Hello All,
This is your Health Insurance Broker Rachel Gardner. I pray this email finds each and every one of you well. I just wanted to reach out to you to let you know that Annual Open Enrollment (AEP) is just around the corner (October 15th thru December 7th).
There are changes that are going to take place for Medicare Advantage and PDP 2026 plans. Starting with Prescription Drugs as you all know, the beginning of 2025 brought good news concerning the IRA (Inflation Reduction Act) introducing significant changes to Medicare Part D. The most significant change was the Coverage Gap, or “Donut Hole”, being eliminated and your out-of-pocket maximum cost had become lower than ever. That means you were more protected from high drug costs this year. For 2026, these provisions continue putting more financial responsibility on plan sponsors. As a result of this you may see changes to your pharmacy benefits structure, including the addition of coinsurance (in Tiers 3-5) instead of copays and an increase in deductible. There will be a maximum deductible of $615 for 2026 ($590 deductible 2025) to meet if your prescriptions fall into the Tier 3,4 and 5 category and the out-of-pocket maximum will increase to $2100 ($2000 for 2025) . That means you will pay the deductible and cost for your drugs first (in the first month- January). Then you will move to the Initial Coverage Stage. In the Initial Coverage Stage you will pay your plans coinsurance. Once you have paid a combined total of $2100, which includes the amount you paid towards your deductible amount and Initial Coverage Stage, you move to the Catastrophic Coverage stage. In that stage, you won’t pay anything for your Medicare-covered Part D drugs for the rest of the plan year. These updates are based on the CMS (Centers for Medicare and Medicaid) Rate Notice. Also, Negotiated drugs- as part of the IRA, the secretary of Health and Human Services (HHS) is required to negotiate prices with drug companies on certain drugs covered under Part D starting in 2026. To know which drugs, you can reach out to member services or myself. Prescriptions that are not on the formulary and get a formulary exception (approval) will now be rated as a Tier 4 formulary instead of Tier 5, as it is currently.
Please everyone review the formulary below to make sure your prescriptions will be covered for next year. Also, contact your providers and or me if you want to make sure your doctors will still be in network for next year. If you are wanting a copy of your Evidence of Coverage (EOC) for the plan that you want to continue with for next year, in order to make sure you like the plan coverage, costs and benefits, then email me back your request and I will send it.
There are major changes taking place with a few of our plans. For instance, our PPO plans will no longer be available for purchase. They will be discontinued December 31st. Everyone who currently has a PPO plan should have received an ANOC (A Notice of Change) form for UHC. If you have or haven’t received it, please contact me so that I can help you navigate and select another plan that will fit your health needs. Our HMO (Health Maintenance Organization) plans going forward will require referrals if you need to see a specialist. UHC has a large provider network that includes broad local networks of quality providers. Also, HMOs work by lowering overall healthcare cost by avoiding unnecessary or duplicate services. Care with a HMO helps you to stay connected within a single network by reducing the risk of surprise bills, which helps you to ensure better communication between providers. It offers more personalized consistent care through strong provider relationships and a focus on long-term goals. HMO referrals simplify specialist selection by connecting to trusted in-network providers with negotiated rates.
*** For existing plans with new referral requirements starting January 1,2026, if a member goes to a specialist appointment before May 1,2026, without a required referral, they will still be able to have the appointment.***
**** PLEASE CONTACT ME IF YOU HAVE A PPO PLAN, BEFORE DECEMBER 7th 2025. THOSE PPO PLANS WILL NOT AUTO RENEW. YOU HAVE TO CHOOSE ANOTHER PLAN!!***
When it comes to our MAPD (Medicare Advantage Prescription Drug) HMO plans, there is one new plan. The plan is called the AARP Medicare Advantage from UHC CO -21P (HMO-POS). The plan looks good for individuals who are looking for a lower out-of-pocket maximum and medical copays. The dental has a $1000 allowance and the OTC is $45 every quarter (3 months). If you want to know more about this plan, please let me know. When it comes to the remaining MAPD HMO and the Chronic and Patriot plans the out- of-pocket maximums have increased a bit, as well as most of the Part A&B services (Original Medicare) on your plan (inpatient and outpatient services). There is still just one of our MAPD plans that has a premium and as always there are no medical deductibles on any of the plans. The only deductibles on the plans come into play if you have a prescription(s) that fall into the Tier 3-5 category, as stated above. All MAPD plans have a POS (Point of Service) for our dental coverage only. What that means is that the plan gives members the option to use out-of-network providers (for dental only), for certain services, generally at a higher cost. Ancillary benefits such as Over the Counter (OTC) have decreased slightly in a few plans and every additional coverage such as dental, vision and hearing are still included in most of our plans. To know more about the changes that are taking place, I can also send you the Benefit Highlights of the 2026 plan (at your request) that you will be automatically renewed in. If I don’t hear back from you before December 7th stating you would like to change your plan, you will automatically be renewed into the 2026 version of the plan you have currently (with the exception of the PPO plans. Please contact me as soon as possible)!!! In other words, if you like your plan you don’t have to do anything and you will automaticallybe renewed in the same plan you are in now for 2026.
****The new plan that came in 2025 the UHC Dual Complete CO-S4 (HMO POS D-SNP) and the two PPO’s (UHC Dual Complete CO-V001 and CO-S001 PPO D-SNP), as well as the (UHC Dual Complete CO- S002 HMO-POS D-SNP) are still continuing for 2026. These plans come with stipulations concerning the Healthy Food, Utilities and OTC benefits called the VBID (Value Based Insurance Design).
*****The VBID is going away for next year and is being replaced with the SSBCI (Special Supplemental Benefits for the Chronically Ill) program. The Centers for Medicare & Medicaid Services (CMS) is terminating the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model December 31, 2025. As VBID ends, Medicare Advantage plans will experience changes. However, the SSBCI program will remain a key component to support individuals with specific chronic health needs. For UnitedHealthcare, there are important changes to Dual Special Needs Plans (D-SNPs), which will be explained below. The SSBCI program is a program that allows Medicare Advantage plans to offer additional benefits to members with one or more complex conditions, who are at high risk for hospitalization or adverse health outcomes and who require intensive care coordination. Like Value-Based Insurance Design (VBID), SSBCI allows Medicare Advantage plans to offer non-medical and non-primarily health-related benefits—such as healthy foods and utilities—tailored to individuals with serious chronic illnesses.
To understand the VBID and SSBCI program you have to know that they are Supplemental Benefits. All Medicare Advantage plans are required to offer the same benefits as Original Medicare*, benefits beyond this are considered supplemental benefits. Medicare Advantage plans have also been able to offer supplemental benefits such as gym memberships, dental, vision and credits for over-the-counter expenses. Beyond these, Medicare Advantage plans began offering non-medical supplemental benefits to address health-related social needs. Through the VBID model and SSBCI, Medicare Advantage plans also began to offer non-medical supplemental benefits addressing social needs, like food, transportation, and utilities .**
Why should SSBCI matter to United Healthcare members is because (as stated above) it allows Medicare Advantage plans to offer non-primarily health-related benefits tailored to the unique needs of chronically ill individuals, such as the healthy food and utilities benefit. The UnitedHealthcare healthy food and utilities benefit was historically offered through VBID. However, with VBID being terminated, UnitedHealthcare is making sure the healthy food and utilities benefit is still being offered through SSBCI.* This is a change in particular for D’SNP members who may now need to take steps to qualify for SSBCI.
What this means for members who currently have a Dual Complete plan is that UHC members must meet specific criteria, including having one or more qualifying conditions. Keep in mind, SSBCI verification is different from the C-SNP verification. C-SNP Verification is for the chronic conditions associated with enrollment into the C-SNP plan (Diabetes, Chronic Heart Failure, Cardiovascular Disorders). I will provide the D-SNP SSBCI Eligible Conditions towards the end of this email.
Qualifying D-SNP members will be able to use their OTC credit on covered healthy foods and approved utilities like electricity or home heat such as natural gas and transportation in select markets. To access SSBCI benefits, members must have a verified qualifying condition (*To be eligible for SSBCI, members must meet several requirements and will need to be confirmed by the plan, including diagnosis of a qualifying chronic condition, plan eligibility, and additional clinical criteria such as being at high risk for hospitalization or adverse health outcomes and requiring intensive care coordination). Therefore, not all UnitedHealthcare D-SNP plan enrollees will qualify to use their OTC credits toward non-primarily health-related supplemental benefits such as healthy food or utilities, if they do not qualify. However, all plan members can still use their credit toward over-the-counter (OTC) products and wellness support.
SSBCI does not apply to Part D benefits. VBID previously allowed UnitedHealthcare D-SNPs to offer $0 copays on all covered prescriptions. Without VBID, members may see changes to their covered prescription drug benefit. Drugs costs will vary by individual and plan.
Please note that D’SNP plans are for any individual who has full Medicaid benefits or is a Qualified Medicare Beneficiary (QMB), as well can verify that they have at least one of the SSBCI qualifying conditions below. You will pay $0 for your Medicare-covered services, with the exception of prescriptions. Also, the UHC DualComplete CO V001 (PPO DSNP) has small copays for in and out-of-network medical services.
So everyone who is enrolled in a Dual Complete Plan, please contact me. ***You may or may not qualify for the SSBCI program, but let’s have a conversation concerning your options****. We have to get you enrolled into the new plan before December 7th, if you don’t .
Below is the list of UnitedHealthcare’s D-SNP SSBCI qualifying conditions (may vary by carrier):
❑ Diabetes mellitus (type 1 or type 2) ❑ Cardiovascular disorders ❑ Chronic heart failure ❑ Chronic hypertension (chronic high blood pressure) ❑ Chronic hyperlipidemia (chronic high cholesterol) ❑ Autoimmune disorders ❑ Cancer ❑ Chronic alcohol use disorder and other substance use disorders (SUDs) ❑ Chronic gastrointestinal disease ❑ Chronic kidney disease (CKD) ❑ Chronic lung disorders ❑ Chronic and disabling mental health conditions ❑ Dementia
❑ HIV/AIDS ❑ Immunodeficiency and immunosuppressive disorders ❑ Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome/Inflammatory and Toxic Neuropathy ❑ Neurologic disorders ❑ Overweight, obesity and metabolic syndrome ❑ Post-organ transplantation care ❑ Severe hematologic disorders ❑ Stroke ❑ Conditions associated with cognitive impairment ❑ Conditions with functional challenges and require similar services including spinal cord injuries, paralysis, limb loss, stroke and arthritis
***UnitedHealthcare aims to make the transition to SSBCI benefits seamless for most current members.*** If UnitedHealthcare has internal data of a qualifying condition, the member’s record is also reviewed for high risk of hospitalization and intensive care management. This could mean: • Member gains access to SSBCI benefits • No action is needed from members.
New Member and Plan Change Journey:
D-SNP Enrollment – Member Self-Indicates Condition on Enrollment with HIPAA authorization. Plan Effective- 60-day access to Healthy Food/Utilities begins (whether verified or not). Provider Notified- Member receives status reminders (where verification process is). Members who self-indicate a qualifying condition will have 60 days to access SSBCI benefits once their plan becomes effective while the verification process is happening.
Member(s) who are NOT Verified- If UHC is unable to verify that the member has an eligible condition within the first 60 days on the plan, members will no longer have access to the healthy food and utilities benefits.* They will still have access to OTC, wellness support and fitness benefits, as well as rewards and discounts (if available on the member’s plan). The member will receive a confirmation letter in their preferred delivery method. If UHC can’t verify a qualifying condition for the SSBCI benefit, the member will receive a letter letting them know UHC couldn’t verify their qualifying condition, and they need to go online or call UHC if they have one of the qualifying conditions.
I am going to provide a Frequently Asked Questions (FAQ) to the bottom of this email for D’SNP members. You can also call if you need any further questions answered.
I would also like to let everyone know that you will be receiving a new UCard, even if you received one last year. This is because of the new plan, discontinuation of plans and the SSBCI Qualifying process. Once you receive your Ucard, you’ll have to activate it foryour ancillary benefits i.e. over the counter benefits (OTC), gym services, healthy food, utilities (for those on Dual Complete plans and UHC rewards). You do not need to activate the card for doctor visits or to receive prescriptions, but most definitely for the ancillary benefits.
United Healthcare has a mobile app that you can download on your phone that will allow you to see what’s covered with things like OTC and Healthy Foods. It will allow you to see how much you have left to spend for these ancillary benefits, as well as a host of other great benefits that can save you time and answer many questions you may have about a particular subject. If you have any trouble with the mobile app, you can always go to the website uhc.com for the same service, or call me for assistance.
Attached below are three documents.Two documents are the 2026 Complete Drug List (Formulary) for all the MAPD HMO plans and the other is the Complete Drug List (Formulary) for all D’SNP Plans. The last document is the Benefit Highlights for the new plan AARP Medicare Advantage from UHC CO -21P (HMO-POS). Look at the plan name numbers you have on your Ucard or Enrollment Guides currently and then choose which Drug List Formulary is for your plan, as well as look over the Benefit Highlights for the new plan.
If you need guidance, please let me know.
Take your time and please review these changes. Let me know if you would like to enroll in the new MAPD HMO plan or continue with the coverage you currently have. For most who have a Dual Complete D-SNP HMO plan currently, watch out for your verification or denial letter/email concerning the SSBCI ****Once again, I want to say if you like the plan you’re currently on, you don’t have to do anything. Your plan will automatically renew, unless you have a PPO Plan (PLEASE CONTACT ME BEFORE DECEMBER 7TH 2025)!!!**** For those of you who just have some questions about your plan for next year, we definitely can speak. Please do not hesitate to give me a call and we can set up a time to go over your questions and concerns.
Just a reminder that the documents below are for everybody, as well as the Benefits Highlights for the new MAPD HMO plan in 2026. Let me know if you want to change your plan before December 7th 2025.
It is truly my honor and pleasure to serve you all. Thank you so much for allowing me to be your broker.