Your plan details for
11218 Kings County

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UHC Medicare Advantage Patriot No Rx NY-MA02 (Regional PPO)

The information provided in this document may be subject to change over time and may become outdated. For the most current and up-to-date information, please refer to our website at UHC.com/medicare.

Discover the benefits

  • Medicare Part B premium giveback

    Up to $1,200 giveback a year on your Medicare Part B premium

  • Dental benefits

    $0 copay for network dental such as exams, x-rays and routine cleanings

  • OTC credit

    $50 credit every quarter for OTC products in-store or online

Explore the plan details

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Explore the plan details

Doctor visits

Find out about this plan’s copays for primary care providers and specialists.

Primary care provider (PCP)

$0 copay
In-network
$58 copay
Out-of-network

Specialist

$50 copay
In-network
$80 copay
Out-of-network

Virtual visits

$0 copay

to talk with a network telehealth provider online through live audio and video.

Annual routine physical

$0 copay

1 per year

In-network
50% of the cost

combined visits in and out-of-network

Preventive services (such as covered screenings, vaccinations, etc.)

$0 copay

for covered services

In-network
$0 - 50% of the cost

(depending on the service)

Out-of-network

Mental health (outpatient)

Group:

$15 copay

Individual:

$25 copay

In-network

Group:

$30 copay

Individual:

$40 copay
Out-of-network

Opioid treatment services

$0 copay
In-network
$0 copay
Out-of-network

Medical benefit information

See this plan's benefits, costs and copays. For full plan details, see the Evidence of Coverage or Summary of Benefits under the Plan Documents section.

Inpatient hospital care

$495 copay

per day: days 1-5

$0 copay

per day: days 6 and beyond for unlimited days

In-network
$595 copay

per day: days 1-20

$0 copay

per day: days 21 and beyond for unlimited days

Out-of-network

Skilled nursing facility

$0 copay

per day: days 1-20

$203 copay

per day: days 21-100

In-network
$225 copay

per day: days 1-100

Out-of-network

Outpatient hospital services (including surgery and observation)

$495 copay
In-network
50% of the cost
Out-of-network

Ambulatory surgical center

$445 copay
In-network
50% of the cost
Out-of-network

Physical and speech therapy

$40 copay
In-network
$80 copay
Out-of-network

Occupational therapy

$40 copay
In-network
$80 copay
Out-of-network

Lab services

$0 copay
In-network
$0 copay
Out-of-network

Outpatient X-rays

$35 copay
In-network
$55 copay
Out-of-network

Diagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.)

$45 copay
In-network
50% of the cost
Out-of-network

Diagnostic radiology services (such as MRIs, CT scans, etc.)

$250 copay
In-network
50% of the cost
Out-of-network

Diabetes monitoring supplies

$0 copay

for covered brands

In-network
50% of the cost
Out-of-network

Home health care

$0 copay
In-network
50% of the cost
Out-of-network

Urgent care

$55 copay

per visit (

$0 copay

when outside of the United States)

Emergency care

$125 copay

per visit (

$0 copay

when outside of the United States)

Ambulance services

$290 copay

for ground or air

Dental coverage

Learn about this plan’s dental coverage options and costs.

Routine dental

$0 copay

for covered network preventive services such as oral exams, routine cleanings, X-rays, and fluoride

You will have access to one of Medicare Advantage's largest dental networks, or you can choose any dentist. Seeing a network dentist may save you money.

Platinum Dental Rider

add $54 to your monthly premium.


$1,500 per year for covered dental services through the Platinum Dental Rider.

$0 copay for covered network preventive services such as oral exams, routine cleanings, X-rays and fluoride

50% coinsurance for bridges and dentures, $0 copay for all other covered network comprehensive services such as fillings, crowns, root canals and extractions

You will have access to one of Medicare Advantage's largest dental networks, or you can choose any dentist. Seeing a network dentist may save you money.

Extra benefits and programs

See more of the benefits and programs offered by this plan that are not provided under Original Medicare.

See the UnitedHealthcare plan difference

Routine eye exam

$0 copay

1 per year

In-network
$80 copay

combined visits in and out-of-network

Routine eyewear

Plan pays

up to $250

every two years 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 sounds better with more access

Routine hearing exam

$0 copay

1 per year

In-network
$80 copay

combined visits in and out-of-network

Hearing aids

Copays from

$99 - $1,249

for a broad selection of OTC and brand-name prescription hearing aids through UnitedHealthcare Hearing, up to 2 hearing aids every year

Get more for your everyday needs

OTC credit

$50 credit

per quarter to buy covered OTC products.

$50 credit

per quarter to buy covered OTC products.

Rewards

Earn up to $155

in rewards every year for getting an annual wellness visit, being physically active, connecting with others and more.

Earn up to $155

in rewards every year for getting an annual wellness visit, being physically active, connecting with others and more.

Fitness program

$0 copay

for Renew Active®, which includes a free membership at core gyms, plus online fitness classes and brain health challenges.

$0 copay

for Renew Active®, which includes a free membership at core gyms, plus online fitness classes and brain health challenges.

Routine foot care

$45 copay

6 visits per year

In-network
$80 copay

combined visits in and out-of-network

Meal benefit

$0 copay

for 28 home-delivered meals immediately after an inpatient hospitalization or skilled nursing facility (SNF) stay.

Plan documents

Important documents that provide the details you need about this plan's coverage and benefits, prescription drugs, enrollment, providers and more.

Language

General Plan Information

Medical Providers

General Plan Information

Footnotes & disclaimers

footnote
Disclaimer information

 

Enrollment Disclaimer Information:

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies. For Medicare Advantage and/or Prescription Drug Plans: A Medicare Advantage organization with a Medicare contract and/or a Medicare-approved Part D sponsor. For Dual Special Needs Plans: A Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan's contract renewal with Medicare.

 

AARP-related Disclaimer:

UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers. You do not need to be an AARP member to enroll in a Medicare Advantage or Prescription Drug Plan. AARP encourages you to consider your needs when selecting products and does not make specific product recommendations for individuals. AARP does not employ or endorse agents, producers or brokers.

 

Featured Benefits:

- Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply.

 

- Optum HouseCalls may not be available in all areas.

 

- OTC, food, and/or utility benefits have expiration timeframes. Review your Evidence of Coverage (EOC) for more information. The healthy food and utilities benefit is a special supplemental benefit only available to chronically ill enrolles with a qualifying condition, such as diabetes, cardiovascular disorders, chronic heart failure, chronic high blood pressure and/or chronic high cholesterol, and who also meet all applicable plan coverage criteria. There may be other qualified chronic conditions not listed.

 

- The Giveback benefit is a reduction in your Medicare Part B premium.

 

- A 50% coinsurance applies to covered dental comprehensive services. If your plan offers out-of-network dental coverage and you see an out-of-network dentist, you might be billed more. Network size varies by local market.

 

- Reward offerings may vary by plan. Reward program Terms of Service apply.

 

- If your plan offers out-of-network dental coverage and you see an out-of-network dentist, you might be billed more. Network size varies by local market.

 

- Routine transportation not for use in emergencies. A trip is one-way and roundtrip is two trips.

 

- Annual routine eye exam and an allowance for contacts or one pair of frames, with standard (single, bi-focal, tri-focal or standard progressive) lenses covered in full every one or two years. Review your Evidence of Coverage (EOC) for more information.

 

- CareFlex benefit credits can only be used by members of AARP Medicare Advantage CareFlex plans for cost-shares for certain Medicare Parts A and B covered items and services. CareFlex credits are loaded on a Visa debit card. Unused credits will rollover each quarter and expire Dec. 31. Credits not redeemable for cash.

 

- The fitness benefit and gym network varies by plan/area and participating locations may change. The fitness benefit includes a standard fitness membership at participating locations. Not all plans offer access to premium locations. Consult your doctor prior to beginning an exercise program or making changes to your lifestyle or health care routine.

 

- The plan only covers hearing aids from a UnitedHealthcare Hearing network provider. Other hearing exam providers are available in the UnitedHealthcare network.

 

Other Languages:

This information is available for free in other languages. Please contact Customer Service for additional information. 

 

Esta información está disponible sin costo en otros idiomas. Para obtener más información comuníquese con nuestro Servicio al Cliente. 

 

本資訊可以其他語言免費提供。如需更多資訊，請聯絡客戶服務部。 

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