Submit to UCare within 30 days after each quarter-end.
From 5 columns to 4
|
Service Category |
Essentia Health Provider Requirements | Other EssentiaCare Network Providers |
Codes Requiring Authorization - CPT/HCPC Codes
|
|
Outpatient Therapy (PT, OT & ST) Includes therapy in the home and outpatient therapy provided in a nursing facility. |
Physical Therapy - Authorization required beyond threshold of 20 visits per calendar year. Occupational Therapy - Authorization required beyond threshold of 20 visits per calendar year. Speech Therapy - Authorization required beyond threshold of 30 visits per calendar year. Magellan Healthcare: |
Physical Therapy - Authorization required beyond threshold of 20 visits per calendar year. Occupational Therapy - Authorization required beyond threshold of 20 visits per calendar year. Speech Therapy - Authorization required beyond threshold of 30 visits per calendar year. Magellan Healthcare: |
20560, 20561, 92507, 92508, 92526, 92606, 92630, 92633, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97799, G0151, G0152, G0153 |
Updated February 2020
Region |
UCare Product |
Eligibility |
Service Area |
Narrow network? |
| North | UCare Medicare Plans (HMO-POS) |
Must have Medicare Part A & Part B to enroll Do not have end-stage renal disease |
Aitkin, Becker, Beltrami, Carlton, Cass, Clay, Clearwater, Cook, Crow Wing, Douglas, Grant, Hubbard, Itasca, Kanabec, Kittson, Koochiching, Lake, Lake of the Woods, Mahnomen, Marshall, Morrison, Norman, Otter Tail, Pennington, Pine, Polk, Red Lake, Roseau, St. Louis, Todd, Wadena, Wilkin | All UCare network providers |
| North | UCare Medicare Plans (HMO-POS) |
Must have Medicare Part A & Part B Do not have end-stage renal disease |
Aitkin, Becker, Carlton, Cass, Clay, Cook, Crow Wing, Hubbard, Kanabec, Lake, Morrison, Pine and St. Louis | All UCare network providers |
| Metro | UCare Medicare Plans (HMO-POS) |
Must have Medicare Part A & Part B Do not have end-stage renal disease |
Anoka, Benton, Carver, Chisago, Dakota, Hennepin, Isanti, Mille Lacs, Ramsey, Scott, Sherburne, Stearns, Washington, Wright | All UCare network providers |
| South | UCare Medicare Plans (HMO-POS) |
Have Medicare Part A & Part B Do not have end-stage renal disease |
Big Stone, Blue Earth, Brown, Chippewa, Cottonwood, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Houston, Jackson, Kandiyohi, Lac qui Parle, Le Sueur, Lincoln, Lyon, Martin, McLeod, Meeker, Mower, Murray, Nicollet, Nobles, Olmsted, Pipestone, Pope, Redwood, Renville, Rice, Rock, Sibley, Steele, Stevens, Swift, Traverse, Wabasha, Waseca, Watonwan, Winona, Yellow Medicine | All UCare network providers |
| South | UCare Medicare Plans (HMO-POS) |
Have Medicare Part A & Part B Do not have end-stage renal disease |
Blue Earth, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Houston, Le Sueur, Mower, Nicollet, Olmsted, Rice, Steele, Wabasha, Waseca, Watonwan, Winona | All UCare network providers |
In-Network Services |
|||||||
|---|---|---|---|---|---|---|---|
| Primary Care Office Visits | $0 copay | $25 copay | $0 copay | $20 copay | $0 copay | $0 copay | $0 copay |
| Specialist Office Visits | $35 copay | $50 copay | $20 copay | $45 copay | $40 copay | $10 copay | $35 copay |
| Inpatient Hospital Care | $400 copay per stay (not per day), then 100% coverage, unlimited days per admission | $300 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission | $250 copay per stay (not per day), then 100% coverage, unlimited days per admission | $300 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission | $500 copay per day (days 1 - 3), then 100% coverage, unlimited days per admission | $100 copay per stay (not per day), then 100% coverage, unlimited days per admission | $150 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission |
| Urgent Care | $50 copay | $45 copay | $50 copay | $50 copay | $40 copay | $0 copay | $50 copay |
| Worldwide Emergency Care | $100 copay | $90 copay | $100 copay | $100 copay | $90 copay | $100 copay | $100 copay |
| Medicare Part D Prescription Drug Coverage* | No Prescription Drug Coverage | $400 deductible | Copays based on drug tiers | $200 deductible | Copays based on drug tiers | $400 deductible | Copays based on drug tiers | $400 deductible | Copays based on drug tiers | Copays based on drug tiers | $200 deductible | Copays based on drug tiers |
| Preventive Dental Coverage | Yes | No | Yes | Yes | Yes | No | No |
| Vision Coverage-Routine | Routine Eye Exam: 1 per year, $0 Copay | Routine Eye Exam: Not Covered | Routine Eye Exam: 1 per year, $0 Copay | Routine Eye Exam: 1 per year, $0 Copay | Routine Eye Exam: 1 per year, $0 Copay | Routine Eye Exam: 1 per year, $0 Copay | Routine Eye Exam: 1 per year, $0 Copay |
| Vision Coverage-Diagnostic | Diagnostic Eye Exam: $35 copay | Diagnostic Eye Exam: $50 copay | Diagnostic Eye Exam: $20 copay | Diagnostic Eye Exam: $45 copay | Diagnostic Eye Exam: $40 copay | Diagnostic Eye Exam: $10 copay | Diagnostic Eye Exam: $35 copay |
| Hearing Services-Routine | Routine Hearing Exam: 1 per year, $0 Copay | Routine Hearing Exam: Not Covered | Routine Hearing Exam: 1 per year, $0 Copay | Routine Hearing Exam: 1 per year, $0 Copay | Routine Hearing Exam: 1 per year, $0 Copay | Routine Hearing Exam: 1 per year, $0 Copay; $500 allowed every 36 months for hearing aids | Routine Hearing Exam: 1 per year, $0 Copay |
| Hearing Services-Diagnostic | Diagnostic Hearing Exam: $35 copay | Diagnostic Hearing Exam: $50 copay | Diagnostic Hearing Exam: $20 copay | Diagnostic Hearing Exam: $45 copay | Diagnostic Hearing Exam: $40 copay | Diagnostic Hearing Exam: $10 copay | Diagnostic Hearing Exam: $35 copay |
| Out of Pocket Maximum | $3,400 | $5,000 | $3,400 | $3,400 | $4,500 | $3,000 | $3,000 |
* Part D deductible only applies to some drugs. See the Drug Formulary for details.