UHC Complete Care VA-21 (HMO-POS C-SNP)
Available to residents of New Kent County, VA for 2026. Contract H5253, plan 195, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in New Kent County
- Plan website
- Browse the UHC Complete Care VA-21 (HMO-POS C-SNP) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $5,900.00? |
| Drug deductible | $440.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO-POS C-SNP? |
| Special needs plan | Chronic-condition SNP |
| Contract / plan | H5253-195-0 |
| Offered by | UnitedHealthcare |
| Parent organization | UnitedHealth Group, Inc. |
| Formulary drugs | 3,594 |
| Formulary exception tier | 4? |
| Pharmacy search | UHC.com/Medicare |
| Member services | (800)555-5757TTY 711 |
CMS star ratings
- Overall
- 4 out of 5 stars for Overall
- Health plan (Part C)
- 4 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H5253 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0–$40 copay(authorization and referral required) |
| Other health care professional | $0–$40 copay(authorization and referral required) |
| Additional telehealth services | $0 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $30 copay(authorization required) |
| Lab services | $0 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$260 copay(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | $25 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $130 copay |
| Urgent care | $0–$50 copay |
| Worldwide emergency coverage | $0 copay |
| Worldwide urgent care | $0 copay |
| Worldwide emergency transportation | $0 copay |
| Hospital care | |
| Inpatient hospital stay | $395 per day for days 1–6; $0 per day for days 7–90; $0 per day for days 91–999 (additional days)(authorization required) |
| Outpatient hospital services | $0–$395 copay(authorization required) |
| Outpatient observation | $395 copay(authorization required) |
| Ambulatory surgical center | $0–$345 copay(authorization required) |
| Outpatient blood services | $0 copay(authorization required) |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance(authorization required) |
| Rehabilitation | |
| Occupational therapy | $40 copay(authorization and referral required) |
| Physical therapy and speech-language therapy | $40 copay(authorization and referral required) |
| Cardiac rehabilitation | $0 copay(authorization required) |
| Pulmonary rehabilitation | $15 copay(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $395 per day for days 1–5; $0 per day for days 6–90(authorization required) |
| Outpatient mental health, individual session | $0–$25 copay(authorization required) |
| Outpatient mental health, group session | $15 copay(authorization required) |
| Psychiatrist, individual session | $0–$25 copay(authorization required) |
| Psychiatrist, group session | $15 copay(authorization required) |
| Partial hospitalization | $55 copay(authorization required) |
| Intensive outpatient program | $55 copay(authorization required) |
| Outpatient substance use, individual session | $0–$25 copay(authorization required) |
| Outpatient substance use, group session | $15 copay(authorization required) |
| Opioid treatment program | $0 copay(authorization required) |
| Ambulance and transportation | |
| Ground ambulance | $275 copay(authorization required) |
| Air ambulance | $275 copay(authorization required) |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay(authorization required) |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $40 copay(authorization required) |
| Routine foot care | $40 copay(authorization required, limits apply) |
| Dental? | |
| Medicare-covered dental services | 20% coinsurance(authorization required) |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Optional supplemental benefit (extra premium) |
| Other preventive dental services | $0 copay(limits apply) |
| Restorative services (fillings, crowns) | Not covered |
| Endodontics (root canals) | Not covered |
| Periodontics (gum disease) | Not covered |
| Dentures and other removable prosthodontics | Not covered |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | Not covered |
| Orthodontics | Not covered |
| Adjunctive general services | Not covered |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay(authorization required) |
| Routine eye exam | $0 copay(authorization required, limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $300 plan limit every two years |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | Not covered |
| Eyeglass lenses | $0–$153 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0 copay(authorization required) |
| Routine hearing exam | $0 copay(authorization required, limits apply) |
| Hearing aid fitting and evaluation | Not covered |
| Hearing aids (all types) | $199–$1,249 copay(authorization required, limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Covered (allowance not stated) |
| Meals after a hospital stay or for a chronic condition | $0 copay(authorization required) |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | $0 copay |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $14.00 |
| Tier 3 | 18% |
| Tier 4 | 41% |
| Tier 5 | 28% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $14.00 | $14.00 | n/a | $42.00 | $42.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $14.00 | $14.00 | n/a | $42.00 | $42.00 | $0.00 |
| Tier 3: Preferred Brand | 18% | 18% | n/a | 18% | 18% | 18% |
| Tier 4: Non-Preferred Drug | 41% | 41% | 41% | n/a | n/a | n/a |
| Tier 5: Specialty Tier | 28% | 28% | 28% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 11 other VA counties
Benefits in plain text
UHC Complete Care VA-21 (HMO-POS C-SNP) (H5253-195-0) is a 2026 HMO-POS C-SNP Medicare Advantage plan offered by UnitedHealthcare, available to residents of New Kent County, VA.
The monthly premium is $0.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $5,900.00.
The drug deductible is $440.00. Tier 1 and 2 exempt.
It is a special needs plan (Chronic-condition SNP).
The plan's formulary lists 3,594 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $14.00; tier 3: 18%; tier 4: 41%; tier 5: 28%.
CMS gives the plan's contract (H5253) an overall rating of 4 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.