In-network
Inpatient hospital
Per admission $1,980 per stay
Plan-listed inpatient copay $1,980
● CMS 2026 plan record
UHC Dual Complete VA-Y4 (PPO D-SNP)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network20% coinsurance
Air · in-network20% coinsurance
Emergency services
Emergency room
$115 copay
Waived if admitted within 24 hours
Medical maximum
Maximum out-of-pocket
In-network$9,250
Combined in + out$13,900
Skilled care at home
Home health
In-network$0 copay
Out-of-network$0 copay
Monthly cost
Premium & giveback
Part C premium$0 / month
Consolidated C + D$24.60 / month
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Primary care physician
In: 0%–20% coinsurance · Out: 30% coinsurance
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Specialist
In: 0%–20% coinsurance · Out: 30% coinsurance
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Preventive care
In: $0 copay · Out: 0%–40% coinsurance
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Diagnostic procedures & tests
In: 20% coinsurance · Out: 40% coinsurance
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Laboratory services
In: $0 copay · Out: $0 copay
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X-rays & standard imaging
In: 0%–20% coinsurance · Out: 40% coinsurance
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MRI, CT & PET imaging
In: 20% coinsurance · Out: 20% coinsurance
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Urgent care
In: Cost share not reported · Out: Not separately reported
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Emergency room
In: $115 copay · Out: Not separately reported
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Ground ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Air ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Outpatient hospital
In: 0%–20% coinsurance · Out: 40% coinsurance
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Outpatient surgery / ASC
In: 0%–20% coinsurance · Out: 40% coinsurance
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Home health
In: $0 copay · Out: $0 copay
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Skilled nursing facility
In: Cost share not reported · Out: Not separately reported
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Cardiac & pulmonary rehabilitation
In: 20% coinsurance · Out: 30% coinsurance
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Occupational therapy
In: 20% coinsurance · Out: 30% coinsurance
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Physical & speech therapy
In: 20% coinsurance · Out: 30% coinsurance
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Mental health services
In: $55 copay · Out: 30% coinsurance
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Substance use treatment
In: $55 copay · Out: 30% coinsurance
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Podiatry
In: $0 copay · Out: 30% coinsurance
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Chiropractic
In: 20% coinsurance · Out: 30% coinsurance
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Dental
In: 20% coinsurance · Out: 40% coinsurance
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Vision
In: $0 copay · Out: 30% coinsurance
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Hearing
In: $0 copay · Out: 30% coinsurance
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Transportation
In: $0 copay · Out: 75% coinsurance
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Fitness & wellness
In: $0 copay · Out: $0 copay
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Over-the-counter allowance
In: $0 copay · Out: $0 copay
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Meals
In: $0 copay · Out: $0 copay
Plan details
All plan benefits
No benefits match that search.
Medical care3 benefits
Primary care physician
In-network0%–20% coinsurance
Out-of-network30% coinsurance
Specialist
In-network0%–20% coinsurance
Out-of-network30% coinsurance
Preventive care
In-network$0 copay
Out-of-network0%–40% coinsurance
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-network20% coinsurance
Out-of-network40% coinsurance
Laboratory services
In-network$0 copay
Out-of-network$0 copay
X-rays & standard imaging
In-network0%–20% coinsurance
Out-of-network40% coinsurance
MRI, CT & PET imaging
In-network20% coinsurance
Out-of-network20% coinsurance
Urgent & hospital care6 benefits
Urgent care
In-networkCost share not reported
Out-of-networkNot separately reported
Emergency room
In-network$115 copay
Out-of-networkNot separately reported
Ground ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Air ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Outpatient hospital
In-network0%–20% coinsurance
Out-of-network40% coinsurance
Outpatient surgery / ASC
In-network0%–20% coinsurance
Out-of-network40% coinsurance
Recovery & therapy5 benefits
Home health
In-network$0 copay
Out-of-network$0 copay
Skilled nursing facility
In-networkCost share not reported
Out-of-networkNot separately reported
Cardiac & pulmonary rehabilitation
In-network20% coinsurance
Out-of-network30% coinsurance
Occupational therapy
In-network20% coinsurance
Out-of-network30% coinsurance
Physical & speech therapy
In-network20% coinsurance
Out-of-network30% coinsurance
Behavioral health2 benefits
Mental health services
In-network$55 copay
Out-of-network30% coinsurance
Substance use treatment
In-network$55 copay
Out-of-network30% coinsurance
Specialty care2 benefits
Podiatry
In-network$0 copay
Out-of-network30% coinsurance
Chiropractic
In-network20% coinsurance
Out-of-network30% coinsurance
Supplemental benefits7 benefits
Dental
In-network20% coinsurance
Out-of-network40% coinsurance
Vision
In-network$0 copay
Out-of-network30% coinsurance
Hearing
In-network$0 copay
Out-of-network30% coinsurance
Transportation
In-network$0 copay
Out-of-network75% coinsurance
Fitness & wellness
In-network$0 copay
Out-of-network$0 copay
Over-the-counter allowance
In-network$0 copay
Out-of-network$0 copay
Meals
In-network$0 copay
Out-of-network$0 copay
Plan costs & rulesCoverage overview
Premium & Part B giveback
$0 Part C premium / month · Part B giveback not separately reported
Maximum out-of-pocket (MOOP)
In-network$9,250
Combined in + out$13,900
Medical deductibles
In-networkNot reported
Out-of-networkNot reported
Network & referrals
Local PPO · Referrals: Not required · Out-of-network coverage: Yes
Prescription drugs5 tiers
Part D deductible
Not reported
Drug tier 1
$0 retail copay · 30-day supply
Drug tier 2
25% retail coinsurance · 30-day supply
Drug tier 3
25% retail coinsurance · 30-day supply
Drug tier 4
25% retail coinsurance · 30-day supply
Drug tier 5
25% retail coinsurance · 30-day supply
Using this plan
Understand H0421-001-000
Plain-language context built from this plan’s 2026 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.
Plan at a glance
A quick read on this plan
UHC Dual Complete VA-Y4 (PPO D-SNP) is a 2026 Local PPO offered by UnitedHealthcare in Select Counties in Virginia. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $1,980 across null charged days.
Common benefit costs
What you may pay
These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.
Routine care
- Primary care physician
- 0%–20% coinsurance
- Specialist
- 0%–20% coinsurance
- Laboratory services
- $0 copay
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- 20% coinsurance
- MRI, CT & PET imaging
- 20% coinsurance
- Outpatient hospital
- 0%–20% coinsurance
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- $115 copay
- Listed inpatient stages
- $1,980 total
null charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.
Helpful context
Terms worth knowing
Maximum out-of-pocket (MOOP)
This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.
Availability
Who can enroll
- Service area
- Select Counties in Virginia (VA)
- Plan type
- Local PPO
- Special Needs Plan
- Dual-Eligible
- Contract / plan
- H0421-001
- Coverage year
- 2026
This is a Dual-Eligible; enrollment requires the plan's specific eligibility criteria as well as residence in its service area. Confirm eligibility and the exact service area with the plan before enrolling.
Supplemental coverage
Extra benefits reported
Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.
Dental20% coinsurance
Vision$0 copay
Hearing$0 copay
Over-the-counter allowance$0 copay
Fitness & wellness$0 copay
Transportation$0 copay
Meals$0 copay
Plan-specific answers
Frequently asked questions
Where is H0421-001-000 available?
UHC Dual Complete VA-Y4 (PPO D-SNP) is listed for Select Counties in Virginia (VA). This is a Dual-Eligible; enrollment requires the plan's specific eligibility criteria as well as residence in its service area.
What is the in-network maximum out-of-pocket limit for H0421-001-000?
The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $9,250. Prescription drug spending generally does not count toward this medical limit.
What is the monthly plan premium for H0421-001-000?
The listed consolidated Part C and Part D premium is $24.60 per month. This does not replace the standard Medicare Part B premium.
What does an emergency room visit cost on H0421-001-000?
The plan record lists $115 copay, waived when an admission meets the plan's stated timing rule.
Does H0421-001-000 report extra benefits?
Yes. CMS reports dental, vision, hearing, over-the-counter allowance, fitness & wellness, and other supplemental benefits. See the detailed benefit rows and official plan documents for limits and conditions.
Source trail
Official CMS, Contract Year 2026
Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release; county identity is sourced from segment-level Landscape rows and stable codes are enriched from the aligned MA contract service-area release where matched. Quick-reference values should be confirmed in 2026 official plan documents.
Plan context
Where H0421-001-000 fits
- Full CMS plan ID
H0421-001-000- Contract
H0421- Base plan code
H0421-001- Segment
000- Carrier
- UnitedHealthcare
- Plan type
- Local PPO
- Service area
- Select Counties in Virginia (VA)
County/service-area foundation
CMS service-area entries
Named county entries are tied to this exact contract, plan, and segment in CMS Landscape data. County codes are enriched from the aligned CMS contract service-area release where a match exists.
- Accomack, VA
- Albemarle, VA
- Alexandria City, VA
- Alleghany, VA
- Amelia, VA
- Amherst, VA
- Appomattox, VA
- Arlington, VA
- Augusta, VA
- Bath, VA
- Bedford, VA
- Bland, VA
120 additional service-area entries are retained in the data record.
About this code
What H0421-001-000 identifies
H0421-001-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H0421-001, H0421 001, or the compact full CMS ID H0421001000 refer to this plan or its base plan code.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.