The Medicare Advantage Base Plan (referred to as Plan 13759 by Medicare) is a group plan available to Medicare-eligible retirees and their dependents. However, if you are a pre-1990 retiree who never enrolled in Medicare due to your pre-1990 status, or are a Federal Civil Service retiree and are not eligible for Medicare, you will have the same plan options as retirees or dependents that are not Medicare eligible. Those plan options are listed on the retiree benefits overview webpage.
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Monthly premiums
Your share of insurance premiums is determined by a formula that considers your age and years of service at retirement and the program under which your benefits are payable. If you are looking for an idea of what premiums would be for your particular circumstances, use the Retiree Insurance Premiums Estimator. For additional details, see the Summary Plan Description for the university-sponsored Medicare Advantage Base Plan under the forms and guides section of this page.
Note: You still need to pay your Original Medicare Part B premiums, in addition to the premiums for the university-sponsored Medicare Advantage Base Plan. In most cases, there is no premium requirement for Original Medicare Part A. If, however ,you are not eligible for no-cost Medicare Part A coverage and are paying for this coverage, you are required to continue to pay this premium when enrolled in the university-sponsored Medicare Advantage Base Plan.
Annual deductible
The Medicare Advantage Base Plan has two annual deductibles: one for medical and a second for prescription drug costs.
- Medical deductible: $0 per person
- Rx deductible: $200 (retail only)
Cost of covered expenses
What you pay for covered expenses is as follows:
- Primary care office visit: $10
- Specialist office visit: $20
- Inpatient hospital stay: $200/admittance
- Outpatient surgery: $100
- Ambulance service: $50
- Emergency room: $65
- Urgent care: $35
- Durable medical equipment: 20% coinsurance
- Lab services X-ray: $0 outpatient; $25 diagnostic
- Preventive care: $0
*For a full schedule of benefit coverages, refer to the UnitedHealthcare (UHC) Medicare Advantage Plan Guide.
Out-of-pocket limit
The university-sponsored Medicare Advantage Base Plan has two annual out-of-pocket limits: one for medical and a second for prescription drug costs.
- Medical out-of-pocket limit: $2,000/person
- Rx out-of-pocket limit: $4,130
Preauthorization
In some cases, prior authorization is necessary for non-emergency use of certain facilities, diagnostic testing, and other health services before care is provided. You can access the preauthorization list for active employees (PDF, 14KB) to see a similar list of services/treatments.
Network providers
As long as your doctor, hospital, or other provider participates in (i.e., accepts payment from) Medicare, you will receive the same level of coverage whether or not your provider is a member of the UHC Group National PPO Network. The university-sponsored group Medicare Advantage Base Plan and Medicare Advantage Enhanced Plan provide the flexibility to see providers in or out of network at the same cost.
- Retiree Benefits Change Form - This form packet also includes the "Retiree Beneficiary Designation Information" form (for Basic Life, Additional Life, and Accidental Death and Dismemberment)
- 2021 Medicare Advantage Base Plan Summary of Benefits
- 2021 Medicare Advantage Plan Guide
- The Summary of Benefits and Coverage (SBC) information is included in this guide. See pp. 18-41.
- Medicare Advantage Plan Summary Plan Description (SPD)
- FAQs: University-sponsored Medicare Advantage plans
- 2021 Medicare Part D Prescription Drug Formulary - list of covered drugs for Express Scripts Medicare plans
- Full list of forms and guides about retiree medical insurance
* In the event of a difference between this webpage and the plan document or summary plan description, the plan document and plan description prevail.
Reviewed 2021-07-02
