CurrentUnitedHealthcarePolicy N/A

UnitedHealthcare Medicare Advantage — Copay and Coinsurance Guidance

Defines cost-sharing rules and coverage-related billing guidance for UnitedHealthcare Medicare Advantage members and providers, including preventive services, drugs, DME, hospital and outpatient services. Affects network and out-of-network providers serving UnitedHealthcare Medicare Advantage members.

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage copay and coinsurance guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor home infusion services, continue using the established authorization protocol per your contract with UnitedHealthcare Medicare Advantage and contact provider resources with questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0Medicare-covered preventive services (network)

1Annual alcohol misuse screening

10Diabetes self-management hours/year

$0Diagnostic mammogram/colonoscopy copay (most plans)

190Psychiatric hospital lifetime day limit

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Coverage rules and cost-sharing guidance

Coverage criteria and billing rules — general

General coverage stance and provider billing expectations for UnitedHealthcare Medicare Advantage members.

All UnitedHealthcare Medicare Advantage plans follow CMS Medicare coverage and coding guidelines (NCD/LCD). Providers should bill Medicare-covered services according to Medicare rules and UnitedHealthcare Medicare Advantage billing guidance.

Medicare-covered preventive services are covered with no copay, coinsurance or deductible when rendered by a network provider and may be provided any time during the calendar year in which the member is eligible to receive the service.

Modifier 26: Professional component charges billed with a 26 modifier are covered with no additional member copay in-network and out-of-network on HMO and PPO Medicare Advantage plans.

Employer group plans may have custom cost sharing that differs from this guide as outlined in the member's Evidence of Coverage (EOC). Providers should refer to the member's EOC for plan-specific cost sharing.

Providers must follow CMS Medicare Preventive Services guidance for frequency and billing (see CMS Medicare Preventive Services Educational Tool) and consult the CMS Medicare Coverage Database (NCD/LCD) for coverage specifics.

For services that combine multiple benefit categories during the same visit (for example, office visit plus diagnostic tests or Part B drugs), a separate cost share may apply for each benefit category; providers should bill each service under the appropriate benefit category.

Observation services billed with an outpatient hospital place of service are subject to the outpatient hospital cost share. If ER and observation are billed together, only the ER cost share applies. Observation should not be billed concurrently with diagnostic/therapeutic services that include active monitoring unless appropriate; a separate cost share may apply.

Prior authorization, medical necessity documentation, and correct coding are required where indicated by CMS or UnitedHealthcare Medicare Advantage policies; providers should contact their provider advocate or visit UHCprovider.com/contactus for assistance.

Coverage criteria — service categories and cost sharing guidance

Cost sharing and coverage guidance for specific service categories under UnitedHealthcare Medicare Advantage plans. All Medicare-covered preventive services listed below have $0 member cost share when provided by a network provider, at the same frequencies as Original Medicare.

Preventive services covered at $0 cost sharing when rendered by a network provider include: abdominal aortic aneurysm screening ultrasound; alcohol misuse screening and counseling; 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 cancer screening with HPV test; colorectal cancer screening; COVID-19, flu, pneumonia and hepatitis B vaccines; depression screening; diabetes screening; diabetes self-management training; glaucoma tests for those at high risk; hepatitis B and C screening; HIV PrEP and HIV screening; lung cancer screening with low-dose CT; medical nutrition therapy services; Medicare Diabetes Prevention Program; obesity screening and counseling; Pap tests and pelvic exams; PSA test (men 50+) with no copay/coinsurance/deductible; sexually transmitted infection screening and counseling; tobacco use cessation counseling; Welcome to Medicare preventive visit; and prostate cancer screening per Medicare guidelines.

Prostate cancer screening: PSA test for men ages 50 and older covered once per year with no copay/coinsurance/deductible; digital rectal exam is subject to member's EOC cost sharing per Medicare guidelines and some UnitedHealthcare Medicare Advantage plans may not charge cost sharing.

Preventive service billing notes: If during a preventive visit the member is treated or monitored for an existing medical condition, cost sharing may apply for the treatment of that condition. Preventive services may be provided any time during the calendar year in which the member is eligible.

Coding rules and program limits

Medicare/CMS coding rulesmixed

Follow CMS Medicare coverage and coding guidelines for network services; use NCD/LCD lookup and Medicare preventive services guidance.

Preventive services guidancemixed

For more information on Medicare-covered preventive services, see the CMS Medicare Preventive Services Educational Tool.

Part B drug distinctionsmixed

No codes listed

Diabetes self-management training limit

Annual training limitUp to 10 hours of diabetes self-management training per year (in 30-minute group sessions).

Follow-up trainingMay qualify for up to 2 hours of follow-up training each year when ordered by a provider as part of the patient’s care plan (must occur in a calendar year after the initial training).

Individual sessionsIndividual sessions covered if no group sessions are available or patient has special needs preventing group participation.

Content includedEducation includes monitoring blood sugar, diet, exercise, medication management and risk reduction.

Timing/provisionAll Medicare-covered preventive services (including applicable diabetes services) can be provided any time during the calendar year in which the member is eligible; no copay/coinsurance/deductible for preventive services when rendered by a network provider.

Provider authorization, referral and billing actions

Prior Authorization

Home infusion authorization protocol

To authorize home infusion services, continue using the established protocol in your contract with UnitedHealthcare Medicare Advantage or its affiliates. For questions, use the contact resources (chat options and contact information). Note that a cost share for DME and components may apply when medications are administered in a home setting.

Follow the established authorization protocol per your UnitedHealthcare Medicare Advantage contract.
Refer to UnitedHealthcare contact resources for questions or chat/contact support.
Be aware a DME/components cost share may apply for home-administered medications.

Documentation Required

SET referral and documentation requirement

Obtain a referral from the physician responsible for treating the member's peripheral artery disease (PAD) and document that the SET program requirements are met before providing supervised exercise therapy (SET).

Key definitions and scope notes

Medicare-covered preventive services

No cost sharing for preventive servicesAll Medicare-covered preventive services have no copay, coinsurance or deductible when rendered by a network provider.

Examples includedIncludes screenings, immunizations and specified preventive visits as defined by Medicare (see CMS Medicare Preventive Services Educational Tool).

Timing flexibilityMedicare-covered preventive services can be provided any time during the calendar year in which the member is eligible to receive the service.

Medicare Part B drugs

Definition (Part B drugs)Drugs administered in outpatient or office settings (e.g., certain injectables, chemotherapy, immunosuppressives) for which the Medicare Part B drug cost share applies (assessed per drug per day).

Billing interactions

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage copay and coinsurance guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor home infusion services, continue using the established authorization protocol per your contract with UnitedHealthcare Medicare Advantage and contact provider resources with questions.

SourceLink

On This Page

Ambulance transportation: Covered when medically necessary to the nearest facility that can provide care; cost share applies per one-way trip according to Medicare guidelines. Nonemergency ambulance requires documentation that other transportation would endanger the member's health. Transportation back to the U.S. from another country is not covered. If member was alive when ambulance called but died before arrival, no member cost sharing applies.

Immunosuppressive drugs: Covered post-transplant under Medicare Part B rules; Medicare Part B cost share applies.

Opioid treatment program services: Covered under Medicare Part B. Outpatient OTP/OBOT coverage includes FDA-approved medications, dispensing/administration, counseling, therapy, toxicology testing, intake and periodic assessments. OBOT visits may have outpatient visit cost share plus prescription drug copay; OTP dispensing/ingestion on-site uses the OTP benefit cost share ($0 copay with network and out-of-network providers on all Medicare Advantage plans for the outpatient opioid treatment services benefit).

Outpatient hospital services and outpatient surgery: Medically necessary services provided in outpatient facilities are covered and may be subject to applicable cost sharing. When multiple benefit categories are provided in same visit, separate cost shares may apply for each category (examples: Part B drugs, lab, radiology, therapy, dialysis, observation). Outpatient surgery cost sharing may include surgery, anesthesia, professional services and observation; additional separately billed services (diagnostics, therapeutic services, prosthetics/orthotics, supplies, Part B drugs) may have separate cost sharing.

Physician services including office visits: Primary care and specialist professional services are subject to plan cost sharing per EOC. Cost sharing is not all-inclusive for other services rendered during the visit (labs, diagnostics, Part B drugs) — those categories' cost shares also apply. Telehealth and house calls may have different cost shares per plan. Separate surgery-related office visits during the global postoperative period are included in the surgical allowance and not billed separately.

Radiology and non-radiological diagnostic tests: Medicare-covered screening mammography and bone mass measurement are preventive with no cost share. Flat-film X-rays may be subject to a cost share per standard view in addition to any office visit copay. Specialized diagnostic scans (CT, PET, MRI, MRA, nuclear studies, radiopharmaceuticals, ultrasounds, diagnostic mammograms, interventional radiology) are subject to applicable cost share.

Rehabilitation services: Medicare-covered outpatient rehabilitation (cardiac, pulmonary, physical, speech, occupational therapies) may have applicable cost sharing per session.

Supervised exercise therapy (SET) for symptomatic PAD: Covered with physician referral; up to 36 sessions over 12 weeks; may extend for an additional 36 sessions if medically necessary; copay or coinsurance applies per session.

Mental health inpatient: Covered services include inpatient psychiatric hospital stays (190-day lifetime limit; does not apply to psychiatric unit of general hospital) and inpatient substance abuse services; some plans may have different inpatient mental health cost share per day or different maximum days — refer to EOC.

Vision benefits: Medicare-covered vision exams for medical care and diabetic retinopathy screening for people with diabetes (once per year) are billed to medical insurance. UnitedHealthcare Medicare Advantage plans cover glaucoma screening once per year at $0 cost sharing for high-risk members. Medicare-covered eyewear after cataract surgery (one pair of eyeglasses or contact lenses) is covered.

Prosthetic devices and orthotics: DME prosthetics and orthotics cost share applies for each medically necessary, Medicare-covered device (including replacements and repairs) and related supplies; coverage includes items such as colostomy supplies, pacemakers, braces, prosthetic shoes, artificial limbs and breast prostheses.

Radiation therapy: Therapeutic radiology cost share applies per procedure or per visit (copay or coinsurance depending on plan). Examples include brachytherapy, radioactive implants, conformal proton beam, therapeutic radiology; gamma knife and stereotactic procedures are covered as outpatient surgery with applicable cost share.

Urgent and walk-in clinic services: Cost sharing varies by plan; urgent care copay is not all-inclusive and additional cost shares may apply for services provided during the visit (e.g., X-rays). Retail walk-in clinics follow urgent care cost share.

STI screening and high-intensity behavioral counseling: Covered per Medicare when indicated (pregnancy or increased risk); STI testing covered once per year or at certain times during pregnancy; up to 2 individual 20–30 minute in-person counseling sessions per year by a PCP in a primary care setting as preventive service, with no cost share.

Coding and coverage resources and notes: Providers should reference the CMS Medicare Coverage Database (NCD/LCD Lookup), CMS Medicare Preventive Services resources, and UnitedHealthcare Medicare Advantage policy pages at UHCprovider.com > Coverage and payments > Policies and protocols > For Medicare Advantage Plans for detailed coding, frequency, and billing rules.

Chemotherapy setting rule

Setting-based Part B designationChemotherapy drugs are Medicare Part B drugs when administered in an outpatient or office setting, regardless of method of administration.

Home infusionChemotherapy drugs administered in the home by infusion may be either Part B or Part D (setting and billing determine coverage).

Cost share applies to drug and administrationThe chemotherapy drug cost share applies to both the chemotherapy drug and its administration; when administered in outpatient hospital or physician office settings, cost sharing for both the setting and the drug may apply.

SET is covered for symptomatic PAD with a physician referral.
Up to 36 sessions over 12 weeks are covered when program requirements are met; an additional 36 sessions may be authorized if medically necessary.
A copay or coinsurance applies per SET session.

If an injectable medication is given in the physician’s office and an office visit is billed, cost sharing for both the office visit and the injectable drug may apply; administration alone has no separate cost share beyond the office visit.

Outpatient hospital administrationWhen administered in an outpatient hospital setting, cost sharing for both outpatient hospital services and the injectable drug may apply.

Chemotherapy drugs

Part B designation in clinic/outpatientChemotherapy drugs are Medicare Part B drugs when administered in an outpatient or office setting, regardless of method of administration.

Home infusion possibilityChemotherapy drugs administered in the home by infusion may be either Part B or Part D depending on the drug and billing circumstances.

Cost share scopeThe chemotherapy drug cost share applies to both the drug and its administration; separate outpatient or office cost shares may also apply.

Immunosuppressive drugs

Post-transplant coverageThe Medicare Part B cost share applies to covered immunosuppressive drugs provided post-transplant for all members.

Relation to Part B drug rulesImmunosuppressive drugs are treated under Medicare Part B drug cost-sharing rules when they qualify as Part B drugs administered in the appropriate setting.

Member impactMembers will incur the Medicare Part B drug cost share for covered post-transplant immunosuppressive medications as described in plan benefits.