2016 UnitedHealthcare MedicareDirect Essential (PFFS) H5435-001 By UnitedHealthcare

2016 Medicare Advantage UnitedHealthcare MedicareDirect Essential (PFFS)

UnitedHealthcare MedicareDirect Essential (PFFS) H5435-001 is a 2016 Medicare Advantage or Medicare Part-C plan by UnitedHealthcare available to residents in Arizona California Georgia Kansas Kentucky Louisiana Missouri Montana Nebraska New Hampshire North Carolina Oklahoma Texas Vermont Virginia Wyoming. This plan does not provide additional Medicare prescription drug (Part-D) coverage. The UnitedHealthcare MedicareDirect Essential (PFFS) has a monthly premium of $23.00 and has a in-network Maximum Out-of-Pocket limit of N/A (MOOP). This means that if you get sick or need a high cost procedure your co-pays are capped once you pay out of pocket N/A this can be a very nice safety net.

UnitedHealthcare MedicareDirect Essential (PFFS) is a PFFS *. A Private Fee-For-Service (PFFS) plan is a Medicare Advantage (MA) health plan offered by a contract with the Centers for Medicare & Medicaid Services (CMS) to provide you with benefits. UnitedHealthcare (instead of Medicare) will decide on how much it will cover and how much you will pay for the services you get. You may go to any Medicare approved doctor or hospital or any other health care provider that accepts both Medicare and your plans payment. A PFFS plan has no provider network, and you dont need a referral or a primary care physician for any health care or services. PFFS plans are the most flexible but a doctor will make a visit-by-visit decisions on whether to accept your provider.

This plan from UnitedHealthcare works with Medicare to give you significant coverage beyond Part A and Part B benefits. If you decide to sign up for UnitedHealthcare MedicareDirect Essential (PFFS) you still retain Original Medicare. But you will get additional Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from UnitedHealthcare and not Original Medicare. With Medicare Advantage plans your always covered for urgently needed and emergency care and you receive all of the benefits of Original Medicare from this plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.


2016 UnitedHealthcare Medicare Advantage Plan Details

Plan Name:
UnitedHealthcare MedicareDirect Essential (PFFS)
Plan ID:
Parent:UnitedHealth Group, Inc.
Plan Year:2016
Plan Type: PFFS *
Monthly Premium C+D: $23.00

Plan Services

Monthly premium deductible and limits on how much you pay for covered services

$23.00 per month. In addition you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan:
  • $6 700 for services you receive from any provider.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums. No. There are no limits on how much our plan will pay.

Doctor's office visits

Primary care physician visit:  $25 copay Specialist visit:  $50 copay

Durable medical equipment (wheelchairs oxygen etc.)

20% of the cost

Emergency care

$75 copay If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.

Foot care (podiatry services)

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $50 copay Routine foot care (for up to 6 visit(s) every year):  $50 copay

Hearing services

Exam to diagnose and treat hearing and balance issues:  $20 copay Routine hearing exam (for up to 1 every year):  $20 copay

Home health care

You pay nothing

Mental health care

Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
  • $395 copay per day for days 1 through 3
  • You pay nothing per day for days 4 through 90
Outpatient group therapy visit:  $30 copay Outpatient individual therapy visit:  $40 copay

Outpatient rehabilitation

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):  $50 copay Occupational therapy visit:  $40 copay Physical therapy and speech and language therapy visit:  $40 copay

Outpatient substance abuse

Group therapy visit:  $30 copay Individual therapy visit:  $40 copay

Outpatient surgery

Ambulatory surgical center:  20% of the cost Outpatient hospital:  20% of the cost


Not covered

Over-the-counter items

Not Covered

Prosthetic devices (braces artificial limbs etc.)

Prosthetic devices:  20% of the cost Related medical supplies:  20% of the cost

Renal dialysis

20% of the cost


Not covered

Urgently needed services

$40 copay

Vision services

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  $0-50 copay depending on the service Routine eye exam (for up to 1 every year):  $50 copay Eyeglasses or contact lenses after cataract surgery:  You pay nothing

Preventive care

You pay nothing Our plan covers many preventive services including:
  • Abdominal aortic aneurysm screening
  • Alcohol misuse counseling
  • Bone mass measurement
  • Breast cancer screening (mammogram)
  • Cardiovascular disease (behavioral therapy)
  • Cardiovascular screenings
  • Cervical and vaginal cancer screening
  • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
  • Depression screening
  • Diabetes screenings
  • HIV screening
  • Medical nutrition therapy services
  • Obesity screening and counseling
  • Prostate cancer screenings (PSA)
  • Sexually transmitted infections screening and counseling
  • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
  • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
  • "Welcome to Medicare" preventive visit (one-time)
  • Yearly "Wellness" visit
Any additional preventive services approved by Medicare during the contract year will be covered.


You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.

Inpatient hospital care

Our plan covers an unlimited number of days for an inpatient hospital stay.
  • $395 copay per day for days 1 through 4
  • You pay nothing per day for days 5 through 90
  • You pay nothing per day for days 91 and beyond

Inpatient mental health care

For inpatient mental health care see the "Mental Health Care" section.

Skilled Nursing Facility (SNF)

Our plan covers up to 100 days in a SNF.
  • You pay nothing per day for days 1 through 20
  • $160 copay per day for days 21 through 62
  • You pay nothing per day for days 63 through 100

Outpatient prescription drugs

For Part B drugs such as chemotherapy drugs:  20% of the cost Other Part B drugs:  20% of the cost Our plan does not cover Part D prescription drug.


$250 copay

Chiropractic care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  $20 copay

Dental services

Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  $50 copay

Diabetes supplies and services

Diabetes monitoring supplies:  You pay nothing Diabetes self-management training:  You pay nothing Therapeutic shoes or inserts:  20% of the cost

Diagnostic tests lab and radiology services and x-rays (Costs for these services may be different if received in an outpatient surgery setting)

Diagnostic radiology services (such as MRIs CT scans):  20% of the cost Diagnostic tests and procedures:  20% of the cost Lab services:  $13 copay Outpatient x-rays:  $16 copay Therapeutic radiology services (such as radiation treatment for cancer):  20% of the cost

Coverage Area for UnitedHealthcare MedicareDirect Essential (PFFS)

(Click county to compare all available plans)

State: Arizona
New Hampshire
North Carolina
Alpine, Calaveras, Colusa,
Del Norte, Humboldt, Mendocino,
Merced, Modoc, Plumas,
Siskiyou, Trinity, Berrien,
Calhoun, Carroll, Chattooga,
Clay, Clinch, Crisp,
Decatur, Fannin, Gilmer,
Grady, Haralson, Heard,
Irwin, Lamar, Lanier,
Macon, Pike, Quitman,
Schley, Sumter, Terrell,
Thomas, Tift, Towns,
Troup, Turner, Union,
Allen, Anderson, Chase,
Cheyenne, Clay, Cloud,
Decatur, Ellis, Geary,
Graham, Lane, Logan,
Marshall, McPherson, Nemaha,
Neosho, Phillips, Rawlins,
Republic, Riley, Rooks,
Saline, Scott, Sheridan,
Thomas, Washington, Wilson,
Allen, Calloway, Carter,
Christian, Cumberland, Lyon,
Marshall, Monroe, Trigg,
Wayne, Avoyelles, Adair,
Bollinger, Caldwell, Cape Girardeau,
Clark, Daviess, Grundy,
Iron, Lewis, Madison,
Maries, Marion, Mercer,
New Madrid, Putnam, Ralls,
Schuyler, Scotland, Scott,
Shannon, Stoddard, Sullivan,
Wayne, Carter, Daniels,
Dawson, Fallon, Garfield,
Petroleum, Phillips, Powder River,
Prairie, Roosevelt, Sheridan,
Valley, Arthur, Banner,
Blaine, Boone, Box Butte,
Buffalo, Cedar, Cheyenne,
Dakota, Dawes, Dawson,
Dixon, Gosper, Hall,
Hamilton, Hooker, Kearney,
Keith, Keya Paha, Knox,
Logan, Loup, Madison,
McPherson, Merrick, Morrill,
Nance, Perkins, Platte,
Scotts Bluff, Sheridan, Sherman,
Stanton, Thomas, Wheeler,
Belknap, Cheshire, Grafton,
Merrimack, Burke, Blaine,
Latimer, Okfuskee, Pontotoc,
Pushmataha, Brewster, Brooks,
Brown, Calhoun, Comanche,
Crane, Culberson, DeWitt,
Duval, Eastland, Erath,
Frio, Gillespie, Goliad,
Gonzales, Jack, Jackson,
Karnes, Kerr, La Salle,
Live Oak, Loving, Matagorda,
Maverick, McMullen, Pecos,
Presidio, Reeves, Refugio,
Terrell, Uvalde, Victoria,
Ward, Winkler, Caledonia,
Essex, Franklin, Grand Isle,
Windham, Windsor, Augusta,
Brunswick, Carroll, Danville City,
Emporia City, Greensville, Harrisonburg City,
Henry, Martinsville City, Mecklenburg,
Patrick, Rockingham, Spotsylvania,
Staunton City, Waynesboro City, Albany,
Crook, Fremont, Natrona,
Sheridan, Teton, Weston,

Ratings for UnitedHealthcare MedicareDirect Essential (PFFS) H5435

2016 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing

Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination

Member Complaints and Changes in UnitedHealthcare MedicareDirect Essential (PFFS) Plans Performance

Total Rating
Members Leaving the Plan
Complaints about Health Plan
Beneficiary Access
Health Plan Quality Improvement

Health Plan Customer Service Rating for UnitedHealthcare MedicareDirect Essential (PFFS)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language

Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancel Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment

Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Rheumatoid Arthritis
Improving Bladder Control
Reducing Risk of Falling
Plan - Cause Readmissions

Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs

Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
High Risk Medication
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR

Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Beneficiary Access
Drug Plan Quality Improvement

UnitedHealthcare MedicareDirect Essential (PFFS) Drug Plan Customer Service ratings

Total Rating
Appeals Auto Forward
Appeals Upheld
Call Center, TTY, Foreign Language

Source: CMS.

Plans as of September 9, 2015

Star Rating as of September 30, 2015.

For More Information on Ratings Please See the CMS Tech Notes Here.

Notes: Data are subject to change as contracts are finalized. For 2016, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit

Includes 2016 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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