2027 Medicare Advantage plan
AARP Medicare Advantage Patriot No Rx SI-MA2 (PPO): 2027 benefits and costs
UnitedHealthcare PPO
CMS plan ID: H2001-139-0 · Plan year: 2027
AARP Medicare Advantage Patriot No Rx SI-MA2 (PPO) is a 2027 Medicare Advantage plan offered by UnitedHealthcare. It is listed in Nebraska, South Dakota.
2027 plan costs at a glance
- Organization
- UnitedHealthcare
- Plan organization
- SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC.
- Parent company
- UnitedHealth Group, Inc.
- Plan type
- PPO
- Part C premium
- $0.00
- Prescription drug coverage
- No
- 2027 CMS Star Rating
- Standard monthly Medicare Part B premium
- $209.50 (estimated)
- Monthly Part B premium after plan reduction
- $94.50 (estimated)$209.50 standard premium less $115.00 plan reduction.
You must continue to pay your Medicare Part B premium.
- Annual medical deductible
- None
- In-network medical maximum
- $7,150.00
- Combined in/out-of-network medical maximum
- $10,750.00
- Out-of-network medical maximum
- Not applicable
- Part B premium reduction
- $115.00
2027 benefit summary
Doctor visits and medical care
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Primary care doctor | $0.00 copay
| $25.00 copay
| |
| Specialist visit | $0.00 to $50.00 copay
| $60.00 copay
|
|
| Emergency care | $130.00 copay | Not summarized. Check coverage with the plan. | |
| Urgent care | $0.00 to $50.00 copay | Not summarized. Check coverage with the plan. | |
| Home health | $0.00 copay
| 50% coinsurance
|
|
| Dialysis | 20% coinsurance
| 20% coinsurance
|
|
| Part B chemotherapy and radiation drugs | 0% to 20% coinsurance
| 40% coinsurance
|
|
| Other Part B drugs | 0% to 20% coinsurance
| 0% to 40% coinsurance
|
|
| Kidney disease education services | $0.00 copay
| 40% coinsurance
|
|
| Medicare-covered chiropractic | $15.00 copay
| $60.00 copay
|
|
| Medicare-covered foot care | $45.00 copay
| $60.00 copay
|
|
| Other health professionals | $0.00 to $50.00 copay
| $25.00 to $60.00 copay
|
|
Hospital, outpatient surgery and observation care
Inpatient stays and skilled nursing care
| Care | Your share of the cost | What to know |
|---|---|---|
| Inpatient hospital stay | $0.00 copay per stay Days 1–6: $445.00 copay per day Days 7–90: $0.00 copay per day |
|
| Inpatient mental health care | $0.00 copay per stay Days 1–5: $445.00 copay per day Days 6–90: $0.00 copay per day |
|
| Skilled nursing facility | Days 1–20: $0.00 copay per day Days 21–100: $221.00 copay per day |
|
See plan documents for out-of-network hospital and skilled nursing costs.
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Outpatient hospital care | $0.00 to $445.00 copay
| $0.00 to $545.00 copay
| |
| Hospital observation services | $445.00 copay
| $545.00 copay
| |
| Ambulatory surgical center | $0.00 to $395.00 copay
| $0.00 to $545.00 copay
|
|
| Outpatient blood | $0.00 copay
| $0.00 copay
|
|
Tests, imaging and laboratory services
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Diagnostic procedures and tests | $10.00 copay
| $65.00 copay
|
|
| Laboratory services | $0.00 copay
| $0.00 copay
|
|
| Diagnostic radiology (CT, MRI) | $0.00 to $320.00 copay
| $0.00 to $420.00 copay
|
|
| Therapeutic radiology | $60.00 copay
| 40% coinsurance
|
|
| X-rays | $5.00 copay
| $55.00 copay
|
|
Mental health and substance use treatment
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Partial hospitalization | $55.00 copay
| $75.00 copay
|
|
| Intensive outpatient program | $55.00 copay
| $75.00 copay
|
|
| Substance use treatment, individual sessions | $0.00 to $10.00 copay
| $25.00 copay
|
|
| Substance use treatment, group sessions | $10.00 copay
| $25.00 copay
|
|
| Opioid treatment program | $0.00 copay
| $0.00 copay
|
|
| Mental health, individual sessions | $0.00 to $10.00 copay
| $25.00 copay
|
|
| Mental health, group sessions | $10.00 copay
| $25.00 copay
|
|
| Psychiatry, individual sessions | $0.00 to $10.00 copay
| $25.00 copay
|
|
| Psychiatry, group sessions | $10.00 copay
| $25.00 copay
|
|
Therapy and rehabilitation
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Occupational therapy | $50.00 copay
| $60.00 copay
|
|
| Physical and speech therapy | $50.00 copay
| $60.00 copay
|
|
| Cardiac rehabilitation | $0.00 copay
| $60.00 copay
|
|
| Intensive cardiac rehabilitation | $0.00 copay
| $60.00 copay
|
|
| Pulmonary rehabilitation | $0.00 copay
| $60.00 copay
|
|
| Supervised exercise for peripheral artery disease | $0.00 copay
| $60.00 copay
|
|
Ambulance, medical equipment and supplies
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Ground ambulance | $150.00 copay
| $150.00 copay
|
|
| Air ambulance | $150.00 copay
| $150.00 copay
|
|
| Durable medical equipment | 20% coinsurance
| 50% coinsurance
|
|
| Prosthetic devices | 20% coinsurance
| 50% coinsurance
|
|
| Medical supplies | 20% coinsurance
| 50% coinsurance
|
|
| Diabetic supplies | $0.00 copay
| 50% coinsurance
|
|
| Diabetic shoes and inserts | 20% coinsurance
| 50% coinsurance
|
|
| Diabetic monitors | $0.00 copay
| 50% coinsurance
|
|
Dental benefits
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Medicare-covered dental | 20% coinsurance | 40% coinsurance
| |
| Oral examsAdditional plan benefit | $0.00 copay | $0.00 copay
| |
| Dental X-raysAdditional plan benefit | $0.00 copay | $0.00 copay
| |
| Other diagnostic dentalAdditional plan benefit | $0.00 copay | $0.00 copay
| |
| Dental cleaningAdditional plan benefit | $0.00 copay | $0.00 copay
| |
| FluorideAdditional plan benefit | $0.00 copay | $0.00 copay
| |
| Other preventive dentalAdditional plan benefit | $0.00 copay | $0.00 copay
| |
| Restorative dental careAdditional plan benefit | 50% coinsurance | 50% coinsurance
| |
| Root canal treatment (endodontics)Additional plan benefit | 50% coinsurance | 50% coinsurance
| |
| Gum treatment (periodontics)Additional plan benefit | 50% coinsurance | 50% coinsurance
| |
| Removable dentures (prosthodontics)Additional plan benefit | 50% coinsurance | 50% coinsurance
| |
| Maxillofacial prostheticsAdditional plan benefit | 50% coinsurance | 50% coinsurance
| |
| Fixed dental restorations (prosthodontics)Additional plan benefit | 50% coinsurance | 50% coinsurance
| |
| Oral surgeryAdditional plan benefit | 50% coinsurance | 50% coinsurance
| |
| Other dental servicesAdditional plan benefit | 50% coinsurance | 50% coinsurance
|
Additional network details
These costs apply to the listed service categories and networks.
| Service | Network | Your share of the cost | What to know |
|---|---|---|---|
| Diagnostic and preventive dental (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
| Comprehensive dental (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
Vision benefits
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Medicare-covered eye exams | $0.00 copay
| $60.00 copay
|
|
| Routine eye examsAdditional plan benefit | $0.00 copay | $60.00 copay
|
|
| Medicare-covered eyewear | $0.00 copay
| $60.00 copay
|
|
| Contact lensesAdditional plan benefit | $0.00 copay | 90% coinsurance
|
|
| Eyeglasses, lenses and framesAdditional plan benefit | $0.00 copay | 90% coinsurance
|
|
Additional network details
These costs apply to the listed service categories and networks.
| Service | Network | Your share of the cost | What to know |
|---|---|---|---|
| Eye exams (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
| Eyewear (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
Hearing benefits
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Medicare-covered hearing exams | $0.00 copay
| $60.00 copay
|
|
| Routine hearing examsAdditional plan benefit | $0.00 copay | $60.00 copay
|
|
| Prescription hearing aids (all types)Additional plan benefit | $0.00 copay
| 90% coinsurance
|
|
Additional network details
These costs apply to the listed service categories and networks.
| Service | Network | Your share of the cost | What to know |
|---|---|---|---|
| Hearing exams (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
| Prescription hearing aids (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
Extra benefits
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Over-the-counter health itemsAdditional plan benefit | $0.00 copay
| 90% coinsurance
| |
| Annual physical examAdditional plan benefit | $0.00 copay
| 40% coinsurance
|
|
| Fitness benefitAdditional plan benefit | $0.00 copay
| 90% coinsurance
|
|
Additional services and network costs
Additional network details
These costs apply to the listed service categories and networks.
| Service | Network | Your share of the cost | What to know |
|---|---|---|---|
| Podiatry Services - Routine Foot CareAdditional plan benefit | Out-of-network | $60.00 copay
|
|
| Medicare-covered preventive servicesMedicare-covered care | Out-of-network | 0% to 40% coinsurance
| |
| Home and Bathroom Safety Devices and ModificationsAdditional plan benefit | Out-of-network | 90% coinsurance
|
|
| Glaucoma ScreeningMedicare-covered care | Out-of-network | $60.00 copay
| |
| Diabetes Self-Management TrainingMedicare-covered care | Out-of-network | 40% coinsurance
| |
| Digital Rectal ExamsMedicare-covered care | Out-of-network | 40% coinsurance
| |
| EKG after a Welcome to Medicare visitMedicare-covered care | Out-of-network | 40% coinsurance
| |
| Medicare Part B insulinMedicare-covered care | Out-of-network | 40% coinsurance
|
Allowances and optional benefits
Combined Benefit 1
One shared limit covers the listed services, not a separate allowance for each service.
- Services sharing this allowance
- Over-the-counter health items; Home and Bathroom Safety Devices and Modifications
- How benefits are provided
- Catalogue Purchase; Debit Card
- Advance choice of benefits required
- No
- Shared benefit limit
- $50.00
- How often this limit applies
- Every three months
- Shared limit on visits or trips
- No
Prescription drug coverage
This plan does not include a Part D prescription drug benefit.
Where this plan is offered
CMS lists this plan in 2 states or territories. Availability can vary by county and ZIP code.
View all locations 49 county listings across 2 states or territories
Nebraska
South Dakota
- Aurora, South Dakota
- Beadle, South Dakota
- Bon Homme, South Dakota
- Brookings, South Dakota
- Brown, South Dakota
- Butte, South Dakota
- Campbell, South Dakota
- Charles Mix, South Dakota
- Clark, South Dakota
- Clay, South Dakota
- Codington, South Dakota
- Corson, South Dakota
- Custer, South Dakota
- Davison, South Dakota
- Day, South Dakota
- Deuel, South Dakota
- Dewey, South Dakota
- Douglas, South Dakota
- Fall River, South Dakota
- Haakon, South Dakota
- Hamlin, South Dakota
- Hanson, South Dakota
- Harding, South Dakota
- Hutchinson, South Dakota
- Jackson, South Dakota
- Kingsbury, South Dakota
- Lake, South Dakota
- Lawrence, South Dakota
- Lincoln, South Dakota
- Marshall, South Dakota
- McCook, South Dakota
- Meade, South Dakota
- Miner, South Dakota
- Minnehaha, South Dakota
- Moody, South Dakota
- Pennington, South Dakota
- Perkins, South Dakota
- Roberts, South Dakota
- Sanborn, South Dakota
- Spink, South Dakota
- Turner, South Dakota
- Union, South Dakota
- Walworth, South Dakota
- Yankton, South Dakota
- Ziebach, South Dakota