The following UnitedHealthCare plans are accepted at Oak Street Health locations. Plan Name. Effective Year. Benefit Package. Summary. AARP Medicare Advantage. 2023. H1944-024. AARP Medicare Advantage. 2023 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Durham, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. 2021 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Catawba, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. Sep 26, 2022 · AARP® Medicare Advantage Plan 2 (HMO-POS) dummy spacing Benefits In-Network Inpatient Hospital Care2 $250 copay per day: days 1-5 $0 copay per day: days 6 and beyond Our plan covers an unlimited number of days for an 3 Your Summary of Benefits “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. Sep 27, 2022 · 1 2023-H3146.006.1 H3146-006 Aetna Medicare Value Plus Plan (HMO) H3146 ‑ 006 Here’s a summary of the services we cover from January 1, 2023 through Decembe Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $4000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined. Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00. Copayment for Non-routine Services $0.00. 3 Your Summary of Benefits “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. 3 Your Summary of Benefits “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. Details. Dental care. In-Network: Preventive Dental: Maximum Plan Allowance of $1500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined. Comprehensive Dental: Copayment for Medicare-covered Benefits $30.00. Details. Dental care. In-Network: Preventive Dental: Maximum Plan Allowance of $1500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined. Comprehensive Dental: Copayment for Medicare-covered Benefits $30.00. H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M Jan 1, 2023 · Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 Service area: North Carolina - Alamance, Alexander, Anson, Bertie, Bladen, Buncombe, Burke, Copayment for Hearing Aids $175.00 to $1225.00. Maximum 2 Hearing Aids every year. Prior Authorization Required for Hearing Aids. Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $175 to a maximum of $1 ,225 based on features and style. Details. Dental care. In-Network: Preventive Dental: Maximum Plan Allowance of $1500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined. Comprehensive Dental: Copayment for Medicare-covered Benefits $30.00. Y0066_EOC_H5253_041_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage Original Medicare. Dr. Miller accepts Original Medicare Part A and Part B plans. Also known as traditional Medicare, Original Medicare is a fee-for-service plan, with Medicare paying a portion of the bill for Medicare covered services. Our Durham, North Carolina locations accept Part B plans, though some require both Part A and Part B. Sep 26, 2022 · Summary of Benefits 2023 UnitedHealthcare Dual Complete® Select (HMO-POS D-SNP) H5253-116-000 Look inside to take advantage of the health services and drug coverages the plan provides. 2022 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Buncombe, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. Feb 22, 2011 · Medicare Advantage & Other Health Plans in Iowa 2023 Iowa Insurance Division 1963 Bell Ave, Suite 100, Des Moines, IA 50315 1-800-351-4664 TTY 1-800-735-2942 2021 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Catawba, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M We would like to show you a description here but the site won’t allow us. Oak Street Health Gate City accepts Original Medicare Part A and Part B plans. Also known as traditional Medicare, Original Medicare is a fee-for-service plan, with Medicare paying a portion of the bill for Medicare covered services. Our Greensboro, North Carolina locations accept Part B plans, though some require both Part A and Part B. o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number AARP Medicare Advantage Plan 2 (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B). Coverage. Cost. Chiropractic Services. In-Network: Copayment for Medicare-covered Chiropractic Services $20.00. Prior Authorization Required for Chiropractic Services. o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ Femenino H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Y0066_SB_H5253_041_000_2022_M o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number H5253-041: Download: AARP Medicare Advantage Walgreens (HMO-POS) 2023: H5253-110: Download: UnitedHealthcare Dual Complete RP (Regional PPO D-SNP) 2023: R1548-001: Download: AARP Medicare Advantage Plan 3 (HMO-POS) 2023: H5253-117: UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) 2023: H5253-116: UnitedHealthcare Dual Complete Choice (PPO ... Y0066_EOC_H5253_041_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage Sep 27, 2022 · 1 2023-H3146.006.1 H3146-006 Aetna Medicare Value Plus Plan (HMO) H3146 ‑ 006 Here’s a summary of the services we cover from January 1, 2023 through Decembe Sep 26, 2022 · Summary of Benefits 2023 UnitedHealthcare Dual Complete® Select (HMO-POS D-SNP) H5253-116-000 Look inside to take advantage of the health services and drug coverages the plan provides. TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the AARP Medicare Advantage Plan 2 (HMO-POS) benefit details. — Medicare Plan Features —. Monthly Premium: $28.00 (see Plan Premium Details below) Annual Deductible: $0. Annual Initial Coverage Limit (ICL): Jan 1, 2023 · Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 Service area: North Carolina - Alamance, Alexander, Anson, Bertie, Bladen, Buncombe, Burke, 2023 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Durham, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. 2021 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Catawba, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H5253-041-000; 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H5253-116-000; 2023 UnitedHealthcare Dual Complete Plan Frequently Asked Questions H1889-005-000; 2023 UnitedHealthcare Dual Complete Plan Frequently Asked Questions H5253-041-000 o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number Copayment for Hearing Aids $175.00 to $1225.00. Maximum 2 Hearing Aids every year. Prior Authorization Required for Hearing Aids. Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $175 to a maximum of $1 ,225 based on features and style. Learn more about the UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 plan for North Carolina. Check eligibility, explore benefits, and enroll today. Hmm … it looks like your browser is out of date. Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $4000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined. Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00. Copayment for Non-routine Services $0.00. Sep 27, 2022 · 1 2023-H3146.006.1 H3146-006 Aetna Medicare Value Plus Plan (HMO) H3146 ‑ 006 Here’s a summary of the services we cover from January 1, 2023 through Decembe In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $20.00. Prior Authorization Required for Doctor Specialty Visit. Inpatient hospital care. In-Network: Acute Hospital Services: $295.00 per day for days 1 to 5. $0.00 per day for days 6 to 90. H5253-041-000 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud que proporciona el plan. Llame a Servicio al Cliente o visite el sitio web para obtener más información sobre el plan. Llamada gratuita 1-855-545-9340, TTY 711 8 a.m. a 8 p.m., hora local, los 7 días de la semana UHCCommunityPlan.com H5253-041: Download: AARP Medicare Advantage Walgreens (HMO-POS) 2023: H5253-110: Download: UnitedHealthcare Dual Complete RP (Regional PPO D-SNP) 2023: R1548-001: Download: AARP Medicare Advantage Plan 3 (HMO-POS) 2023: H5253-117: UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) 2023: H5253-116: UnitedHealthcare Dual Complete Choice (PPO ... Number of Members enrolled in this plan in (H5253 - 041): 23,173 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 4 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... The average monthly premium for Medicare Advantage plans in Wake is $9.46 per month in 2023, though there may be plans available where you live that feature different premiums. Medicare Advantage plans in Wake County have an average Medicare Star Rating of 3.90 in 2023.*. Plans rated four stars or higher are considered top-rated Medicare plans. The UnitedHealthcare Dual Complete (HMO-POS D-SNP) (H5253 - 041) currently has 43,512 members. There are 545 members enrolled in this plan in Orange, North Carolina, and 43,321 members in North Carolina. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. The UnitedHealthcare Dual Complete (HMO-POS D-SNP) (H5253 - 041) currently has 43,512 members. There are 2,168 members enrolled in this plan in Buncombe, North Carolina, and 43,321 members in North Carolina. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number Feb 22, 2011 · Medicare Advantage & Other Health Plans in Iowa 2023 Iowa Insurance Division 1963 Bell Ave, Suite 100, Des Moines, IA 50315 1-800-351-4664 TTY 1-800-735-2942 Copayment for Hearing Aids $175.00 to $1225.00. Maximum 2 Hearing Aids every year. Prior Authorization Required for Hearing Aids. Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $175 to a maximum of $1 ,225 based on features and style. In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $20.00. Prior Authorization Required for Doctor Specialty Visit. Inpatient hospital care. In-Network: Acute Hospital Services: $295.00 per day for days 1 to 5. $0.00 per day for days 6 to 90. H5253-041: Download: AARP Medicare Advantage Walgreens (HMO-POS) 2023: H5253-110: Download: UnitedHealthcare Dual Complete RP (Regional PPO D-SNP) 2023: R1548-001: Download: AARP Medicare Advantage Plan 3 (HMO-POS) 2023: H5253-117: UnitedHealthcare Dual Complete Select (HMO-POS D-SNP) 2023: H5253-116: UnitedHealthcare Dual Complete Choice (PPO ... H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M 533 Medicare Advantage Plans from UnitedHealthcare. Coverage varies by plan. Select a Medicare Advantage Plan below to view details about the coverage it provides: Plan CodePlan Name. H0271:007-0 UnitedHealthcare Medicare Advantage Assure (PPO) H0271:012-0 UnitedHealthcare Medicare Advantage Assure (PPO) H0271:017-0 UnitedHealthcare Medicare ... The UnitedHealthcare Dual Complete (HMO-POS D-SNP) (H5253 - 041) currently has 43,512 members. There are 545 members enrolled in this plan in Orange, North Carolina, and 43,321 members in North Carolina. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. The average monthly premium for Medicare Advantage plans in Wake is $9.46 per month in 2023, though there may be plans available where you live that feature different premiums. Medicare Advantage plans in Wake County have an average Medicare Star Rating of 3.90 in 2023.*. Plans rated four stars or higher are considered top-rated Medicare plans. TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the AARP Medicare Advantage Plan 2 (HMO-POS) benefit details. — Medicare Plan Features —. Monthly Premium: $28.00 (see Plan Premium Details below) Annual Deductible: $0. Annual Initial Coverage Limit (ICL): 2020 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Guilford, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. Maximum 3 visits every year. Copayment for Fluoride Treatment $0.00. Maximum 2 visits every year. Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $4000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined. H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M Jan 1, 2023 · Summary of Benefits 2023 AARP® Medicare Advantage Plan 1 (HMO-POS) H5253-111-001 Look inside to take advantage of the health services and drug coverages the plan provides. UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 plans for North Carolina and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about lookup tools. Original Medicare. Oak Street Health High Point accepts Original Medicare Part A and Part B plans. Also known as traditional Medicare, Original Medicare is a fee-for-service plan, with Medicare paying a portion of the bill for Medicare covered services. Our High Point, North Carolina locations accept Part B plans, though some require both Part ... Number of Members enrolled in this plan in (H5253 - 041): 23,173 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 4 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... Number of Members enrolled in this plan in (H5253 - 041): 23,173 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 4 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... Oct 1, 2022 · Wellcare by Health Net for California Post Office Box 10420 Van Nuys, CA 91410 From October 1 – March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H5253-041-000; 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H5253-116-000; 2023 UnitedHealthcare Dual Complete Plan Frequently Asked Questions H1889-005-000; 2023 UnitedHealthcare Dual Complete Plan Frequently Asked Questions H5253-041-000 Jan 1, 2023 · H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M Feb 22, 2011 · Medicare Advantage & Other Health Plans in Iowa 2023 Iowa Insurance Division 1963 Bell Ave, Suite 100, Des Moines, IA 50315 1-800-351-4664 TTY 1-800-735-2942 H5253-041-000 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud que proporciona el plan. Llame a Servicio al Cliente o visite el sitio web para obtener más información sobre el plan. Llamada gratuita 1-855-545-9340, TTY 711 8 a.m. a 8 p.m., hora local, los 7 días de la semana UHCCommunityPlan.com Jan 1, 2023 · Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 Service area: North Carolina - Alamance, Alexander, Anson, Bertie, Bladen, Buncombe, Burke, 2023 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Mecklenburg, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. The following UnitedHealthCare plans are accepted at Oak Street Health locations. Plan Name. Effective Year. Benefit Package. Summary. AARP Medicare Advantage. 2023. H1944-024. AARP Medicare Advantage. H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M H5253-041-000 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud que proporciona el plan. Llame a Servicio al Cliente o visite el sitio web para obtener más información sobre el plan. Llamada gratuita 1-855-545-9340, TTY 711 8 a.m. a 8 p.m., hora local, los 7 días de la semana UHCCommunityPlan.com H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 plans for North Carolina and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about lookup tools. Original Medicare. Chinyere E. accepts Original Medicare Part A and Part B plans. Also known as traditional Medicare, Original Medicare is a fee-for-service plan, with Medicare paying a portion of the bill for Medicare covered services. Our Durham, North Carolina locations accept Part B plans, though some require both Part A and Part B. 3 Your Summary of Benefits “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. Y0066_EOC_H5253_041_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage The UnitedHealthcare Dual Complete (HMO-POS D-SNP) (H5253 - 041) currently has 43,512 members. There are 2,168 members enrolled in this plan in Buncombe, North Carolina, and 43,321 members in North Carolina. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number Sep 26, 2022 · AARP® Medicare Advantage Plan 2 (HMO-POS) dummy spacing Benefits In-Network Inpatient Hospital Care2 $250 copay per day: days 1-5 $0 copay per day: days 6 and beyond Our plan covers an unlimited number of days for an 2022 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Buncombe, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. Maximum 3 visits every year. Copayment for Fluoride Treatment $0.00. Maximum 2 visits every year. Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $4000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined. Sep 26, 2022 · Summary of Benefits 2023 UnitedHealthcare Dual Complete® Select (HMO-POS D-SNP) H5253-116-000 Look inside to take advantage of the health services and drug coverages the plan provides. Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $4000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined. Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00. Copayment for Non-routine Services $0.00. .