Y0066_SB_H7778_001_000_2024_M
UHC Dual Complete MN-Y001 (HMO D-SNP)
H7778-001-000
Look inside to take advantage of the health services and drug coverages the plan provides.
Call UHC Dual Complete® (HMO D-SNP) Member Services or go online for more information
about the plan.
Toll-free 1-844-368-5888, TTY 711, or your preferred relay service
8 a.m.–8 p.m., 7 days a week, October–March; Monday–Friday, April–September
myuhc.com/communityplan
Summary of
Benefits 2024
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024
Introduction
This document is a brief summary of the benefits and services covered by UHC Dual Complete®
(HMO D-SNP). It includes answers to frequently asked questions, important contact information,
an overview of benefits and services offered, and information about your rights as a member of
UHC Dual Complete® (HMO D-SNP). Key terms and their definitions appear in alphabetical order in
the last chapter of the Member Handbook.
Table of Contents
A. Disclaimers ...................................................................................................................................... 1
B. Frequently asked questions (FAQ) ................................................................................................ 5
C. List of covered Services ...............................................................................................................11
D. Services covered outside of UHC Dual Complete® (HMO D-SNP) ..........................................29
E. Services that UHC Dual Complete® (HMO D-SNP) Medicare, or Medical Assistance
do not cover ..................................................................................................................................29
F. Your rights as a member of the plan ........................................................................................... 30
G. How to file a complaint or appeal a denied service ...................................................................32
H. What to do if you suspect fraud ..................................................................................................32
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 1
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
A. Disclaimers
This is a summary of health services covered by UHC Dual Complete® (HMO D-SNP)
for January 1–December 31, 2024. This is only a summary. Please read the Member
Handbook for the full list of benefits. You can view the Member Handbook on our
website at myuhc.com/communityplan. If you would like a print copy, call UHC Dual
Complete® (HMO D-SNP) Member Services at the number of the bottom of this page.
• UHC Dual Complete® (HMO D-SNP) is a health plan that contracts with both Medicare and
the Minnesota Medical Assistance program to provide benefits of both programs to enrollees.
Enrollment in UHC Dual Complete® (HMO D-SNP) depends on contract renewal.
• For information about choice counseling services, call the Minnesota Department of Human
Services Health Care Consumer Support (HCCS) line at 1-651-297-3862 or 1-800-657-3672.
• This is not a complete list. The benefit information is a brief summary, not a complete
description of benefits. For more information call UHC Dual Complete® (HMO D-SNP) Member
Services or read the Member Handbook.
• UHC Dual Complete® (HMO D-SNP) is for people who:
– Are at least 18 years of age and under age 65
– Have a certified disability through the Social Security Administration or the State Medical
Review Team or through the Developmental Disability Waiver
– Live in the service area
– Have Medicare Parts A and B and Medical Assistance
• UHC Dual Complete® (HMO D-SNP) you can get your Medicare and Medical Assistance
services in one health plan. A UHC Dual Complete® (HMO D-SNP) care coordinator will help
manage your health care needs.
• UnitedHealthcare does not discriminate on the basis of race, color, national origin, sex, age or
disability in health programs and activities.
• For more information about Medicare, you can read the Medicare & You handbook. It has
a summary of Medicare benefits, rights, and protections and answers to the most frequently
asked questions about Medicare. You can get it at the Medicare website (medicare.gov) or by
calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should
call 1-877-486-2048. For more information about Medical Assistance, call the Minnesota
Department of Human Services at 1-651-431-2203 or toll-free at 1-800-657-3739. TTY users
should call 1-800-627-3529.
• ATTENTION: If you speak Spanish, language assistance services, free of charge, are available
to you. Call UHC Dual Complete® (HMO D-SNP) Member Services at the number at the bottom
of this page. The call is free.
• FIIRO GAAR AH: Haddii aad kuhadasho af-soomaali, adeegyada kaalmada luuqadda, lacag
la’aan, ayaa diyaar kuu ah. Ka wac UHC Dual Complete® (HMO D-SNP) Member Adeegyada
Xubinta lambarka ku yaal boggan hoose. Wacitaanka waa bilaash.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 2
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
• You can get this document for free in languages other than English and in other formats, such
as large print, braille, or audio. Call UHC Dual Complete® (HMO D-SNP) Member Services at
the number at the bottom of this page.
• To make or change a standing request to get this document, now and in the future, in a
language other than English or in an alternate format, call UHC Dual Complete® (HMO D-SNP)
Member Services at the number at the bottom of this page.
• Participation in the Renew Active® program is voluntary. Consult your doctor prior to beginning
an exercise program or making changes to your lifestyle or health care routine. Renew Active
includes standard fitness membership. Fitness membership, equipment, classes, personalized
fitness plans, caregiver access and events may vary by location. Certain services, discounts,
classes, events, and online fitness offerings are provided by affiliates of UnitedHealthcare
Insurance Company or other third parties not affiliated with UnitedHealthcare. Participation in
these third-party services are subject to your acceptance of their respective terms and policies.
UnitedHealthcare is not responsible for the services or information provided by third parties.
The information provided through these services is for informational purposes only and is not a
substitute for the advice of a doctor. Gym network may vary in local market.
• Benefits may change on January 1 of each year.
• The Formulary, pharmacy network, and/or provider network may change at any time. You will
receive notice when necessary. We will notify affected enrollees about changes at least 30 days
in advance.
• UHC Dual Complete® (HMO D-SNP) is insured through UnitedHealthcare Insurance Company
or one of its affiliated companies, 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.
• We do not offer every plan available in your area. Any information we provide is limited to those
plans we do offer in your area. Please contact medicare.gov or 1-800-MEDICARE to get
information on all of your options.
• Out-of-network/non-contracted providers are under no obligation to treat UHC Dual Complete®
(HMO D-SNP) members, except in emergency situations. Please call our Member Services
number or see your Member Handbook for more information, including the cost-sharing that
applies to out-of-network services.
• OptumRx is an affiliate of UnitedHealthcare Insurance Company. You are not required to use
OptumRx home delivery for a 90 day supply of your maintenance medication. If you have not
used OptumRx home delivery, you must approve the first prescription order sent directly from
your doctor to OptumRx before it can be filled. New prescriptions from OptumRx should arrive
within five business days from the date the completed order is received, and refill orders should
arrive in about seven business days. Contact OptumRx anytime at 1-877-266-4832, TTY 711.
• Benefits and features vary by plan/area. Limitations and exclusions apply.
• OTC benefits have expiration timeframes. Call UHC Dual Complete® (HMO D-SNP) or review
your Member Handbook for more information.
1-844-368-5888, TTY 711, or your preferred relay service
Attention. If you need free help interpreting this document, call
Member Services at the number above. The call is free.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 5
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Frequently asked questions Answers
What is a Special Needs BasicCare
(SNBC) plan?
UHC Dual Complete® (HMO D-SNP) is part of the
Special Needs BasicCare (SNBC) program. This
program was designed by the Minnesota Department
of Human Services (DHS) to provide special care for
people with disabilities ages 18 through 64. UHC Dual
Complete® (HMO D-SNP) combines your Medicare
and Medical Assistance services. It combines your
doctors, hospital, pharmacies, home health care,
nursing home care, and other health care providers
into one coordinated care system. It also has care
coordinators to help you manage all your providers
and services. They all work together to provide the
care you need.
Our SNBC program is called UHC Dual Complete®
(HMO D-SNP).
B. Frequently asked questions (FAQ)
The following table lists frequently asked questions.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 6
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Frequently asked questions Answers
Will I get the same Medicare and
Medical Assistance benefits in
UHC Dual Complete® (HMO D-SNP)
that I get now?
You will get most of your covered Medicare and
Medical Assistance benefits directly from UHC Dual
Complete® (HMO D-SNP). You will work with a team
of providers who will help determine what services
will best meet your needs. This means that some of
the services you get now may change based on your
needs, and your doctor and care team assessment.
You may also get other benefits outside of your health
plan the same way you do now, directly from another
source, such as the State, county, Federal government,
or Tribal nation.
When you enroll in UHC Dual Complete® (HMO
D-SNP), you and your care team will work together to
develop a care plan to address your health and support
needs, reflecting your personal preferences and goals.
If you are taking any Medicare Part D prescription
drugs that UHC Dual Complete® (HMO D-SNP) does
not normally cover, you can get a temporary supply
and we will help you to transition to another drug or get
an exception for UHC Dual Complete® (HMO D-SNP)
to cover your drug if medically necessary. For more
information, call UHC Dual Complete® (HMO D-SNP)
Member Services at the numbers listed at the bottom
of this page.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 7
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Frequently asked questions Answers
Can I go to the same doctors I use
now?
This is often the case. If your providers (including
doctors, hospitals, therapists, pharmacies, and other
health care providers) work with UHC Dual Complete®
(HMO D-SNP) and have a contract with us, you can
keep going to them.
• Providers with an agreement with us are “in-
network.” Network providers participate in UHC
Dual Complete® (HMO D-SNP). That means they
accept members of UHC Dual Complete® (HMO
D-SNP) and provide services UHC Dual Complete®
(HMO D-SNP) covers. You must use the providers
in UHC Dual Complete® (HMO D-SNP)’s network.
If you use providers or pharmacies that are not
in our network, the plan may not pay for these
services or drugs.
• If you need urgent or emergency care or out-
of-area dialysis services, you can use providers
outside of UHC Dual Complete® (HMO D-SNP).
• If you are currently under treatment with a provider
that is out of UHC Dual Complete® (HMO D-SNP)’s
network, or have an established relationship with a
provider that is out of UHC Dual Complete® (HMO
D-SNP)’s network, call Member Services to check
about staying connected.
To find out if your providers are in the plan’s network,
call Member Services at the numbers listed at the
bottom of this page or read UHC Dual Complete®
(HMO D-SNP)’s Provider and Pharmacy Directory on
the plan’s website at myuhc.com/communityplan. If
UHC Dual Complete® (HMO D-SNP) is new for you, we
will work with you to develop a care plan to address
your needs.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 8
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Frequently asked questions Answers
What is a UHC Dual Complete® (HMO
D-SNP) care coordinator?
A care coordinator is one main person for you
to contact. This person helps to manage all your
providers and services and makes sure you get what
you need, including the following:
• Assisting you in arranging for, getting, and
coordinating assessments, tests, and health and
long-term care supports and services
• Working with you to develop and update your care
plan
• Supporting you and communicating with a variety
of agencies and persons
• Coordinating other services as outlined in your
care plan
What is a care coordinator? A care coordinator is one main person for you
to contact. This person helps to manage all your
providers and services and makes sure you get what
you need, including the following:
• Assisting you in arranging for, getting, and
coordinating assessments, tests, and health and
long-term care supports and services
• Working with you to develop and update your care
plan
• Supporting you and communicating with a variety
of agencies and persons
• Coordinating other services as outlined in your
care plan
Where is this plan available? The service area for this plan includes these
Minnesota counties: Scott and St. Louis County. You
must live in one of these counties to join the plan. Call
Member Services for more information about whether
the plan is available where you live.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 9
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Frequently asked questions Answers
What is prior authorization? Prior authorization means an approval from UHC Dual
Complete® (HMO D-SNP) to get services outside of
our network or to get services not routinely covered
by our network before you get the services. UHC
Dual Complete® (HMO D-SNP) may not cover the
service, procedure, item, or drug if you don’t get prior
authorization.
If you need urgent or emergency care or out-of-
area dialysis services, you don’t need to get prior
authorization first. UHC Dual Complete® (HMO
D-SNP) can provide you or your provider with a list of
services or procedures that require you to get prior
authorization from us before the service is provided.
Refer to Chapter 3, of the Member Handbook to learn
more about prior authorization. Refer to the Benefits
Chart in Chapter 4 of the Member Handbook to learn
which services require a prior authorization.
If you have questions about whether prior authorization
is required for specific services, procedures, items, or
drugs, call Member Services at the numbers listed at
the bottom of this page for help.
Do I pay a monthly amount (also called
a premium) UHC Dual Complete®
(HMO D-SNP)?
No. Because you have Medical Assistance, you will not
pay any monthly premiums, including your Medicare
Part B premium, for your health coverage.
Do I pay a deductible as a member of
UHC Dual Complete® (HMO D-SNP)?
No. You do not pay deductibles in UHC Dual
Complete® (HMO D-SNP).
What is the maximum out-of-pocket
amount that I will pay for medical
services as a member of UHC Dual
Complete® (HMO D-SNP)?
There is no cost-sharing for medical services in UHC
Dual Complete® (HMO D-SNP), so your annual out-of-
pocket costs will be $0.
Do I have a coverage gap for drugs? No. Because you have Medical Assistance, you will not
have a coverage gap stage for your drugs.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 10
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Frequently asked questions Answers
Who should I contact if I have
questions or need help?
If you have general questions or questions about
UHC Dual Complete® (HMO D-SNP), services,
service area, billing, or member cards, call UHC
Dual Complete® (HMO D-SNP)’s Member Services:
Call 1-844-368-5888
Calls to this number are free. 8 a.m.–8 p.m.,
7 days a week, October–March; Monday–
Friday, April–September
Member Services also has free language
interpreter services available for people who
do not speak English.
TTY 711, or your preferred relay service
Calls to this number are free. 8 a.m.–8 p.m.,
7 days a week, October–March; Monday–
Friday, April–September
If you have questions about your health, call the
NurseLine:
Call 1-877-440-9407
Calls to this number are free. 24 hours a
day, 7 days a week.
TTY 711, or your preferred relay service
Calls to this number are free. 24 hours a
day, 7 days a week.
If you need immediate behavioral health services,
call the Behavioral Health Crisis Line:
Call 1-844-368-5888
Calls to this number are free. 8 a.m.–8 p.m.,
7 days a week, October–March; Monday–
Friday, April–September
TTY 711, or your preferred relay service
Calls to this number are free. 8 a.m.–8 p.m.,
7 days a week, October–March; Monday–
Friday, April–September
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 11
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
C. List of covered services
The following table is a quick overview of what services you may need, your costs, and rules about
the benefits.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need hospital
care
Inpatient hospital
stay
$0 Except in an emergency,
your health care provider
must tell the plan of your
hospital admission.
Outpatient hospital
services, including
observation
$0
Doctor or surgeon
care
$0
Ambulatory
surgical center
(ASC) services
$0 Your provider must obtain
prior authorization.
You want to use
a health care
provider
Visits to treat an
injury or illness
$0
Specialist care $0
Wellness visits,
such as a physical
$0
Care to keep you
from getting sick,
such as flu shots
and screenings to
check for cancer
$0
“Welcome
to Medicare”
preventive visit (one
time only)
$0
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 12
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need
emergency care
Emergency room
services
$0
You may use any
emergency room if you
reasonably believe you
need emergency care.
You do not need prior
authorization and you do
not have to be in-network.
Emergency room services
are NOT covered outside of
the U.S. and its territories.
Contact the plan for details.
Urgent care $0
Urgently needed care is
NOT emergency care.
You do not need prior
authorization and you do
not have to be in-network.
Urgently needed care
services are NOT covered
outside the U.S. and its
territories. Contact the plan
for details.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 13
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need medical
tests
Lab tests and
diagnostic
procedures, such
as blood work
$0
Diagnostic
radiology services
(for example, X-rays
or other imaging
services, such
as CAT scans or
MRIs)
$0
Screening tests,
such as tests to
check for cancer
$0
You need hearing/
auditory services
Hearing screenings $0 1 per year
Hearing aids $0 Available through your
Medical Assistance
benefits
You need dental
care
Dental check-ups
and preventive care
$0 Preventative coverage for
exams, cleanings, X-rays
and fluoride. Root canals,
fillings and dentures
covered when medically
necessary.
Restorative and
emergency dental
care
$0
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 14
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need eye care Eye exams $0
Glasses or contact
lenses
$0
Other vision care $0
You need mental
health services
Mental health
services
$0
Inpatient and
outpatient care and
community-based
services for people
who need mental
health services
$0
You need
substance use
disorder services
Substance use
disorder services
$0
You need a place
to live with people
available to help
you
Skilled nursing
care
$0 Medically necessary skilled
nursing care is covered.
Nursing home care $0 Your provider must obtain
prior authorization.
You need therapy
after a stroke or
accident
Occupational,
physical, or speech
therapy
$0 There may be limits
on physical therapy,
occupational therapy, and
speech therapy services.
If so, there may be
exceptions to these limits.
Your provider must obtain
prior authorization.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 15
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need help
getting to health
services
Ambulance
services
$0 Ambulance services
must be medically
necessary. You do not
need prior authorization for
ambulance services and
you do not have to be in-
network.
Emergency
transportation
$0
Transportation
to medical
appointments and
services
$0 UHC Dual Complete®
(HMO D-SNP) is not
required to provide
transportation to your
primary care clinic (PCC) if
it is over 30 miles from your
home.
UHC Dual Complete®
(HMO D-SNP) is not
required to provide
transportation to your
specialty care clinic if it is
over 60 miles from your
home.
Transportation
to other health
services
$0
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 16
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need drugs to
treat your illness
or condition
(continued on the
next page)
Medicare Part B
prescription drugs
$0 Part B drugs include drugs
given by your doctor in
their office, some oral
cancer drugs, and some
drugs used with certain
medical equipment. Read
the Member Handbook for
more information on these
drugs.
Your provider may need to
obtain prior authorization.
Tier 1 Generic
drugs (no brand
name) (continued
on the next page)
$0 for a 30-day supply. There may be limitations on
the types of drugs covered.
Please refer to UHC Dual
Complete® (HMO D-SNP)’s
List of Covered Drugs
(Drug List) at myuhc.com/
communityplan for more
information.
UHC Dual Complete® (HMO
D-SNP) may require you
to first try one drug to treat
your condition before it will
cover another drug for that
condition.
Some drugs have quantity
limits.
Your provider must get
prior authorization from
UHC Dual Complete®
(HMO D-SNP) for certain
drugs.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 17
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need drugs to
treat your illness
or condition
(continued on the
next page)
Tier 1 Generic
drugs (no brand
name)
You must use certain
pharmacies for a very limited
number of drugs, due to
special handling, provider
coordination, or patient
education requirements
that cannot be met by most
pharmacies in your network.
These drugs are listed on
the plan’s website, List of
Covered Drugs (Drug List),
and printed materials, as
well as on the Medicare Plan
Finder on medicare.gov.
Your provider must get
prior authorization from
UHC Dual Complete®
(HMO D-SNP) for certain
drugs.
Important Message
About What You Pay for
Vaccines — Some vaccines
are considered medical
benefits. Other vaccines
are considered Part D
drugs. You can find these
vaccines listed in the plan’s
List of Covered Drugs
(Drug List). Our plan covers
most Part D vaccines at no
cost to you.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 18
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need drugs to
treat your illness
or condition
(continued on the
next page)
Tier 1 Brand name
drugs (continued
on the next page)
$0 for a 30-day supply. There may be limitations on
the types of drugs covered.
Please refer to UHC Dual
Complete® (HMO D-SNP)’s
List of Covered Drugs
(Drug List) at myuhc.com/
communityplan for more
information.
UHC Dual Complete® (HMO
D-SNP) may require you
to first try one drug to treat
your condition before it will
cover another drug for that
contition.
Some drugs have quantity
limits.
Your provider must get prior
authorization from UHC
Dual Complete® (HMO
D-SNP) for certain drugs.
UHC Dual Complete® (HMO
D-SNP) may require you
to first try one drug to treat
your condition before it will
cover another drug for that
condition.
Some drugs have quantity
limits.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 19
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need drugs to
treat your illness
or condition
(continued on the
next page)
Tier 1 Brand name
drugs
You must use certain
pharmacies for a very limited
number of drugs, due to
special handling, provider
coordination, or patient
education requirements
that cannot be met by most
pharmacies in your network.
These drugs are listed on
the plan’s website, List of
Covered Drugs (Drug List),
and printed materials, as
well as on the Medicare Plan
Finder on medicare.gov.
Important Message
About What You Pay for
Vaccines — Some vaccines
are considered medical
benefits. Other vaccines
are considered Part D
drugs. You can find these
vaccines listed in the plan’s
List of Covered Drugs
(Drug List). Our plan covers
most Part D vaccines at no
cost to you.
Your provider must get
prior authorization from
UHC Dual Complete®
(HMO D-SNP) for certain
drugs.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 20
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need drugs to
treat your illness
or condition
(continued on the
next page)
Over-the-counter
(OTC) drugs
$0 There may be limitations on
the types of drugs covered.
Please refer to UHC
Dual Complete® (HMO
D-SNP)’s List of Covered
Drugs (Drug List) for more
information.
Over-the-counter benefits
have expiration timeframes.
Call UHC Dual Complete®
(HMO D-SNP) or review
your Member Handbook
for more information.
Diabetes
medications
$0 for 30-day supply.
When you reach the out-of-
pocket limit of $8,000 for
your Part D prescription
drugs, the Catastrophic
Coverage Stage begins.
You will stay in the
Catastrophic Coverage
Stage until the end of the
calendar year. During this
stage, your copays for
Part D drugs will be $0.
There may be limitations on
the types of drugs covered.
Please refer to UHC Dual
Complete® (HMO D-SNP)’s
List of Covered Drugs
(Drug List) at myuhc.com/
communityplan for more
information.
UHC Dual Complete® (HMO
D-SNP) may require you
to first try one drug to treat
your condition before it will
cover another drug for that
condition.
Some drugs have quantity
limits.
Your provider must get prior
authorization from UHC
Dual Complete® (HMO
D-SNP) for certain drugs.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 21
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
You need help
getting better
or have special
health needs
Rehabilitation
services
$0 Medically necessary
rehabilitation services are
covered.
Medical equipment
for home care
$0
Dialysis services $0
You need foot care Podiatry services $0 Podiatry visits are for
medically necessary foot
care.
Orthotic services $0
You need
durable medical
equipment (DME)
(Note: This is
not a complete
list of covered
DME or supplies.
Call Member
Services or read
the Member
Handbook for
more information.)
Wheelchairs,
crutches, and
walkers
Nebulizers
Oxygen equipment
and supplies
$0 Your provider must obtain
prior authorization.
You need help
living at home
Home health care $0
You need
interpreter
services
Spoken language
interpreter
$0
Sign language
interpreter
$0
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 22
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
Additional
Services
(continued on the
next page)
Acupuncture $0
Care coordination $0
Chiropractic
services
$0
Diabetes supplies
and services
$0
Family planning $0 Family planning,
counseling, and treatment
services are available.
Please see the Member
Handbook for more
information.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 23
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
Additional
Services
(continued)
Fitness benefit $0 Renew Active® benefit
includes a free gym
membership at a gym
near you, access to the
largest national network
of gyms and fitness
locations, access to
many premium gyms and
fitness locations, as well
as an annual personalized
fitness plan.
Members who need
help can bring a workout
assistant to the gym.
Access is available to
thousands of on-demand
workout videos and live
streaming fitness classes,
as well as social activities
at local health and
wellness classes, clubs
and events.
Online Fitbit® Community
is included for Renew
Active — no Fitbit device
needed.
Members have access
to the AARP® Staying
Sharp® App.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 24
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
Additional
Services
(continued)
Housing
stabilization
services
$0
Home support
services
$0 $150 a quarter for home
support services including
pest control and more.
See your Member
Handbook for more
details.
Meal benefit $0 28 home-delivered meals
immediately after an
inpatient hospitalization
or skilled nursing facility
(SNF) stay
Your provider must obtain
prior authorization.
NurseLine $0 Speak with a registered
nurse (RN) 24 hours a
day, 7 days a week.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 25
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
Additional
Services
(continued)
Food, over-the-
counter (OTC) and
utility bill credit
$0 $225 credit every month
to pay for healthy food,
OTC products and utility
bills, to buy healthy foods
like fruits and vegetables,
meat, seafood, dairy
products and water.
Choose from thousands
of OTC products, like
toothpaste, first aid,
bladder control pads and
more.
You can pay home utility
bills like electricity, heat,
water and internet.
Thousands of
participating stores are
available to you, including
Walmart, Walgreens,
Kroger and CVS, or at
neighborhood stores near
you.
Personal
Emergency
Response System
$0 Help is only a button press
away. A PERS device can
quickly connect you to the
help you need, 24 hours a
day in any situation.
You must have a working
landline and/or cellular
phone coverage to use
PERS.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 26
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
Additional
Services
(continued)
Post-discharge
medication
reconciliation
$0 Medication reconciliation
provided after discharge
from an inpatient facility.
Prosthetic services $0 Authorization rules may
apply.
Radiation therapy $0
Routine Foot Care $0 6 visits per year
Routine
Transportation
$0 The plan covers unlimited
trips for medically
necessary appointments
and to pharmacies. In
addition the plan covers
48 one-way trips to or
from approved locations,
such as gyms, community
centers and places of
worship.
AbleTo Self Care $0 AbleTo Self Care is
a self-help mobile
digital application that
focuses on empowering
individuals in improving
their mental health,
through interaction
with their smart phone
application tools and
activities.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 27
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
Additional
Services
(continued)
Second Harvest
Heartland FoodRx
program
$0 Provides a food
prescription program for
subset of members with
chronic conditions and/
or those who recently
experienced an inpatient
stay.
Seeking Safety $0 Seeking Safety is a
manual based model
that helps individuals
dealing with trauma/
PTSD and substance
abuse establish safety in
their lives. Seeking Safety
applies 25 coping skills to
help attain and maintain
safety in relationships,
thinking, behaviors and
emotions.
Services to help
manage your
disease
$0
Virtual Medical
Visits
$0 Talk with a network
telehealth provider online
through live audio and
video.
Virtual Mental
Health Visits
$0 Talk with a network
telehealth provider online
through live audio and
video.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 28
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
Health need or
concern
Services you
may need
Your costs for
in-network providers
Limitations, exceptions
and benefit information
(rules about benefits)
Additional
Services
(continued)
White Bison $0 White Bison offers
sobriety, recovery,
addiction prevention,
and wellness/Wellbriety
learning resources to
the Native American/
Alaska Native community
nationwide.
Eligibility requirements
apply.
This summary of benefits is provided for informational purposes only and is not a complete list of
benefits. Call Member Services or read the Member Handbook to find out about other covered
services.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 29
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
D. Services covered outside of UHC Dual Complete® (HMO D-SNP)
There are some services that you can get that are not covered by UHC Dual Complete® (HMO
D-SNP) but are covered by Medicare, Medical Assistance, or a State or county agency. This is not
a complete list. Call Member Services at the numbers listed at the bottom of this page to find out
about these services.
Other services covered by Medicare or
Medical Assistance
Your costs
Some hospice care services $0
Personal care assistant services $0
Home care nursing services $0
Waiver services provided under Home and
Community-Based Care
$0
E.
Services that UHC Dual Complete® (HMO D-SNP), Medicare, or
Medical Assistance do not cover
This is not a complete list. Call Member Services at the numbers listed at the bottom of this page to
find out about other excluded services.
Services UHC Dual Complete® (HMO D-SNP), Medicare, and Medical Assistance do not
cover
Services not considered “reasonable and necessary” according to standards of Medicare and
Medical Assistance
Experimental medical and surgical treatments, items, or drugs unless covered by Medicare or
under a Medicare-approved clinical study
Surgical treatment for morbid obesity except when medically necessary
Elective or voluntary enhancement procedures
Cosmetic surgery or other cosmetic work unless criteria is met
Lasik surgery
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 30
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
F. Your rights as a member of the plan
As a member of UHC Dual Complete® (HMO D-SNP), you have certain rights concerning your
health care. You can exercise these rights without being punished. You can also use these rights
without losing your health care services. You also have certain responsibilities to the health care
providers who are taking care of you. For more information on your rights and responsibilities,
please read the Member Handbook.
Your rights include, but are not limited to, the following:
• You have a right to respect, fairness and dignity. This includes the right to:
– Get covered services without concern about race, ethnicity, national origin, color, religion,
creed, sex (including sex stereotypes and gender identity) sexual orientation, or public
assistance.
– Get information in other languages and formats (for example, large print, braille, audio) free
of charge
– Be free from any form of physical restraint or seclusion
– Not be billed by network providers
– Have your questions and concerns answered completely and courteously
– Apply your rights freely without any negative effect on the way UHC Dual Complete® (HMO
D-SNP) or your provider treats you
• You have the right to get information about your health care. This includes information on
treatment and your treatment options, regardless of cost or benefit coverage. This information
should be in a format and language you can understand. These rights include getting
information on:
– UHC Dual Complete® (HMO D-SNP)
– The services we cover
– How to get services
– How much services will cost you
– Names of health care providers and Care Coordinators
– Your rights and responsibilities
• You have the right to make decisions about your care, including refusing treatment.
This includes the right to:
– Choose a primary care provider (PCP). You can change your PCP at any time during the year.
You can call 1-844-368-5888 if you want to change your PCP.
– See a women’s health care provider without a referral
– Get your covered services and drugs quickly
– Know about all treatment options, no matter what they cost or whether they are covered
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 31
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
– Refuse treatment as far as the law allows, even if your health care provider advises against it
– Stop taking medicine, even if your health care provider advises against it
– Ask for a second opinion. UHC Dual Complete® (HMO D-SNP) will pay for the cost of your
second opinion visit.
– Make your health care wishes known in an advance directive
• You have the right to timely access to care that does not have any communication or
physical access barriers. This includes the right to:
– Get timely medical care
– Get in and out of a health care provider’s office. This means barrier-free access for people
with disabilities, in accordance with the Americans with Disabilities Act.
– Have interpreters to help with communication with your doctors, other providers, and your
health plan. Call 1-844-368-5888 if you need help with this service.
– Have your Member Handbook and any printed materials from UHC Dual Complete® (HMO
D-SNP) translated into your primary language, and/or to have these materials read out
loud to you if you have trouble seeing or reading. Oral interpretation services will be made
available upon request and free of charge.
– Be free of any form of physical restraint or seclusion that would be used as a means of
coercion, force, discipline, convenience, or retaliation
• You have the right to seek emergency and urgent care when you need it. This means you
have the right to:
– Get emergency and urgent care services, 24 hours a day, 7 days a week, without prior approval
– See an out-of-network urgent or emergency care provider, when necessary
• You have a right to confidentiality and privacy. This includes the right to:
– Ask for and get a copy of your medical records in a way that you can understand and to ask
for your records to be changed or corrected
– Have your personal health information kept private
– Have privacy during treatment
• You have the right to make complaints about your covered services or care. This includes
the right to:
– File a complaint or grievance against us or our providers. You also have the right to appeal
certain decisions made by us or our providers.
– Ask for a State Appeal (Medicaid Fair Hearing with the State)
– Get a detailed reason why services were denied
For more information about your rights, you can read the Member Handbook. If you have
questions, you can call Member Services at the numbers listed at the bottom of this page.
UHC Dual Complete® (HMO D-SNP): Summary of Benefits 2024 32
If you have questions, please call UHC Dual Complete® (HMO D-SNP) Member Services
at 1-844-368-5888, TTY 711, or your preferred relay service, 8 a.m.–8 p.m., 7 days a week,
October–March; Monday–Friday, April–September. The call is free. For more information,
visit myuhc.com/communityplan.
G. How to file a complaint or appeal a denied service
If you have a complaint or think UHC Dual Complete® (HMO D-SNP) should cover something we
denied, call Member Services at the numbers listed at the bottom of this page. You may be able to
appeal our decision.
For questions about complaints and appeals, you can read Chapter 9 of the Member Handbook.
You can also call UHC Dual Complete® (HMO D-SNP) Member Services at the numbers listed at
the bottom of this page.
For complaints/grievances or medical appeals:
UnitedHealthcare Appeals and Grievance
Department
P.O. Box 6106, MS CA124-0187
Cypress, CA 90630-0016
For Part D or Medicaid drug appeals only:
UnitedHealthcare Part D Appeal and Grievance
Department
P.O. Box 6106, MS CA124-0197
Cypress, CA 90630-0016
H. What to do if you suspect fraud
Most health care professionals and organizations that provide services are honest. Unfortunately,
there may be some who are dishonest.
If you think a doctor, hospital or other pharmacy is doing something wrong, please contact us.
• Call us at UHC Dual Complete® (HMO D-SNP)’s Member Services. Phone numbers are at the
bottom of the page.
• Or, call the Minnesota Fraud Hotline at 1-800-627-9977. The call is free. TTY users may call
711 toll-free number.
• Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users may call 1-877-486-2048.
You can call these numbers for free, 24 hours a day, 7 days a week.
UHMN24PO0115434_003
If you have general questions or questions about UHC Dual Complete®
(HMO D-SNP), services, service area, billing, or Member ID Cards,
please call UHC Dual Complete® (HMO D-SNP) Member Services:
Call 1-844-368-5888
The call is free. 8 a.m.–8 p.m., 7 days a week, October–March; Monday–Friday,
April–September Member Services also has free language interpreter services available for
non-English speakers.
TTY 711, or your preferred relay service
The call is free. 8 a.m.–8 p.m., 7 days a week, October– March; Monday–Friday,
April–September
If you have questions about your health:
• Call your primary care provider (PCP). Follow your PCP’s instructions for getting care when the
office is closed.
• If your PCP’s office is closed, you can also call the NurseLine. A nurse will listen to your
problem and tell you how to get care. (Example: urgent care, emergency room). The numbers
for the NurseLine are:
Call 1-877-440-9407
Calls to this number are free. 24 hours a day, 7 days a week
UHC Dual Complete® (HMO D-SNP) also has free language
interpreter services available for non-English speakers.
TTY 711, or your preferred relay service
The call is free. 24 hours a day, 7 days a week
