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2024 UnitedHealthcare Medicare
Advantage copay guidelines
Cost-sharing: Preventive services
• All UnitedHealthcare Medicare Advantage plans cover Medicare-covered preventive services for a $0
copay with a network provider
If you have questions, contact your provider advocate or call Provider Services at 877-842-3210.
Benefit Copay and coinsurance guidelines
Alcohol Misuse
Counseling
Medicare covers 1 annual alcohol misuse screening for adults who misuse alcohol but aren’t
alcohol dependent. Coverage is limited to 1 screening per year.
People who screen positive can receive up to 4 brief face-to-face counseling sessions per year
(if they’re competent and alert during counseling). A primary care doctor or practitioner must
provide the counseling in a primary care setting.
Coding guidelines and coverage summaries
• We follow the Centers for Medicare & Medicaid Services (CMS) Medicare coverage and coding
guidelines for all network services. See the CMS Medicare Coverage Database (NCD/LCD Lookup).
• For more information on Medicare-covered preventive services, see the Medicare Preventive
Services Educational Tool at cms.gov
• You can view coverage summaries on UHCprovider.com > Resources > Health plans, policies,
protocols and guides > For Medicare Advantage Plans > Coverage Summaries for Medicare
Advantage Plans
Overview
Frequently asked questions
Copays and coinsurance may vary depending on the member’s plan. Member’s
cost-share should not exceed the provider’s reimbursement rate. Please use the
following cost-sharing information when treating and servicing UnitedHealthcare
Medicare Advantage members.
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Alcohol Misuse
Counseling (cont.)
All Medicare-covered preventive services can be provided any time during the calendar
year in which the member is eligible to receive the service. There is no copay, coinsurance
or deductible.
Allergy Testing
and Treatment
A non-radiological diagnostic procedures and tests copay or coinsurance applies for
allergy testing.
There’s no cost-share for professional services for allergen immunotherapy, including
provision of the allergen extracts.
Ambulance
Transportation
A cost-share applies for every one-way ambulance trip, according to Medicare guidelines. If a
provider group starts a transfer between facilities and arranges for transportation, cost-sharing
will be included either on the transferring hospital claim or the receiving hospital claim and
will be included in the inpatient or ambulatory reimbursement.
Covered ambulance services include air and ground services to the nearest facility that
can provide care only if the member’s health would be endangered by other means of
transportation or if authorized by the plan.
The member’s condition must require both the ambulance transportation and the level of
service provided for the billed service to be considered medically necessary.
Non-emergency transportation by ambulance is appropriate only if it’s documented that the
member’s condition is such that other means of transportation could endanger their health —
regardless if another form of transportation is available — and that transportation by ambulance
is medically necessary.
Annual
Wellness Visit
There’s no coinsurance, copay or deductible for an annual wellness visit.
• If the member has had Medicare Part B for more than 12 months, they’re entitled to an
annual wellness visit with a primary care provider to develop or update a personalized
prevention plan, based on their current health and risk factors
• The annual wellness visit is covered once every calendar year. Visits don’t need to be
12 months apart.
• Visits do not include lab tests, drugs, radiological diagnostic tests or non-radiological
diagnostic tests. Additional applicable cost-share may apply to any lab or diagnostic testing
performed during the visit. If ordered and performed during the preventive visit, these
additional services will be billed separately, according to Medicare guidelines, and the
applicable cost-share may apply depending on the member’s filed benefit.
• The member’s first annual wellness visit can’t take place within 12 months of their “Welcome
to Medicare” preventive visit. However, a “Welcome to Medicare” visit isn’t required if
they’ve had Medicare Part B for 12 months.
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Annual Routine
Physical Exam
All of our Medicare Advantage plans cover an annual routine physical examination with no
cost-share. The exam includes a comprehensive physical exam and evaluates the status of
chronic diseases.
• The annual routine physical exam doesn’t include any other services such as lab tests,
drugs, radiological diagnostic tests or non-radiological diagnostic tests. Additional applicable
cost-share may apply to any lab or diagnostic testing performed during the visit. If ordered
and performed during the preventive visit, these additional services will be billed separately,
according to Medicare guidelines, and the applicable cost-share may apply depending on
the member’s filed benefit.
• The annual routine physical exam is covered once every calendar year. Visits don’t need to be
12 months apart.
Behavior
Therapy for
Cardiovascular
Disease
Coverage extends to 1 visit a year for members with high-risk factors to help lower risk for
cardiovascular disease.
All Medicare-covered preventive services can be provided any time during the calendar year in
which the member is eligible to receive the service. There is no copay, coinsurance or deductible.
Breast Cancer
Screening
The following services are covered:
• 1 baseline mammogram for women ages 35–39
• 1 screening mammogram every year for women ages 40 and older
• Clinical breast exams once every 2 years
A screening mammogram is used for early detection of breast cancer in women who have no
signs or symptoms of the disease. We cover both 2D and 3D mammograms.
All Medicare-covered preventive services can be provided any time during the calendar
year in which the member is eligible to receive the service. There is no copay, coinsurance
or deductible.
Women with a history of breast cancer or any signs or symptoms of breast cancer are not
eligible for a screening mammogram, but may be eligible for a diagnostic mammogram,
which is typically subject to a radiologic diagnostic cost-share under Original Medicare.
• However, in 2024, most UnitedHealthcare Medicare Advantage plans have a $0 copayment
for diagnostic mammograms. (Exception: Institutional Special Needs Plans and
employer group plans may apply radiologic diagnostic cost-sharing.)
Cervical and
Vaginal Cancer
Screening (Pap
Test and Pelvic
Exam)
Covered once a year for high-risk women and every 2 years for all other women.
All Medicare-covered preventive services can be provided any time during the calendar
year in which the member is eligible to receive the service. There is no copay, coinsurance
or deductible.
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Colorectal Cancer
Screening
We follow Medicare coverage coding guidelines to determine whether a colonoscopy is
screening or diagnostic.
For members ages 45 and older, we cover the following services:
• Guaiac-based fecal occult blood test (gFOBT) or fecal immunochemical test (FIT) once a year
• Screening colonoscopy once every 10 years or every 2 years for members at high risk of
colorectal cancer, but not within 4 years of a screening sigmoidoscopy
• Flexible sigmoidoscopy or screening barium enema once every 4 years
• Cologuard
®
multitarget stool DNA test once every 3 years
All Medicare-covered preventive services can be provided any time during the calendar
year in which the member is eligible to receive the service. There is no copay, coinsurance
or deductible.
No cost-share will be applied to a screening colonoscopy, including when a colonoscopy
that started as a screening procedure turns into a diagnostic procedure because of the
discovery of an abnormality, requiring further surgery during the same operative session.
Under Original Medicare, diagnostic colonoscopies and therapeutic colonoscopies and
sigmoidoscopies are typically subject to cost-sharing. However, in 2024, all UnitedHealthcare
Medicare Advantage plans have a $0 copayment for diagnostic colonoscopies and therapeutic
colonoscopies and sigmoidoscopies, in addition to $0 copayment for preventive services.
(Exception: Employer group plans may apply outpatient surgery cost-sharing.) This includes
the following scenarios:
• Members who have a history of colon cancer, or have had polyps removed during a previous
colonoscopy, are not eligible for a screening colonoscopy, but may be eligible for a
diagnostic colonoscopy
• A colonoscopy or sigmoidoscopy conducted for polyp removal or biopsy
COVID-19
Vaccinations
and Monoclonal
Antibody Therapy
Covered services include the following, administered in accordance with current Medicare
coverage guidelines published by CMS:
• COVID-19 vaccines, including boosters
• Monoclonal antibody COVID-19 infusion
There is no copay, coinsurance or deductible in or out-of-network.
There’s no office visit cost-share if the immunization or vaccination was the only
reason for the visit.
The office visit cost-share may apply if services that would incur a cost-share were provided
during the same visit as the immunization or vaccination.
Drugs for treatment of COVID symptoms are not covered by Medicare but may be covered
under the Medicare Part D prescription drug benefit or the member’s prescription drug plan.
For more information:
• UHCprovider.com/en/resource-library/news/Novel-Coronavirus-COVID-19/
covid19-vaccines.html
• cms.gov/covidvax-provider
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Depression
Screening
We cover 1 screening for depression per year in a primary care setting that can provide
follow-up treatment and referrals. Annual depression screenings may be performed separately
by a primary care provider and can take place during a scheduled office visit.
All Medicare-covered preventive services can be provided any time during the calendar
year in which the member is eligible to receive the service. There is no copay, coinsurance
or deductible.
The “Welcome to Medicare” visit and first annual wellness visit include an annual depression
screening. If a member needs further evaluation to diagnose their condition, or if they need
mental health treatment, refer them to a mental health professional.
Diabetes
Self-Management
Training
• Up to 10 hours of training per year in 30-minute group sessions. This includes education
about how to monitor blood sugar, diet, exercise, medication and reducing risks. We cover
individual sessions if no group sessions are available or if you believe special needs prevent
the member from participating in a group setting.
• May also qualify for up to 2 hours of follow-up training each year when ordered by you or
another provider as part of the patient’s care plan. The follow-up training must take place
in a calendar year after the date the initial training was received.
All Medicare-covered preventive services can be provided any time during the calendar
year in which the member is eligible to receive the service. There is no copay, coinsurance
or deductible.
Diabetes Screening
(Fasting Plasma
Glucose)
Diabetes screening is covered when provided, according to Medicare
coverage guidelines:
• The member has any of the following risk factors:
– High blood pressure (hypertension)
– History of abnormal cholesterol and triglyceride levels (dyslipidemia)
– Obesity
– History of high blood sugar (glucose)
– Overweight with a family history of diabetes
• The member may be eligible for up to 2 diabetes screenings a year based on test results
All Medicare-covered preventive services can be provided any time during the calendar
year in which the member is eligible to receive the service. There is no copay, coinsurance
or deductible.
Diabetes
Self-Management
Training, Diabetic
Services
and Supplies
Covered services are subject to the diabetic supplies cost-share and include supplies to
monitor blood glucose:
• Blood glucose monitor
• Blood glucose test strips
• Lancet devices and lancets
• Glucose-control solutions for checking the accuracy of test strips and monitors
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Diabetes
Self-Management
Training, Diabetic
Services
and Supplies
(cont.)
Continuous glucose monitors (CGMs) are subject to the same cost-share as the
diabetic-monitoring supplies, not the DME cost-share. Coverage is in accordance with
Medicare guidelines; CGMs not covered by Medicare will be denied.
Insulin and insulin syringes
Insulin and insulin syringes are covered under the Medicare Part D prescription drug
benefit or the member’s prescription drug plan.
Insulin pumps worn outside the body are subject to the durable medical equipment
cost-share. Starting July 1, 2023, members of Medicare Advantage plans have a $35
maximum cost-share for Part B insulin drugs.
Dialysis
The outpatient dialysis treatment cost-share applies for dialysis and all related services
performed in a dialysis facility, whether in or out of the service area.
• A separate Medicare Part B drug cost-share is assessed for medications administered
and is billed separately from the dialysis service
• For dialysis performed in an inpatient hospital, the inpatient hospital cost-share applies
• For home dialysis equipment and supplies, the durable medical equipment (DME) and related
supplies cost-share applies
DME and
Related Supplies
The DME cost-share applies to all medically necessary, Medicare-covered DME and related
supplies including, but not limited to:
• Wheelchairs, crutches, powered mattress systems, hospital beds ordered by a provider
for use in the home, IV infusion pumps, speech-generating devices, oxygen equipment,
nebulizers and walkers
Emergency and
Urgent Services
Cost-share for emergency and urgently needed services, including worldwide emergency
coverage, varies by benefit plan.
• An emergency department copay applies but may be waived if the emergency department
visit results in admission. Please refer to the member’s evidence of coverage for details.
• An urgently needed care cost-share applies. Additional cost-shares may apply depending on
services received.
Immunizations
and Vaccinations
Covered services include:
• Pneumonia (covered for a $0 copay with both in-network and out-of-network providers)
• Flu shots, each flu season in the fall and winter, with additional flu shots if medically
necessary (covered for a $0 copay with both in-network and out-of-network providers)
• Hepatitis B vaccine for members at high or intermediate risk
• Other vaccines if members are at risk and they meet Medicare Part B coverage rules
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Immunizations
and Vaccinations
(cont.)
All Medicare-covered preventive services can be provided any time during the calendar
year in which the member is eligible to receive the service. There is no copay, coinsurance
or deductible.
There’s no office visit cost-share if the immunization or vaccination was the only reason
for the visit.
The office visit cost-share may apply if services that would incur a cost-share were provided
during the same visit as the immunization or vaccination.
Other vaccinations and immunizations not covered by Medicare may be covered under
Medicare Part D or the member’s prescription drug plan.
Inpatient Hospital
Admissions and
Care
Depending on the member’s benefit plan, an all-inclusive inpatient hospital cost-share
may apply:
• If the member’s plan requires a per-day copay, the member will have a copay for
each day and/or hospital for the same admission. Once the member reaches the copay
maximum, or their out-of-pocket maximum, there’s no additional copay.
• If the member’s plan requires a per-admission copay, the member is responsible for
1 copay for the admission, even if they’re transferred to another hospital during the same stay
• If the member’s plan requires coinsurance, the coinsurance amount applies per admit for
each hospital stay and applies to professional services in addition to the hospital charges
These amounts are capped at a certain amount depending on the plan, or until the member
reaches the out-of-pocket maximum.
• Some plans cover unlimited days for each hospital stay, while other plans follow Original
Medicare coverage and limit inpatient hospital stays to 90 days per benefit period
• Transfer to a separate facility type, such as an inpatient rehabilitation hospital, is
considered a new admission
• For mental health admissions, some benefit plans may have a different inpatient acute
hospital cost-share: either a different per-day copay or different maximum number of days
Laboratory
Services
The laboratory cost-share applies per day per provider, not per laboratory test. To prevent
multiple lab cost-shares for a single visit, all lab services must be billed by the same provider
on the same date of service on a single claim.
If a member has blood drawn or a specimen collected at the physician’s office, cost-sharing is
not assessed for venipuncture or labs billed with an office place of service:
• An additional cost-share for the physician office visit isn’t assessed if the blood draw or
specimen collection was the primary reason for the member’s visit
• An additional cost-share for the physician office visit may apply if other physician services
are rendered
If a member goes to an outpatient hospital or freestanding lab for lab services
only, the lab cost-share applies.
If a re-draw is required, members will not be assessed an additional lab cost-share.
Additional lab cost-shares may apply for labs performed on later dates.
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Laboratory
Services (cont.)
Lab tests associated with the following Medicare-covered preventive services will not be
assessed a cost-share, including, but not limited to:
• Pap smear
• Colorectal cancer screening
• Prostate cancer screening (a digital rectal exam (DRE) may be subject to cost-sharing,
depending on the plan — most non-special needs plans have a $0 copayment for this service)
• Cardiovascular screenings (subject to member cost-sharing — in most plans, 1 time only
when provided during the Welcome to Medicare visit)
Medical Nutrition
Therapy
Medical nutrition therapy is covered for members with diabetes or renal disease, or after a kidney
transplant when referred by their doctor, including:
• 3 hours of individual counseling during their first year and 2 hours each year after that
• If the member’s condition, treatment or diagnosis changes, the member may receive
additional hours of treatment
All Medicare-covered preventive services can be provided any time during the calendar year in
which the member is eligible to receive the service. There is no copay, coinsurance or deductible.
Medicare Part
B: Outpatient
Injectable
and Infusion
Medications
Physician-administered outpatient injectable and infusion medication policies:
• The Medicare Part B drug cost-share applies, per drug per day, for covered outpatient
injectable drugs when administered at the physician’s office
• If the injectable medication is given in the physician’s office and an office visit is billed,
cost-sharing for both the physician office visit and the injectable drug may apply
• There is no separate cost-share, other than the office visit cost-share, for administering
the injection
• Refer to “Immunizations and Vaccinations” on page 6 for more information on cost-sharing
• When an injectable medication is administered in an outpatient hospital setting, cost-sharing
for both the outpatient hospital services and the injectable drug may apply
Home health injectable and infusion drug policies:
• Medically necessary medications dispensed for home infusion therapy that are administered
through an infusion pump may be covered under either Medicare Part B or the Part
D prescription drug benefit, depending on the medication
• Medically necessary medications dispensed for home infusion therapy that are
administered as injectables may be covered under Medicare Part D or the member’s
prescription drug plan
• To authorize these services, continue using the established protocol based on your contract
with UnitedHealthcare Medicare Advantage or its affiliates. If you have questions, call the
Provider Services number on the member’s ID card.
• A cost-share for durable medical equipment and components may apply when the
medications are administered in a home setting
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Medicare Part
B: Outpatient
Injectable
and Infusion
Medications (cont.)
Self-administered outpatient injectable and infusion medications
• Self-administered outpatient injectable and infusion medications may be covered under
the Medicare Part D prescription drug benefit
Chemotherapy
• Chemotherapy drugs are Medicare Part B drugs when administered in an outpatient or
office setting, regardless of the method of administration
• The chemotherapy drug cost-share applies to the chemotherapy drug and its administration
• Chemotherapy drugs administered in the home by infusion may be either Part B or Part D
Immunosuppressive drugs
The Medicare Part B cost-share applies to all members for covered immunosuppressive drugs
provided post-transplant.
Part B Rebatable Drugs
Starting April 1, 2023, members of Medicare Advantage plans may have lower out-of-pocket
costs for Part B drugs that qualify for a rebate.
• The Medicare Prescription Drug Inflation Rebate program requires drug companies to pay a
rebate if they raise prices for certain drugs faster than the rate of inflation
• CMS will manage and release a list of rebatable drugs on a quarterly basis; drug list and
percentage amounts are subject to change quarterly
• Members may see their cost-share for drugs vary throughout the year, depending on the
rebate amount and if they’re added or removed from the list
Mental Health —
Inpatient
Some benefit plans have a different inpatient acute hospital cost-share for mental health
admissions — either a different per day amount or different maximum number of days.
Covered services include:
• Mental health services that require a hospital stay with a 190-day lifetime limit for inpatient
services in a psychiatric hospital. The 190-day limit doesn’t apply to mental health service
provided in a psychiatric unit of a general hospital.
• Inpatient substance abuse services
Non-Radiological
Diagnostic Tests
A non-radiological diagnostic cost-share applies to the following common tests:
• ECG
• EKG
• Holter monitor
• Pulmonary function testing
• Sleep studies
• Stress tests:
– Treadmill
– Stationary bicycle
– Continuous electrocardiographic monitoring
– Pharmacological stress
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Obesity Screening
and Counseling
Medicare covers body mass index (BMI) screenings and behavioral counseling in a
primary care setting for members who meet the clinical definition of obese: BMI 30
or higher. Obesity screening is covered once per year.
Obesity counseling coverage includes:
• 1 in-person visit every week for the first month
• 1 in-person visit every other week during months 2–6
• 1 in-person visit every month during months 7–12, if they lose at least 6.6 pounds
within the first 6 months
All Medicare-covered preventive services can be provided any time during the calendar year in
which the member is eligible to receive the service. There is no copay, coinsurance or deductible.
Observation Care
Observation billed with an outpatient hospital place of service is subject to the outpatient
hospital cost-share.
If emergency room and observation are billed together, only the emergency room
cost-share applies.
Observation services shouldn’t be billed concurrent with diagnostic or therapeutic services that
include active monitoring. A separate cost-share applies to diagnostic or therapeutic services
billed with observation, when appropriate.
Opioid Treatment
Program Services
Opioid use disorder treatment services are covered under Medicare Part B. Members
receive coverage for these services through the plan. Covered services are subject to an
outpatient Opioid Treatment Services cost-share and include:
• FDA-approved opioid agonist and antagonist treatment medications and the dispensing
and administration of such medications, if applicable
• Substance use counseling
• Individual and group therapy
• Toxicology testing
• Intake activities
• Periodic assessments
Outpatient Hospital
Services
Medically necessary services provided in an outpatient facility or outpatient department of a
hospital for diagnosis or treatment are covered and may be subject to applicable cost-sharing.
When members receive services for multiple benefit categories during the same visit, a
separate cost-share may apply for each service received. The following benefit categories may
incur a separate cost-share including, but not limited to:
• Medicare Part B drugs, including chemotherapy and chemotherapy administration
• Blood
• Physical, occupational, speech and pulmonary therapy
• Mental health and psychiatric services
• Renal dialysis
• Lab
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Outpatient Hospital
Services (cont.)
• Radiological services
• Non-radiological test
• Observation
• Cardiac rehabilitation
• Pulmonary rehabilitation
• Surgery
Outpatient Surgery,
Including Services
Provided at
Hospital Outpatient
Facilities and
Ambulatory
Surgical Centers
There may be additional cost-sharing for any services or items provided other than surgery,
including but not limited to diagnostic tests, therapeutic services, prosthetics, orthotics,
supplies or Part B drugs. Please refer to the appropriate section in the member’s evidence
of coverage for additional information.
Physician Office
Visits, including
Telephonic,
Online Consults,
Anticoagulation
Monitoring
The physician office visit copay may apply when services are received in an office setting.
Covered services include:
• Evaluation and management services
• Office visit
• Medical or surgical services furnished in a physician office
• Monitoring services, consultation, diagnosis and treatment
For physician house calls, the physician office visit cost-share applies to evaluation and
management services done in the member’s home.
For monitoring anticoagulation medications such as Coumadin, heparin and warfarin, the
physician office visit cost-share will be assessed only if the monitoring is provided during an
office visit. To qualify, the physician must:
• Personally perform an initial evaluation of the member
• Order and supervise the anticoagulation monitoring
• Be physically present in the immediate office at the time of service
A Doctor of Pharmacy can provide services at a Coumadin
®
clinic or facility as long
as they are:
• Licensed by the state and performing within the scope of practice
• Performing under the supervision of a Doctor of Medicine or osteopathy,
who must be in the office to offer assistance if needed
The applicable cost-share applies to Medicare-covered telephone or online consultations
based on the service provided.
Separate surgery-related office visits performed during the global post-operative period
aren’t included in the office visit cost-share provision, since these services are already
included in the surgical allowance.
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Preventive Care
We follow Medicare coverage and coding guidelines for network preventive services. If the
member is treated or monitored for an existing medical condition during the preventive visit,
a cost-share may apply for the existing medical condition.
The following preventive services are covered with no cost-share at the same frequency as
with Original Medicare and should be billed according to Medicare guidelines:
• Abdominal aortic aneurysm screening
• Alcohol misuse screening and counseling
• Annual routine physical exam (not Medicare-covered)
• Annual wellness visit
• Bone mass measurements (bone density)
• Breast cancer screening (2D and 3D mammograms)
• Cardiovascular disease risk reduction visit (behavioral therapy)
• Cardiovascular disease screening
• Cervical and vaginal cancer screening (pap test and pelvic exam)
• Colorectal cancer screening
• Depression screening
• Diabetes screening
• Diabetes self-management training
• Flu, pneumonia and hepatitis B vaccines
• Glaucoma tests for those at high risk
• Hepatitis B screening
• Hepatitis C screening
• HIV screening
• Human papillomavirus (HPV) screening
• Lung cancer screening with low-dose computed tomography
• Medical nutrition therapy services
• Medicare Diabetes Prevention program (MDPP)
• Obesity screening and counseling to promote sustained weight loss
• Prostate-specific antigen test
• Sexually transmitted infections screening and counseling
• Tobacco use cessation counseling
• “Welcome to Medicare” preventive visit
All preventive services can be provided any time during the calendar year in which the
member is eligible to receive the service.
Prostate Cancer
Screening
For men, ages 50 and older, covered services include the following once per year:
• Prostate-specific antigen test: There is no copay, coinsurance or deductible.
• Digital rectal exam: Subject to cost-sharing per the member’s evidence of coverage.
– Cost-sharing applies to this preventive service according to Medicare guidelines.
However, many UnitedHealthcare Medicare Advantage plans do not charge member
cost-sharing for this service.
All preventive services can be provided any time during the calendar year in which the
member is eligible to receive the service.
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Prosthetic Devices
and Related
Supplies (including
Orthotics)
The DME prosthetics and orthotics cost-share applies for each medically necessary,
Medicare-covered prosthetic or orthotic device, including replacement or repairs of such
devices and related supplies. Coverage includes, but is not limited to:
• Devices including, but not limited to, colostomy bags and supplies directly related to
colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs and breast prostheses
(including a surgical brassiere after a mastectomy)
• Certain supplies related to prosthetic devices and repair or replacement of prosthetic devices
• Some prosthetic devices following cataract removal or cataract surgery
Radiation Therapy
A therapeutic radiology cost-share per procedure or per visit applies:
• For members with coinsurance, members will pay a percentage of the amount paid to the
provider for all covered procedures
• For members with a copay, members will pay the applicable copay per visit
Examples include, but are not limited to:
• Brachytherapy
• Radioactive implants (separate outpatient surgery cost-share may be applied for
placement of an interstitial device)
• Conformal proton beam radiation
• Therapeutic radiology or radiation (radium and isotope) therapy
Note: Gamma knife and stereotactic procedures are covered as outpatient surgery with the
applicable cost-share.
Radiology
Services
Radiology cost-sharing may vary for the following separate cost-sharing categories:
• Medicare-covered breast cancer screening mammography and bone mass measurement
are Medicare-covered preventive benefits with no cost-share. These services are covered at
the same frequency as covered under Original Medicare and can be provided any time during
the calendar year in which the member is eligible to receive the service.
• Flat-film X-rays, or a conventional X-ray that produces a 2 dimensional planar image, may
be subject to a cost-share for each Medicare-covered standard X-ray service, in addition to
any applicable office visit cost-share billed
For other radiological diagnostic services, not including X-rays or separately identified
preventive services:
• The applicable cost-share applies
• Radiology services that require specialized equipment beyond standard X-ray equipment
performed by specially trained or certified personnel, including:
– Specialized scans: CT, SPECT, PET, MRI, MRA
– Nuclear studies
– Ultrasounds
– Diagnostic mammograms (for cost-share details, see Breast Cancer Screening on page 3)
– Interventional radiological procedures, such as myelogram, cystogram, angiogram an
barium studies
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Rehabilitation
Services:
Medicare-Covered
Outpatient
Rehabilitation,
including Cardiac
and Pulmonary
Rehabilitation,
and Physical,
Speech and
Occupational
Therapies
Applicable cost-sharing may apply per session for Medicare-covered outpatient
rehabilitation services, including:
• Cardiac and pulmonary rehabilitation
• Physical, speech and occupational therapies
Sexually
Transmitted
Infection (STI)
and High-Intensity
Behavioral
Counseling to
Prevent STIs
Medicare covers STI screening for chlamydia, gonorrhea, syphilis or hepatitis B when tests
are ordered by a primary care provider for members who are pregnant or have an increased
risk for an STI. These tests are covered once every year or at certain times during pregnancy.
Medicare also covers counseling sessions to prevent members from contracting an STI
if they’re considered at increased risk, according to Medicare guidelines. Up to 2 individual
20- to 30-minute in-person counseling sessions are covered each year as a preventive service if
they’re provided by a primary care provider and take place in a primary care setting.
All Medicare-covered preventive services can be provided any time during the calendar year in
which the member is eligible to receive the service. There is no copay, coinsurance or deductible.
Supervised
Exercise Therapy
(SET)
SET is covered for members who have symptomatic peripheral artery disease (PAD) and have a
referral from the physician responsible for PAD treatment.
Up to 36 sessions over a 12-week period are covered if the SET program requirements
are met.
SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions
over an extended period of time if deemed medically necessary by a health care provider.
A SET copay or coinsurance applies per session.
Vision Benefits
Examinations for medical care, evaluation of a complaint or follow-up for an existing
medical condition should be billed to the member’s medical insurance plan.
Routine vision exams, screening for disease or updating prescriptions should be billed to the
member’s routine vision insurance benefit.
Medicare-covered vision
Medicare-covered, medically necessary vision care includes:
• Medical exams for the diagnosis and treatment of diseases and injuries of the eye,
including diagnosis or treatment for age-related macular degeneration or cataracts
Benefit Copay and coinsurance guidelines
Vision Benefits
(cont.)
• Glaucoma screening once per year for members at high risk of glaucoma, such as family
history of glaucoma, diabetes, African Americans (ages 50 and older) and Hispanic
Americans (ages 65 and older). These can be provided any time during the calendar
year in which the member is eligible to receive the service. There is no copay, coinsurance
or deductible.
• For people with diabetes or signs and symptoms of eye disease, eye exams to evaluate
for eye disease
• For people with diabetes, screening for diabetic retinopathy is covered once per year
– Subject to cost-sharing per the member’s evidence of coverage. Cost-sharing applies to
this preventive service according to Medicare guidelines. However, many UnitedHealthcare
Medicare Advantage plans do not charge member cost-sharing for this service. Separate
cost- sharing may apply to other ser vices received during the s ame visit, including a
medical or routine eye exam.
• 1 standard pair of eyeglasses or contact lenses after each cataract surgery that
includes insertion of an intraocular lens
• Corrective lenses or frames and replacements needed after a cataract removal
without a lens implant
Routine vision benefits (not available on all plans)
• Routine eye exam: Vision screening and vision refraction performed by an ophthalmologist
or optometrist:
– For members receiving vision screening services during an office visit, 1 copay applies
– If vision refraction is performed in addition to vision screening during an office visit, only 1
copay applies
Limited to 1 exam every year. Refer to the member’s evidence of coverage for details
• Routine eye wear: Credit toward lenses and frames or contact lenses once every 1 or
2 years, depending on the member’s plan, up to the allowed amount. Refer to the member’s
evidence of coverage for details.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided
by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of
California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company,
UnitedHealthcare of New York, Inc., UnitedHealthcare Insurance Company of New York, UnitedHealthcare of Oklahoma, Inc.,
UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Pennsylvania, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits
of Texas, Inc., UnitedHealthcare of Utah, Inc., UnitedHealthcare of Washington, Inc., Optimum Choice, Inc., Oxford Health Insurance,
Inc., Oxford Health Plans (NJ), Oxford Health Plans (CT), Inc., All Savers Insurance Company, Tufts Health Freedom Insurance Company
or other affiliates. Administrative services provided by OptumHealth Care Solutions, LLC, OptumRx, Oxford Health Plans LLC, United
HealthCare Services, Inc., Tufts Health Freedom Insurance Company or other affiliates. Behavioral health products provided by U.S.
Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH), or its affiliates.
PCA-1-23-04043-POE-QRG_12182023
© 2023 United HealthCare Services, Inc. All Rights Reserved.
