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UHC Medicare Advantage NH-001A (PPO) - H2001-028-000
$33.80
Monthly Premium
UHC Medicare Advantage NH-001A (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H2001-028-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$33.80
Monthly Premium
New Hampshire 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 New Hampshire 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 | $33.80 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $590.00 |
| Out-of-pocket maximum | $9,350.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Coinsurance for Primary Care Office Visit 0% to 20% Note: $0 copayment applies to Medicare covered telehealth, Medicare covered remote monitoring, and visits conducted in the member's home. The higher cost share applies to all other Medicare covered services. |
| Specialty doctor visit | In 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 30% 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 care | In Network In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $1880 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 30% 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 $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 transportation | In Network In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services 20% Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance Out of Network 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 Medicare Advantage NH-001A (PPO) covers a range of additional benefits. Learn more about UHC Medicare Advantage NH-001A (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In Network In-Network: Chiropractic Services: Coinsurance for Medicare-covered Chiropractic Services 20% Prior Authorization Required for Chiropractic Services Out of Network Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 30% |
| Diabetes supplies, training, nutrition therapy and monitoring | In Network In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Out of Network Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 30% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 30% |
| Durable medical equipment (DME) | In Network In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 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 30% |
| Diagnostic tests, lab and radiology services, and X-rays | Diagnostic 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 care | In 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 40% |
| Mental health inpatient care | In Network In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $1880 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 30% 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 In-Network: Outpatient Mental Health Services: Coinsurance for Medicare-covered Individual Sessions 0% to 20% Coinsurance for Medicare-covered Group Sessions 20% Out of Network Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 30% Coinsurance for Medicare Covered Group Sessions 30% |
| Outpatient services/surgery | In 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 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 30% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30% 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 care | In Network In-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare-covered Individual Sessions 0% to 20% Coinsurance for Medicare-covered Group Sessions 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 30% Coinsurance for Medicare Covered Group Sessions 30% 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 items | OTC credit: $115 credit per quarter to buy covered OTC products. |
| Podiatry services | In Network In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0 Copayment for Routine Foot Care $0
Out of Network Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 30% Non-Medicare Covered Podiatry Services: Coinsurance for Non-Medicare Covered Podiatry Services 30% |
| 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 | $750 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
| Coverage | Details |
|---|---|
| Vision care | Routine Eye Exam: $0 copay, 1 per year Routine Eyewear: Plan pays up to $150 every year for 1 pair of frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full. Home-delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only). |
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 In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 20% Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $0
Out of Network Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 30% |
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 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 Out of Network Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 30% |
When reviewing New Hampshire 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 New Hampshire 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 |
New Hampshire Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.