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UHC Nursing Home Plan EX-F004 (PPO I-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UHC Nursing Home Plan EX-F004 (PPO I-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on UHC Nursing Home Plan EX-F004 (PPO I-SNP) in 2026, please refer to our full plan details page.
UHC Nursing Home Plan EX-F004 (PPO I-SNP) is a PPO I-SNP plan offered by UnitedHealth Group, Inc. available for enrollment in 2025 to people living in District of Columbia & Select Counties in MD & VA. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that UHC Nursing Home Plan EX-F004 (PPO I-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
UHC Nursing Home Plan EX-F004 (PPO I-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about UHC Nursing Home Plan EX-F004 (PPO I-SNP).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For UHC Nursing Home Plan EX-F004 (PPO I-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $27.80. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.20. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $13900.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $13900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The UHC Nursing Home Plan EX-F004 (PPO I-SNP) features an annual prescription drug deductible of $615. This means you must pay the full cost of your covered medications up to this amount before the plan begins to pay its share. Specific drug coverage tier details, including individual copayments and coinsurance rates, are currently unavailable for this plan. To determine your exact out-of-pocket costs, you should review the plan's comprehensive formulary or contact the provider directly.
Additional Benefits
The UHC Nursing Home Plan EX-F004 (PPO I-SNP) offers robust coverage for core medical needs, featuring no copay for primary care, outpatient services, and skilled nursing facility stays up to 100 days. For emergency care, members pay a $115 copay which is waived upon hospital admission, while inpatient hospital stays require a copayment of $2,210 for acute care and $2,080 for psychiatric care. Many outpatient and specialist services require no copay but may carry a coinsurance of up to 20% and require prior authorization. This plan also includes valuable supplemental benefits like dental care with no copay or coinsurance up to a $2,000 annual limit. Routine vision and hearing exams feature no copay with 20% coinsurance, and the plan provides allowances of up to $300 annually for eyewear and $2,200 every two years for hearing aids. Furthermore, members can benefit from up to 24 one-way transportation trips per year to approved health locations with no copay or coinsurance.
Inpatient Hospital See details
UHC Nursing Home Plan EX-F004 (PPO I-SNP) partially covers inpatient hospital services, with no coinsurance and required prior authorization for covered stays. Patients pay a $2,210 copayment per stay for acute inpatient care and a $2,080 copayment per stay for psychiatric care, though additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UHC Nursing Home Plan EX-F004 (PPO I-SNP) covers outpatient services with no copays, though coinsurance ranges from no coinsurance up to 20% depending on the service. Prior authorization is required for outpatient hospital, ambulatory surgical center, substance abuse, and blood services.
Partial Hospitalization See details
UHC Nursing Home Plan EX-F004 (PPO I-SNP) covers partial hospitalization services with no copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
UHC Nursing Home Plan EX-F004 (PPO I-SNP) covers ambulance services with a 20% coinsurance and no copay, though prior authorization is required. Transportation services are partially covered with no copay or coinsurance for up to 24 one-way trips per year to plan-approved health-related locations, while general transportation to any health-related location is not covered.
Emergency Services See details
UHC Nursing Home Plan EX-F004 (PPO I-SNP) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $40 copay and no coinsurance, while worldwide emergency services are not covered.
Primary Care See details
Primary care benefits under the UHC Nursing Home Plan EX-F004 (PPO I-SNP) generally feature no copay, with coinsurance ranging from no coinsurance up to 20% for primary care, specialist, and mental health services. Physical, occupational, and speech therapies require no copay and 20% coinsurance, whereas telehealth and opioid treatments have no copay and no coinsurance. Chiropractic services are not covered in practice since routine and other chiropractic services are excluded.
Preventive Services See details
UHC Nursing Home Plan EX-F004 (PPO I-SNP) covers preventive services, including annual physical exams and kidney disease education with no copay and no coinsurance, though some services like glaucoma screenings and EKGs require a 20% coinsurance. Additional preventive benefits are only partially covered, excluding services such as fitness benefits, health education, in-home safety assessments, and personal emergency response systems.
Hearing Services See details
Hearing services are partially covered by UHC Nursing Home Plan EX-F004 (PPO I-SNP), excluding fitting and evaluation exams as well as inner ear, outer ear, and over-the-ear prescription hearing aids. Covered routine hearing exams have no copay and 20% coinsurance, while covered prescription hearing aids (up to $2,200 every two years) and over-the-counter hearing aids feature no copay and no coinsurance.
Vision Services See details
Vision services are partially covered under the UHC Nursing Home Plan EX-F004 (PPO I-SNP), as other eye exams, upgrades, and eyeglasses (lenses and frames) are not covered. Routine eye exams are covered once per year with no copay and a 20% coinsurance, while eligible eyewear (including contact lenses, lenses, and frames) is covered with no copay, no coinsurance, and a $300 annual maximum.
Dental Services See details
Dental Services are partially covered by the UHC Nursing Home Plan EX-F004 (PPO I-SNP), with Medicare-covered dental services requiring no copay and a 20% coinsurance. Preventive and comprehensive dental services feature no copay and no coinsurance up to a $2,000 annual limit, though orthodontics are not covered.
Home Infusion bundled Services See details
UHC Nursing Home Plan EX-F004 (PPO I-SNP) covers Home Infusion bundled Services with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy, radiation, and insulin, carry a coinsurance ranging from no coinsurance to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
Dialysis Services are covered by UHC Nursing Home Plan EX-F004 (PPO I-SNP) with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Medical equipment is covered under the UHC Nursing Home Plan EX-F004 (PPO I-SNP) with no copays, though prior authorization is required. Members will pay a 20% coinsurance for durable medical equipment, medical supplies, and diabetic equipment, while prosthetic devices carry a coinsurance ranging from no coinsurance to 20%.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the UHC Nursing Home Plan EX-F004 (PPO I-SNP), with prior authorization required for these services. Diagnostic procedures and tests require a copay and 20% coinsurance, while lab services and diagnostic radiological services have no copay, and therapeutic radiology and outpatient X-rays require a 20% coinsurance with no copay.
Home Health Services See details
Home Health Services are covered under the UHC Nursing Home Plan EX-F004 (PPO I-SNP) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by UHC Nursing Home Plan EX-F004 (PPO I-SNP) with no copay and require prior authorization, though only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered under the primary benefit and instead require a 20% coinsurance.
Skilled Nursing Facility (SNF) See details
UHC Nursing Home Plan EX-F004 (PPO I-SNP) covers Skilled Nursing Facility (SNF) services for days 1 through 100 with no copay and no coinsurance, and does not require a prior three-day inpatient hospital stay. Prior authorization is required for these services, and additional days beyond the standard Medicare-covered period are not covered.
Other Services See details
Other services are partially covered under the UHC Nursing Home Plan EX-F004 (PPO I-SNP), which provides select over-the-counter (OTC) items, including nicotine replacement therapy and naloxone, with no copay and no coinsurance. However, acupuncture, meal benefits, and other additional services are not covered under this plan.
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