Page 54 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 89129
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 2579428096
and more coverage and star ratings.
Password Date: 11/23/2017
Important Coverage Information

You are now viewing 2018 plan data. View 2017 plan data.
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A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
A process through which the enrollee’s primary care physician or other network physician (depending on the plan policy) permits or
instructs the enrollee to obtain an item or service from another physician or other provider type.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated

Senior Dimensions 2716 N Tenaya Way Overall Star Rating: [?] Enroll
Las Vegas, NV 89128
Southern Nevada (HMO)
(H2931-002-0) Members: 3.5 out of 5 stars

1-800-650-6232
Organization: UnitedHealthcare 711 (TTY/TDD)
Plan Type: Non Members:
1-800-555-5757
711 (TTY/TDD)

Benefits Highlights

Monthly health plan premium $0.00
Health plan deductible $0

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $2,500 In-network
responsibility (does not include
prescription drugs)
Optional supplemental benefits [?] Yes

Inpatient hospital coverage $0 for days 1 through 90
$0 for days 91 and beyond

Outpatient hospital coverage $0 copay

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H2931&plnid=002&sgmntid=0#plan_benefits 1/5