Medicare product overview tables - Chapter 5, 2021 UnitedHealthcare Administrative Guide

Product Name:

HMO

  • Medicare Advantage
  • Medicare Advantage Access
  • Medicare Advantage Focus
  • Medicare Advantage Patriot
  • Medicare Advantage Prime
  • Medicare Advantage Value
  • Medicare Advantage Walgreens
  • The Villages Medicare Advantage

HMO-POS

  • Medicare Advantage
  • Medicare Advantage Focus
  • Medicare Advantage Patriot
  • Medicare Advantage Plus
  • Medicare Advantage Profile
  • Medicare Advantage Value
  • Medicare Advantage Walgreens

Medicare Member’s Eligibility:

  • Members who are Medicare eligible for Part A and B, and reside in the plan’s service area.

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.
  • 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 1-877-842-3210.
  • Have the member ID and your TIN available. 
  • PCPs should coordinate care with the appropriate Medicare network specialists.

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

* The plan will cover services from in-network and out-of-network care providers, as long as the services are covered benefits and medically necessary. However, the member’s cost-share may be higher for covered out-of-network services.
** 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 6 for more information.

Product Name:

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

Medicare Member’s Eligibility:

  • Members who are Medicare eligible for Part A and B, and reside in the plan’s service area.

How do members access physicians and health care professionals?

  • Members should 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.*

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

  • No, a referral is not needed.

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

* The plan will cover services from in-network and out-of-network care providers, as long as the services are covered benefits and medically necessary. However, the member’s cost-share may be higher for covered out-of-network services.

Product Name:

  • UnitedHealthcare Assisted Living Plan
  • UnitedHealthcare Nursing Home Plan

Medicare Member’s Eligibility:

  • Members reside in a contracted skilled nursing facility or assisted living facility and require an institutional level of care.

How do members access physicians and health care professionals?

  • Members choose a PCP from the Medicare 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 physician and/or facility required to give notification when providing certain services?

* The plan will cover services from in-network and out-of-network care providers, as long as the services are covered benefits and medically necessary. However, the member’s cost-share may be higher for covered out-of-network services.

Product Name:

Dual Special Needs Plans (HMO, HMO-POS, PPO and Regional PPO)

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.
  • HMO-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 1-877-842-3210.
  • Have the member ID card and your TIN available. PCPs should coordinate care with the appropriate Medicare network specialists.

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

* The plan will cover services from in-network and out-of-network care providers, as long as the services are covered benefits and medically necessary. However, a member’s cost-share may be higher for covered out-of-network services.
** 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.

Product Name:

Chronic Special Needs Plans (HMO, PPO and Regional PPO)

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 1-877-842-3210.
  • Have the member ID card and your TIN available. PCPs should coordinate care with the appropriate Medicare network specialists.

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

* The plan will cover services from in-network and out-of-network care providers, as long as the services are covered benefits and medically necessary. However, a member’s cost-share may be higher for covered out-of-network services.
** 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.

Product Name:

Erickson Advantage Plans (HMO-POS)

Erickson Advantage Freedom Erickson Advantage Liberty Erickson Advantage Signature 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 Medical Group network of physicians. The primary physician coordinates their care.
  • 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?

  • No, a referral is not needed.

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

* The plan will cover services from in-network and out-of-network care providers, as long as the services are covered benefits and medically necessary. However, a member’s cost-share may be higher for covered out-of-network services.

MA - Products for Groups 

Product Name:

UnitedHealthcare Group Medicare Advantage (HMO)

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 member ID card.
  • Have the member ID card and your TIN available. PCPs should coordinate care with the appropriate Medicare network specialists.

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

* The plan will cover services from in-network and out-of-network care providers, as long as the services are covered benefits and medically necessary. However, a member’s cost-share may be higher for covered out-of-network services.
** 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.

Product Name:

UnitedHealthcare Group Medicare Advantage (Regional PPO)

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 Medicare 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 physician and/or facility required to give notification when providing certain services?

* The plan will cover services from in-network and out-of-network care providers, as long as the services are covered benefits and medically necessary. However, a member’s cost-share may be higher for covered out-of-network services.

Product Name:

UnitedHealthcare Group Medicare Advantage (PPO

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 physician and/or facility required to give notification when providing certain services?


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. 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 ID card has the employer group name and number on it.