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 care
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 30%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 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 20%
Coinsurance for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Substance Abuse Services

Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $210.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

Podiatry servicesIn-Network:

Podiatry Services:
Coinsurance for Medicare-Covered Podiatry Services 20%
Copayment for Routine Foot Care $0.00

  • Maximum 4 visits every year
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$170.50 per day for days 21 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 careIn-Network:

Preventive Dental:
Copayment for Oral Exams $0.00

  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 3 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $3500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Coinsurance for Medicare-covered Benefits 20%
Copayment for Non-routine Services $0.00
Copayment for Diagnostic Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Restorative Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $3500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental

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%
Coinsurance for Medicare Covered Eyewear 30%
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 benefits
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 30%
Copayment for Non-Medicare Covered Hearing Aids $0.00

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 programsIn-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 & vagin*l 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

    Prescription Drug Costs and Coverage

    The UnitedHealthcare Medicare Advantage Assure (PPO) offers prescription drug coverage, with an annual drug deductible of $480.00 (excludes Tier 1)

    Coverage

    Cost

    Coverage & Cost
    Annual drug deductible$480.00 (excludes Tier 1)
    Tier 1
  • Preferred retail 25%
  • Standard retail 25%
  • Preferred mail order 25%
  • Standard mail order 25%
    •
    Annual drug deductible$480.00 (excludes Tier 1)
    Tier 1
  • Preferred retail N/A
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
    •
    Annual drug deductible$480.00 (excludes Tier 1)
    Tier 1
  • Preferred retail 25%
  • Standard retail 25%
  • Preferred mail order 25%
  • Standard mail order 25%
    •

    When reviewing Illinois 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 Illinois that offer similar benefits at similar or lower prices than the plan above. Call 1-855-580-1854 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents
    • Summary of benefits
    • Star ratings

    Illinois Counties Served

    Boone Bureau Carroll Cook Dekalb Dupage Henderson Henry Jo Daviess Kane Kankakee Kendall Knox Lake Lee Marshall Mchenry Mclean Mercer Ogle Peoria Putnam Rock Island Sangamon Stark Stephenson Tazewell Warren Whiteside Will Winnebago Woodford

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

    Back to plans in Illinois

    UnitedHealthcare Medicare Advantage Assure (PPO) H0271-004-000 2022 Plan Details and Costs (2024)

    References

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