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UnitedHealthcare Senior Care Options: Summary of Benefits 20217Frequently asked questionsAnswersWill I get the same Medicareand MassHealth benefits inUnitedHealthcare Senior CareOptions that I get now?(continued from previous page)Can I go to the same doctorsI see now?If you are taking any Medicare Part D prescriptiondrugs that UnitedHealthcare Senior Care Optionsdoes not normally cover, you can get a temporarysupply and we will help you to transition to anotherdrug or get an exception for UnitedHealthcare SeniorCare Options to cover your drug if medically necessary.For more information, call Customer Service at thenumbers listed at the bottom of this page.Often that is the case. If your providers (includingdoctors, hospitals, therapists, pharmacies, and otherhealth care providers) work with UnitedHealthcare Senior Care Options and have a contract with us, youcan keep going to them. Providers with an agreement with us are “innetwork.” Network providers participate in ourplan. That means they accept members of ourplan and provide services our plan covers. Youmust use the providers in UnitedHealthcare Senior Care Options’s network. If you useproviders or pharmacies that are not in ournetwork, the plan may not pay for these servicesor drugs. If you need urgent or emergency care orout-of-area dialysis services, you can useproviders outside of UnitedHealthcare SeniorCare Options’s plan.To find out if your doctors are in the plan’s network,call Customer Service or read UnitedHealthcare Senior Care Options’s Provider Directory on the Plan’swebsite at UHCCommunityPlan.com.If UnitedHealthcare Senior Care Options is new foryou, we will work with you to develop an IndividualizedPlan of Care to address your needs.

UnitedHealthcare Senior Care Options: Summary of Benefits 2021Frequently asked questionsAnswersWhat is a UnitedHealthcare SeniorCare Options care coordinator/manager?A UnitedHealthcare Senior Care Options carecoordinator/manager is one main person for youto contact. This person helps to manage all yourproviders and services and make sure you get whatyou need.What are Long-term Services andSupports (LTSS)?Long-term Services and Supports are help for peoplewho need assistance to do everyday tasks like takinga bath, getting dressed, making food, and takingmedicine. Most of these services are provided at yourhome or in your community but could be provided ina nursing home or hospital. A few common examplesof LTSS include Adult Day Health programs, PersonalCare Attendants, Adult Foster Care, and homemakers.What is a Geriatric Services SupportsCoordinator (GSSC)?A UnitedHealthcare Senior Care Options GSSCis a person who works with your care coordinator/manager on your care team who is an expert in LTSS.This person helps you get services that help you liveindependently in your home and can be changed atyour request.What happens if I need a servicebut no one in UnitedHealthcare Senior Care Options’s network canprovide it?Most services will be provided by our networkproviders. If you need a service that cannot beprovided within our network, UnitedHealthcare SeniorCare Options will pay for the cost of an out-of-networkprovider.Where is UnitedHealthcare SeniorCare Options available?The service area for this plan includes: Bristol,Essex, Franklin, Hampden, Hampshire, Middlesex,Norfolk, Plymouth, Suffolk, Worcester Counties,Massachusetts. You must live in one of these areas tojoin the plan.8

UnitedHealthcare Senior Care Options: Summary of Benefits 2021Frequently asked questionsAnswersWhat is prior authorization?Prior authorization means an approval fromUnitedHealthcare Senior Care Options to seekservices outside of our network or to get services notroutinely covered by our network before you get theservices. UnitedHealthcare Senior Care Options maynot cover the service, procedure, item, or drug if you oryour provider doesn’t get prior authorization.If you need urgent or emergency care or out-ofarea dialysis services, you don’t need to get priorauthorization first. UnitedHealthcare Senior CareOptions can provide you or your provider with a list ofservices or procedures that require you to get priorauthorization from UnitedHealthcare Senior CareOptions before the service is provided. If you havequestions about whether prior authorization is requiredfor specific services, procedures, items, or drugs, callCustomer Service at the numbers listed at the bottomof this page for help.Do I pay a monthly amount(also called a premium) underUnitedHealthcare Senior CareOptions?No. Because you have MassHealth, you will not payany monthly premiums, including your Medicare Part Bpremium, for your health coverage.Do I pay a deductible as a memberof UnitedHealthcare Senior CareOptions?No. You do not pay deductibles in UnitedHealthcare Senior Care Options.What is the maximum out-ofpocket amount that I will pay formedical services as a member ofUnitedHealthcare Senior CareOptions?There is no cost sharing for medical services inUnitedHealthcare Senior Care Options, so yourannual out-of-pocket costs will be 0.9

UnitedHealthcare Senior Care Options: Summary of Benefits 202110C. List of covered servicesThe following table is a quick overview of what services you may need, your costs, and rules aboutthe benefits.Health need or concernYour costs forServices you may need in-networkprovidersYou need hospitalcareYou want to see adoctorHospital stay 0Doctor or surgeon care 0Outpatient hospitalservices, includingobservation 0Ambulatory surgicalcenter (ASC) services 0Visits to treat an injury or 0illnessSpecialist care 0Wellness visits, such asa physicalCare to keep you fromgetting sick, such as flushots and screenings tocheck for cancer“Welcome to Medicare”(preventative visit onetime only) 0 0 0Limitations, exceptions, &benefit information (rulesabout benefits) — servicesmust be medically necessaryYour provider will need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Annual routine physicals arelimited to one per calendar year.Your provider may need toobtain prior authorization forservices.Only covered within the first12 months you have MedicarePart B.

UnitedHealthcare Senior Care Options: Summary of Benefits 202111Health need or concernYour costs forServices you may need in-networkprovidersYou needemergency careEmergency roomservices 0Urgent care 0You need medicaltestsDiagnostic radiology 0services, (for example,X-rays or other imagingservices, such as CATscans or MRIs)Lab tests and diagnostic 0procedures, such asblood workYou need hearing/ Hearing screenings 0auditory servicesYou need dentalcareHearing aids 0Dental check-ups andpreventive careRestorative andemergency dental care 0 0Limitations, exceptions, &benefit information (rulesabout benefits) — servicesmust be medically necessaryWorldwide coverage isavailable. You may use anyemergency room, even if out-ofnetwork and no authorization isneeded.Worldwide coverage isavailable. You may use anyurgent care center, even if outof-network and no authorizationis needed.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices. Routine hearingexams do not requireauthorization.Your provider may need toobtain prior authorization forservices.Limited to one visit every sixmonths.Your provider may need toobtain prior authorization forservices.

UnitedHealthcare Senior Care Options: Summary of Benefits 202112Health need or concernYour costs forServices you may need in-networkprovidersYou need eye care Eye examsYou have abehavioral healthcondition 0Glasses or contactlenses 0Other vision care 0Behavioral healthservices 0Inpatient and outpatientcare and communitybased services forpeople who needbehavioral health careSubstance use disorderservices 0You have asubstance usedisorderYou need a place Skilled nursing careto live with peopleavailable to helpyouNursing home care 0 0 0Adult Foster Care and 0Group Adult Foster CareLimitations, exceptions, &benefit information (rulesabout benefits) — servicesmust be medically necessaryYour provider may need toobtain prior authorization forservices. Routine eye exams donot require authorization. 0 copay every year; up to 200for frames or contact lenses.Standard (single, bifocal,trifocal, or progressive) lensesare covered in full.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Up to 100 days per calendaryear. Your provider may needto obtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.

UnitedHealthcare Senior Care Options: Summary of Benefits 202113Health need or concernYour costs forServices you may need in-networkprovidersYou need therapyafter a stroke oraccidentYou need helpgetting to healthservicesOccupational, physical,or speech therapy 0Ambulance services 0Emergencytransportation 0Transportation tomedical appointmentsand services 0You need drugs to Medicare Part Bprescription drugstreat your illnessor condition 0(continued on thenext page)Generic drugs (no brand 0name)Limitations, exceptions, &benefit information (rulesabout benefits) — servicesmust be medically necessaryYour provider may need toobtain prior authorization forservices.Authorization is required forNon-emergency Medicarecovered ambulance groundand air transportation.Available worldwide and withinthe U.S and its territorieswithout authorization.Necessary taxi, and chaircartransport for medical reasons,within the Commonwealthof Massachusetts. Out-ofstate transport requires priorauthorization. Reservationsrequired.Part B drugs include drugsgiven by your doctor in his orher office, some oral cancerdrugs, and some drugsused with certain medicalequipment. Read the Evidenceof Coverage for moreinformation on these drugs.There may be limitations on thetypes of drugs covered. Pleasesee UnitedHealthcare SeniorCare Options’s List of CoveredDrugs (Drug List) for moreinformation.Extended-day supplies areavailable at retail and/or mailorder pharmacy locations at noextra cost to you.

UnitedHealthcare Senior Care Options: Summary of Benefits 202114Health need or concernYour costs forServices you may need in-networkprovidersYou need drugs to Brand name drugstreat your illnessor condition 0(continued fromprevious page)You need helpgetting betteror have specialhealth needsOver-the-counter (OTC)drugs 0Rehabilitation services 0Medical equipment forhome care 0Dialysis services 0Limitations, exceptions, &benefit information (rulesabout benefits) — servicesmust be medically necessaryThere may be limitations on thetypes of drugs covered. Pleasesee UnitedHealthcare SeniorCare Options’s List of CoveredDrugs (Drug List) for moreinformation.Extended-day supplies areavailable at retail and/or mailorder pharmacy locations at noextra cost to you.There may be limitations on thetypes of drugs covered. Pleasesee UnitedHealthcare SeniorCare Options’s List of CoveredDrugs (Drug List) for moreinformation.Your provider may need toobtain prior authorization forservices.Prior authorization required forcertain medical equipment.Please work with your carecoordinator/manager todetermine if prior authorizationis required.Your provider may need toobtain prior authorization forservices.

UnitedHealthcare Senior Care Options: Summary of Benefits 202115Health need or concernYour costs forServices you may need in-networkprovidersYou need footcareYou needdurable medicalequipment (DME)Note: This is nota complete list ofcovered DME. Fora complete list,contact CustomerService or referto Chapter 4 ofthe Evidence ofCoverage.Podiatry services 0Orthotic services 0Wheelchairs, crutches,and walkers 0Nebulizers 0Oxygen equipment andsupplies 0Limitations, exceptions, &benefit information (rulesabout benefits) — servicesmust be medically necessarySix routine foot care visits andall medically necessary visits.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Prior authorization required forcertain medical equipment.Please work with your carecoordinator/manager todetermine if prior authorizationis required.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.

UnitedHealthcare Senior Care Options: Summary of Benefits 202116Health need or concernYour costs forServices you may need in-networkprovidersYou need helpliving at homeHome health services 0Home services,such as cleaning orhousekeeping 0Adult day health or other 0support servicesDay habilitation services 0Services to help youlive on your own (homehealth care services orpersonal care attendantservices) 0Limitations, exceptions, &benefit information (rulesabout benefits) — servicesmust be medically necessaryYour provider may need toobtain prior authorization forservices.Prior authorization requiredfor certain home services.Please work with your carecoordinator/manager todetermine if prior authorizationis required.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.

UnitedHealthcare Senior Care Options: Summary of Benefits 202117Health need or concernYour costs forServices you may need in-networkprovidersAdditionalservicesChiropractic services 0(continued on thenext page)Diabetes supplies andservices 0Fitness program through 0Renew ActiveTMHealth and WellnessProducts Card 0Healthy Foods benefit 0Limitations, exceptions, &benefit information (rulesabout benefits) — servicesmust be medically necessaryUp to 20 visits withoutauthorizationWe only cover Accu-Chek and OneTouch brands.Covered glucose monitorsinclude: OneTouch Verio Flex ,OneTouch Verio Reflect ,Accu-Chek Guide Me, andAccu-Chek Guide. Test strips:OneTouch Verio , OneTouchUltra , Accu-Chek Guide,Accu-Chek Aviva Plus, andAccu-Chek SmartView. Otherbrands are not covered by yourplan.Your provider may need toobtain prior authorization forsome services.Renew Active provides astandard gym membership toan extensive network of fitnesslocations nationwide, plusa personalized fitness plan,online fitness classes, and anonline brain health program allat no cost to you. 150 credit per quarter to useon approved health productsfrom network retail locations.Order online, over the phone, orby mail through your Health &Wellness Products Catalog. 25 credit per month to spendon healthy food items such asvegetables, fruit, grains, milk,meats and more.

UnitedHealthcare Senior Care Options: Summary of Benefits 202118Health need or concernYour costs forServices you may need in-networkprovidersAdditionalservices(continued fromprevious page)Prosthetic services 0Radiation therapy 0Services to help manage 0your diseaseVirtual medical visits 0Virtual mental healthvisits 0Limitations, exceptions, &benefit information (rulesabout benefits) — servicesmust be medically necessaryYour provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Your provider may need toobtain prior authorization forservices.Speak to network telehealthproviders using your computeror mobile device.Speak to network telehealthproviders using your computeror mobile device.The above summary of benefits is provided for informational purposes only and is not acomplete list of benefits. For a complete list and more information about your benefits, you canread the UnitedHealthcare Senior Care Options Evidence of Coverage. If you don’t have anEvidence of Coverage, call UnitedHealthcare Senior Care Options Customer Serviceat the number at the bottom of this page to get one. If you have questions, you can also callUnitedHealthcare Senior Care Options Customer Service or visit www.UHCCommunityPlan.com.

UnitedHealthcare Senior Care Options: Summary of Benefits 202119D. Benefits covered outside of UnitedHealthcare SeniorCare OptionsThere are some services that you can get that are not covered by UnitedHealthcare Senior CareOptions but are covered by Medicare, MassHealth, or a State Agency. This is not a complete list.Call Customer Service at the number at the bottom of this page to find out about these services.Other services covered by Medicare, MassHealth, or a State AgencyYour CostsCertain hospice care services covered outside ofUnitedHealthcare Senior Care Options (If you only haveMassHealth, you will be responsible for costs unless thehospice is contracted with UnitedHealthcare.) 0Psychosocial rehabilitationPlease call the state agency formore information.Targeted case managementPlease call the state agency formore information.Rest home room and boardPlease call the Department ofTransitional Assistance for moreinformation.

UnitedHealthcare Senior Care Options: Summary of Benefits 202120E. Services that UnitedHealthcare Senior Care Options,Medicare, and MassHealth do not coverThis is not a complete list. Call Customer Service at the number at the bottom of this page to findout about other excluded services.Services UnitedHealthcare

Jan 1, 2021