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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 2025, 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 2025.
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 $39.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $0.60. 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 $590.00 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 $6200.00 (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 $6200.00 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) has a $590 deductible for prescription drugs. After the deductible is met, you will pay the costs for your drugs based on the tier and pharmacy you use. This plan's premium may be reduced if you qualify for the low-income subsidy (LIS). If you qualify for LIS, you will pay $39.00 per month for Part D.
Additional Benefits
The UHC Nursing Home Plan EX-F004 (PPO I-SNP) offers comprehensive coverage, including no copay for primary care physician services, physical therapy, speech-language pathology, home health, skilled nursing facility days 1-100, and vision services. This plan also covers inpatient hospital stays with a $2,000 copay, and outpatient services with coinsurance requirements. Additional benefits include hearing services, dental services with a $5,000 annual maximum, and coverage for ambulance, emergency, and preventive services, all with varying cost-sharing structures.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered under the UHC Nursing Home Plan EX-F004 (PPO I-SNP) with a $2,000 copay for a Medicare-covered stay. Additional days, non-Medicare stays, and upgrades for both acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient Services includes coverage for Outpatient Hospital Services with a coinsurance between 0% and 10%, Observation Services with a 10% coinsurance, Ambulatory Surgical Center (ASC) Services with a coinsurance between 0% and 10%, Outpatient Substance Abuse Services with a coinsurance between 0% and 20%, and Outpatient Blood Services with a coinsurance between 0% and 20%. This plan requires prior authorization for all services.
Partial Hospitalization See details
Partial Hospitalization is covered with no copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the UHC Nursing Home Plan EX-F004 (PPO I-SNP), including ground and air ambulance services with a 20% coinsurance, and transportation services to plan-approved health-related locations with no copay for up to 24 one-way trips per year. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered under the UHC Nursing Home Plan EX-F004 (PPO I-SNP), with a $110 copay and no coinsurance. Urgently Needed Services are also covered, with a copay between $0 and $40, and no coinsurance. Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are not covered.
Primary Care See details
Primary Care Physician Services are covered with no copay. Chiropractic services are covered, but routine care is not covered and requires prior authorization, and has a coinsurance between 0% and 20%. Occupational Therapy Services are covered with no coinsurance and no copay. Physician Specialist Services, Mental Health Specialty Services, Psychiatric Services, and Podiatry Services are covered, with coinsurance between 0% and 20%, and prior authorization required. Physical Therapy and Speech-Language Pathology Services are covered with no copay, and require prior authorization. Additional Telehealth Benefits and Opioid Treatment Program Services are covered with no copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered zero dollar preventive services, annual physical exams with no copay, and additional preventive services. Additional preventive services have a copay, and other services such as health education, in-home safety assessments, and counseling services are not covered. Glaucoma screenings, EKG following Welcome Visit, and Digital Rectal Exams have a coinsurance between 0-20%, Diabetes Self-Management Training, and Barium Enemas have no copay.
Hearing Services See details
The UHC Nursing Home Plan EX-F004 (PPO I-SNP) covers hearing exams with a coinsurance of at most 20% and no copay, and covers prescription hearing aids with no copay. This plan also covers OTC hearing aids with no copay.
Vision Services See details
The UHC Nursing Home Plan EX-F004 (PPO I-SNP) plan covers vision services, including routine eye exams with no copay and 0-20% coinsurance, contact lenses with no copay, eyeglass lenses with no copay, and eyeglass frames with no copay. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with 0% to 20% coinsurance and other services with a $5,000 maximum benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), maxillofacial prosthetics, implant services, prosthodontics (fixed), and oral and maxillofacial surgery are covered with no copay. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. The plan covers Medicare Part B Insulin Drugs with a $35 copay and between 0-20% coinsurance. The plan also covers Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, with between 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the UHC Nursing Home Plan EX-F004 (PPO I-SNP) plan, but require prior authorization. The coinsurance for dialysis services ranges from 0% to 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 20% coinsurance with no copay, and Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 0% to 20% coinsurance with no copay, and Medical Supplies have a 20% coinsurance with no copay. Diabetic Supplies and Therapeutic Shoes/Inserts have a 20% coinsurance with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a coinsurance of up to 20%, Lab Services with no copay, Diagnostic Radiological Services with a coinsurance of up to 20%, Therapeutic Radiological Services with a 20% coinsurance, and Outpatient X-Ray Services with no copay. Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the UHC Nursing Home Plan EX-F004 (PPO I-SNP) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the UHC Nursing Home Plan EX-F004 (PPO I-SNP), but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for these services, and there is coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the UHC Nursing Home Plan EX-F004 (PPO I-SNP) with no copay for days 1-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services for the UHC Nursing Home Plan EX-F004 (PPO I-SNP) includes Over-the-Counter (OTC) Items with no copay, while acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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