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Medicare Product Overview Tables - Chapter 4, 2020 UnitedHealthcare Administrative Guide

Medicare Product Overview Tables

Organized by Medicare Advantage (MA) product name, the following information answers these questions:

  • Medicare Member's Eligibility
  • How do members access physicians and health care professionals?
  • Does a primary care physician have to make a referral to a specialist?
  • Is the treating network physician and/or facility required to give notification when providing certain services? 

To view details, click on the "+" sign by the product name of interest. 

MA – Products for Individuals 

Each plan name below is preceded by either the AARP or UnitedHealthcare brand name:

HMO

  • Medicare Advantage
  • Medicare Advantage Access
  • Medicare Advantage Essential
  • Medicare Advantage Focus
  • Medicare Advantage Mosaic
  • Medicare Advantage Value
  • Medicare Advantage Walgreens
  • The VillagesMedicare Advantage

HMO-POS

  • Medicare Advantage
  • Medicare Advantage Essential
  • Medicare Advantage Focus
  • Medicare Advantage Plus
  • Medicare Advantage Premier
  • Medicare Advantage Profile
  • Medicare Advantage Value
  • The VillagesMedicare Advantage

Medicare Member's Eligibility: Members who are Medicare eligible for Part A and B, reside in the plan’s service area and do not have ESRD.

How do members access physicians and health care professionals?

Members choose a PCP from the network of physicians who can help coordinate their care.

HMO benefit plans do not cover out-of-network services, except for emergency services, urgently needed services and out-of- area renal dialysis.

HMO-POS benefit plans provide out-of-network coverage for some covered benefits.*

Does a primary care physician have to make a referral to a specialist?

A referral may or may not be required to see a specialist, depending on the benefit plan.**

For further information, go online to see Medicare Advantage (MA) Referral Required Plans, or call 877-842-3210. Please have the health care ID and your TIN available.

PCPs should coordinate care with the appropriate network specialists.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, see guidelines in Chapter 6: Medical Management.

* The benefit level for non-emergency services from non-network physicians and other care providers is generally less than that for services from Medicare network physicians and other care providers.

** Most services provided to members of gatekeeper benefit plans require referrals and/or authorizations from the PCP or Physician Hospital Organization, dependent upon contractual arrangement. See Medicare Advantage (MA) Referral Required Plans in Chapter 5 for more information.

Each plan name below is preceded by either the AARP or UnitedHealthcare brand name:

  • Medicare  Advantage Assure
  • Medicare  Advantage Choice
  • Medicare Advantage Choice Essential
  • Medicare Advantage Essential
  • Medicare Advantage Focus
  • Medicare Advantage Headwaters
  • Medicare Advantage Lakeshore
  • Medicare Advantage Mosaic Choice
  • Medicare Advantage Open
  • Medicare Advantage Open Essential
  • Medicare Advantage Open Premier
  • Medicare Advantage Riverbank
  • Medicare Advantage Walgreens
  • Sync

Local PPO plan in Virginia:

  • Piedmont Select Medicare

Medicare Member's Eligibility: Members who are Medicare eligible for Part A and B, reside in the plan’s service area and do not have ESRD.

How do members access physicians and health care professionals?

Members choose a PCP from the network of physicians who can help coordinate their care.

PPO benefit plans provide out-of-network coverage for all covered network benefits.*

Does a primary care physician have to make a referral to a specialist?

No, a referral is not needed.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, see guidelines in Chapter 6: Medical Management.

* The benefit level for non-emergency services from non-network physicians and other care providers is generally less than that for services from Medicare network physicians and other care providers.

** Most services provided to members of gatekeeper benefit plans require referrals and/or authorizations from the PCP or Physician Hospital Organization, dependent upon contractual arrangement. See Medicare Advantage (MA) Referral Required Plans in Chapter 5 for more information.

Medicare Member's Eligibility: Members reside in a contracted skilled nursing facility or assisted living communities and require an institutional level of care.

How do members access physicians and health care professionals?

Members choose a PCP from the network of physicians to coordinate their care.

PPO and HMO-POS benefit plans provide out-of-network coverage.*

HMO benefit plans do not cover out-of-network services, except for emergency services, urgently needed services and out-of-area renal dialysis.

Does a primary care physician have to make a referral to a specialist?

No, a referral is not needed.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, see guidelines in Chapter 6: Medical Management.

* The benefit level for non-emergency services from non-network physicians and other care providers is generally less than that for services from Medicare network physicians and other care providers.

** Most services provided to members of gatekeeper benefit plans require referrals and/or authorizations from the PCP or Physician Hospital Organization, dependent upon contractual arrangement. See Medicare Advantage (MA) Referral Required Plans in Chapter 5 for more information.

HMO, HMO-POS, PPO, RPPO:

  • UnitedHealthcare Dual Complete

HMO:

  • UnitedHealthcare Dual Complete Focus
  • UnitedHealthcare Senior Care Options (Massachusetts)

PPO, RPPO:

  • UnitedHealthcare Dual Complete Choice

Medicare Member's Eligibility: Members who are both Medicare and Medicaid eligible.

How do members access physicians and health care professionals?

Members choose a PCP from the Medicare network of physicians, to coordinate their care.

POS and PPO benefit plans provide out-of- network coverage.*

HMO benefit plans do not cover out-of-network services, except for emergency services, urgently needed services and out-of- area renal dialysis.

Does a primary care physician have to make a referral to a specialist?

A referral may or may not be required to see a specialist, depending on the benefit plan.**

For further information, call 877-842-3210.

Please have the health care ID card and your TIN available. PCPs should coordinate care with the appropriate Medicare network specialists.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, see guidelines in Chapter 6: Medical Management.

* The benefit level for non-emergency services from non-network physicians and other care providers is generally less than that for services from Medicare network physicians and other care providers.

** Most services rendered to members in referral-required benefit plans require referrals and/or authorizations from the PCP or Physician Hospital Organization, dependent upon contractual arrangement.

HMO:

  • UnitedHealthcare Chronic Complete
  • UnitedHealthcare Medicare
  • Advantage Assist
  • UnitedHealthcare Medicare
  • Advantage Walgreens

PPO:

  • UnitedHealthcare Medicare
  • Advantage Assist

RPPO:

  • UnitedHealthcare Medicare Gold
  • UnitedHealthcare Medicare Silver

Medicare Member's Eligibility: Members who have one or more of the following qualifying chronic conditions: diabetes, chronic heart failure, and/ or cardiovascular disorders.

How do members access physicians and health care professionals?

Members choose a PCP from the Medicare network of physicians who can help coordinate their care.

PPO benefit plans provide out-of-network coverage for all covered network benefits.*

HMO benefit plans do not cover out-of-network services, except for emergency services, urgently needed services and out-of-area renal dialysis.

Does a primary care physician have to make a referral to a specialist?

A referral may or may not be required to see a specialist, depending on the benefit plan.**

For further information, call 877-842-3210.

Please have the health care ID card and your TIN available. PCPs should coordinate care with the appropriate Medicare network specialists.

Is the treating network physician and/or facility required to give notification when providing certain services? 

* The benefit level for non-emergency services from non-network physicians and other care providers is generally less than that for services from Medicare network physicians and other care providers.

** Most services rendered to members in referral-required benefit plans require referrals and/or authorizations from the PCP or Physician Hospital Organization, dependent upon contractual arrangement.

HMO:

  • Erickson Advantage Liberty

HMO-POS:

  • Erickson Advantage Signature
  • Erickson Advantage Freedom

HMO-POS (Special Needs Plans):

  • Erickson Advantage Champion (Chronic)
  • Erickson Advantage Guardian (Institutional)

Medicare Member's Eligibility: Members who reside in an Erickson Retirement Community.

How do members access physicians and health care professionals?

Members are assigned a PCP from the Erickson Health Group network of physicians. The primary physician coordinates their care.

HMO-POS benefit plans provide out-of-network coverage for some covered benefits.*

HMO benefit plans do not cover out-of-network services, except for emergency services, urgently needed services and out-of-area renal dialysis.

Does a primary care physician have to make a referral to a specialist?

No, a referral is not needed.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, see guidelines in Chapter 6: Medical Management.

* The benefit level for non-emergency services from non-network physicians and other care providers is generally less than that for services from Medicare network physicians and other care providers.

** Most services rendered to members in referral-required benefit plans require referrals and/or authorizations from the PCP or Physician Hospital Organization, dependent upon contractual arrangement.

MA - Products for Groups 

Medicare Member's Eligibility: Members must meet all Medicare eligibility requirements as well as the employer’s requirements.

How do members access physicians and health care professionals?

Members choose a PCP from the Medicare network of physicians. The primary physician coordinates their care.

HMO benefit plans provide out-of-network coverage for some covered benefits.*

HMO benefit plans do not cover out-of-network services, except for emergency services, urgently needed services and out-of-area renal dialysis.

Does a primary care physician have to make a referral to a specialist?

A referral may or may not be required to see a specialist based on the benefit plan.**

For further information, go online to see Medicare Advantage (MA) Referral Required Plans, or call the number on the back of the health care ID card.

Please have the health care ID and your TIN available. PCPs should coordinate care with the appropriate Medicare network specialists.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, see guidelines in Chapter 6: Medical Management.

* The benefit level for non-emergency services from non-network physicians and other care providers is generally less than that for services from Medicare network physicians and other care providers.

** Most services rendered to members in referral-required benefit plans require referrals and/or authorizations from the PCP or Physician Hospital Organization, dependent upon contractual arrangement.

Medicare Member's Eligibility: Members must meet all Medicare eligibility requirements as well as the employer’s requirements.

How do members access physicians and health care professionals?

Members may choose a primary care physician from the network of physicians. If a primary physician is chosen, the primary physician coordinates their care.

Regional PPO plans provide out-of-network coverage.*

Does a primary care physician have to make a referral to a specialist?

No, a referral is not needed.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, see guidelines in Chapter 6: Medical Management.

* The benefit level for non-emergency services from non-network physicians and other care providers is generally less than that for services from Medicare network physicians and other care providers.

** Most services rendered to members in referral-required benefit plans require referrals and/or authorizations from the PCP or Physician Hospital Organization, dependent upon contractual arrangement.

Medicare Member's Eligibility: Members must meet all Medicare eligibility requirements as well as the employer’s requirements.

How do members access physicians and health care professionals?

Members are encouraged but not required to see a primary care physician from the Medicare network of physicians to help coordinate their care.

Does a primary care physician have to make a referral to a specialist?

No, a referral is not needed.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, see guidelines in Chapter 6: Medical Management.

* The benefit level for non-emergency services from non-network physicians and other care providers is generally less than that for services from Medicare network physicians and other care providers.

** Most services rendered to members in referral-required benefit plans require referrals and/or authorizations from the PCP or Physician Hospital Organization, dependent upon contractual arrangement.

MA Products

Individual HMO, HMO-POS and PPO Plans

These plans provide all of the benefits covered under Original Medicare and more. Our plans do not have limits for pre-existing conditions and they do not require physical exams. Members with end-stage renal disease (ESRD) may not be eligible to enroll in a plan. The member may have multiple choices of health plans depending on where they live.

While exact benefits may vary, these plans may give:

  • Access to medical care through a trusted network of care providers
  • Coverage for many preventive services with no copays
  • Help with financial protection with annual out-of-pocket limits
  • Worldwide emergency care coverage
  • Medicare Part D prescription drug coverage
  • Coverage for additional benefits like routine vision and hearing exams

Some plans do not require an additional monthly premium for this coverage. The member simply continues to pay the Medicare Part B premium unless the member has coverage through Medicaid or another third party.

Dual Special Needs Plans

This Special Needs Plan (SNP) meets the needs of individuals enrolled in Medicare who also qualify for Medicaid (called dual eligible). This plan combines the benefits of Medicare and Medicaid.

Chronic Special Needs Plans

This SNP is for members who have one or more severe or disabling chronic conditions. We help members manage their condition as well as their overall health and well-being.

Institutional Special Needs Plans

These SNPs are for members who reside in a contracted skilled nursing facility or assisted living facility and require an institutional level of care.

UnitedHealthcare Group MA

We offer these plans to employer groups for their retired Medicare-eligible employees. They have benefits similar to the individual plans. The member’s health care ID card has the employer group name and number on it.