Unitedhealthcare Out Of Pocket Maximum
UnitedHealthcare Sync (PPO) H7404-004 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by UnitedHealthcare available to residents in Minnesota North Dakota. This plan includes additional Medicare prescription drug (Part-D) coverage. The UnitedHealthcare Sync (PPO) has a monthly premium of $39.00 and has an in-network Maximum Out-of-Pocket limit of $5,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,900 out of pocket. This can be a extremely nice safety net.
UnitedHealthcare Sync (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of 'preferred' providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.
UnitedHealthcare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for UnitedHealthcare Sync (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from UnitedHealthcare and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from UnitedHealthcare except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.
- Self-only: $9,100. Self-only: $8,550. Family: $18,200. Family: $17,100. The OOPM is adjusted annually by the U.S. Department of Health and Human Services (HHS) and was released in the annual Notice of Benefit and Payment Parameters on Dec.
- Out-of-pocket maximum. Recent guidance from the Department of Health and Human Services (HHS), Department of the Treasury (IRS) and the Department of Labor (DOL) clarified that effective for January 1, 2016 and later plan years, no individual, even when in a family coverage tier, can face an OOPM exposure more than the statutory single-tier ACA OOPM ceiling ($7,350 in 2018).
Try to use UnitedHealthcare network providers when possible. If you receive services from an out-of-network provider, you may be balance billed, which may mean higher out-of-pocket costs for you. John severely cuts his leg and goes to the closest emergency room (ER). The ER doctor is out-of-network.
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2020 UnitedHealthcare Medicare Advantage Plan Details
| Name: | |
|---|---|
| ID: | H7404-004 |
| Provider: | UnitedHealthcare |
| Year: | 2020 |
| Type: | Local PPO |
| Monthly Premium C+D: | $39.00 |
| Part C Premium: | $8.60 |
| MOOP: | $5,900 |
| Part D (Drug) Premium: | $30.40 |
| Part D Supplemental Premium | $0.00 |
| Total Part D Premium: | $30.40 |
| Drug Deductible: | $295.00 |
| Tiers with No Deductible: | 1 |
| Gap Coverage: | No |
| Benchmark: | not below the regional benchmark |
| Type of Medicare Health: | Enhanced Alternative |
| Drug Benefit Type: | Enhanced |
Part-C Premium
UnitedHealthcare plan charges a $8.60 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
Part-D Deductible and Premium
UnitedHealthcare Sync (PPO) has a monthly drug premium of $30.40 and a $295.00 drug deductible. This UnitedHealthcare plan offers a $30.40 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by UnitedHealthcare above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $30.40. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.
Premium Assistance
Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The UnitedHealthcare Sync (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $7.60 for 75% low income subsidy $15.20 for 50% and $22.80 for 25%.
| Full LIS Premium: | $0.00 |
|---|---|
| 75% LIS Premium: | $7.60 |
| 50% LIS Premium: | $15.20 |
| 25% LIS Premium: | $22.80 |
Gap Coverage
In 2020 once you and your plan provider have spent $4020 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA 'donut hole') You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This UnitedHealthcare plan does not offer additional coverage through the gap.
UnitedHealthcare Drug Coverage and Formulary
A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 UnitedHealthcare Sync (PPO) H7404-004 Formulary here.
See the 2020 UnitedHealthcare Formulary
2019 Plan Services
(*2020 Plan services will be added when available)
Health plan deductible
| $0 |
|---|
Emergency care/Urgent care
| Emergency | $90 per visit (always covered) |
|---|---|
| Urgent care | $30-40 per visit (always covered) |
Diagnostic procedures/lab services/imaging
| Diagnostic tests and procedures | Out-of-Network | 40% |
|---|---|---|
| Diagnostic tests and procedures | In-Network | 20% |
| Lab services | Out-of-Network | $10 |
| Lab services | In-Network | $10 |
| Diagnostic radiology services (e.g., MRI) | Out-of-Network | 40% |
| Diagnostic radiology services (e.g., MRI) | In-Network | 20% |
| Outpatient x-rays | Out-of-Network | $21 |
| Outpatient x-rays | In-Network | $14 |
Hearing
| Hearing exam | Out-of-Network | 40% |
|---|---|---|
| Hearing exam | In-Network | $15 |
| Fitting/evaluation | Not covered | |
| Hearing aids - inner ear | Out-of-Network | $330-380 |
| Hearing aids - inner ear | In-Network | $380 |
| Hearing aids - outer ear | Not covered | |
| Hearing aids - over the ear | Out-of-Network | $330-380 |
| Hearing aids - over the ear | In-Network | $330 |
Preventive dental
| Oral exam | Out-of-Network | $0 copay |
|---|---|---|
| Oral exam | In-Network | $0 copay |
| Cleaning | Out-of-Network | $0 copay |
| Cleaning | In-Network | $0 copay |
| Fluoride treatment | Out-of-Network | $0 copay |
| Fluoride treatment | In-Network | $0 copay |
| Dental x-ray(s) | Out-of-Network | $0 copay |
| Dental x-ray(s) | In-Network | $0 copay |
Comprehensive dental
| Non-routine services | Not covered | |
|---|---|---|
| Diagnostic services | Out-of-Network | 0-50% |
| Diagnostic services | In-Network | 0-50% |
| Restorative services | Out-of-Network | 0-50% |
| Restorative services | In-Network | 20-50% |
| Endodontics | Out-of-Network | 0-50% |
| Endodontics | In-Network | 50% |
| Periodontics | Out-of-Network | 0-50% |
| Periodontics | In-Network | 50% |
| Extractions | Out-of-Network | 0-50% |
| Extractions | In-Network | 50% |
| Prosthodontics, other oral/maxillofacial surgery, other services | Out-of-Network | 0-50% |
| Prosthodontics, other oral/maxillofacial surgery, other services | In-Network | 0-50% |
Vision
| Routine eye exam | Out-of-Network | 40% |
|---|---|---|
| Routine eye exam | In-Network | $0 copay |
| Other | Not covered | |
| Contact lenses | Out-of-Network | 40% |
| Contact lenses | In-Network | $0 copay |
| Eyeglasses (frames and lenses) | Out-of-Network | 40% |
| Eyeglasses (frames and lenses) | In-Network | $0 copay |
| Eyeglass frames | Not covered | |
| Eyeglass lenses | Not covered | |
| Upgrades | Not covered |
Mental health services
| Inpatient hospital - psychiatric | Out-of-Network | 40% per stay |
|---|---|---|
| Inpatient hospital - psychiatric | In-Network | $400 per day for days 1 through 4 $0 per day for days 5 through 90 |
| Outpatient group therapy visit with a psychiatrist | Out-of-Network | $35-45 |
| Outpatient group therapy visit with a psychiatrist | In-Network | $30 |
| Outpatient individual therapy visit with a psychiatrist | Out-of-Network | $35-45 |
| Outpatient individual therapy visit with a psychiatrist | In-Network | $40 |
| Outpatient group therapy visit | Out-of-Network | $35-45 |
| Outpatient group therapy visit | In-Network | $30 |
| Outpatient individual therapy visit | Out-of-Network | $35-45 |
| Outpatient individual therapy visit | In-Network | $40 |
Skilled Nursing Facility
| Out-of-Network | 40% per stay |
|---|---|
| In-Network | $0 per day for days 1 through 20 $160 per day for days 21 through 57 $0 per day for days 5 |
Rehabilitation services
| Occupational therapy visit | Out-of-Network | 40% |
|---|---|---|
| Occupational therapy visit | In-Network | $40 |
| Physical therapy and speech and language therapy visit | Out-of-Network | 40% |
| Physical therapy and speech and language therapy visit | In-Network | $40 |
Ground ambulance
| Out-of-Network | $250 |
|---|---|
| In-Network | $250 |
Other health plan deductibles?
| In-Network | No |
|---|
Transportation
| Not covered |
|---|
Foot care (podiatry services)
| Foot exams and treatment | Out-of-Network | 40% |
|---|---|---|
| Foot exams and treatment | In-Network | $50 |
| Routine foot care | Out-of-Network | 40% |
| Routine foot care | In-Network | $50 |
Medical equipment/supplies
| Durable medical equipment (e.g., wheelchairs, oxygen) | Out-of-Network | 50% per item |
|---|---|---|
| Durable medical equipment (e.g., wheelchairs, oxygen) | In-Network | 20% per item |
| Prosthetics (e.g., braces, artificial limbs) | Out-of-Network | 40% per item |
| Prosthetics (e.g., braces, artificial limbs) | In-Network | 20% per item |
| Diabetes supplies | Out-of-Network | 40% per item |
| Diabetes supplies | In-Network | $0 per item |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
|---|
Medicare Part B drugs
| Chemotherapy | Out-of-Network | 40% |
|---|---|---|
| Chemotherapy | In-Network | 20% |
| Other Part B drugs | Out-of-Network | 40% |
| Other Part B drugs | In-Network | 20% |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $10,000 In and Out-of-network $5,900 In-network |
|---|
Optional supplemental benefits
| No |
|---|
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network | No |
|---|
Inpatient hospital coverage
| Out-of-Network | 40% per stay |
|---|---|
| In-Network | $400 per day for days 1 through 4 $0 per day for days 5 through 90 $0 per day for days 91 |
Outpatient hospital coverage
| Out-of-Network | 40% per visit |
|---|---|
| In-Network | $400 per visit |
Doctor visits
| Primary | Out-of-Network | 40% per visit |
|---|---|---|
| Primary | In-Network | $15 per visit |
| Specialist | Out-of-Network | 40% per visit |
| Specialist | In-Network | $50 per visit |
Preventive care
| Out-of-Network | 0-40% |
|---|---|
| In-Network | $0 copay |
Ready to Enroll?
Or Call
1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST
United Healthcare Out Of Pocket Maximum
Coverage Area for UnitedHealthcare Sync (PPO)
(Click county to compare all available Advantage plans)
| State: | Minnesota North Dakota |
|---|---|
| County: | Aitkin, Anoka, Becker, Beltrami, Benton, Blue Earth, Brown, Burleigh, Carlton, Carver, Cass, Cass, Chisago, Clay, Clearwater, Crow Wing, Dakota, Douglas, Goodhue, Grand Forks, Grant, Hennepin, Hubbard, Isanti, Itasca, Kanabec, Koochiching, Le Sueur, McLeod, Meeker, Mille Lacs, Morrison, Morton, Nicollet, Otter Tail, Pine, Polk, Ramsey, Rice, Scott, Sibley, St. Louis, Wabasha, Wadena, Washington, Winona, Wright, |
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Does Out Of Pocket Maximum Include Deductible Unitedhealthcare
Source: CMS.
Data as of September 4, 2019.
Star Rating as of October 10, 2019.
Plan Services are 2019 information as reference. 2020 information will be added when released.
Notes: Data are subject to change as contracts are finalized. For 2020, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit.Includes 2020 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.