United Healthcare Insurance Plan Guide for Texas 2024

All You Need to Know About UnitedHealthcare Plans for 2024

Everyone understands the importance of having health coverage, but which company you should choose is a whole different story. Who has the best coverage, with the best options, and is most affordable? This is what CoverMile is here to help you with. We find the best insurance company to fit your needs at the lowest cost. Our job is to take the confusion out of the process. Through this review, we intend to show you what UnitedHealthcare offers. We will explain their coverage charts and what their benefits mean to you. By the end of our time together, we trust you will have a better understanding of health insurance in general and if UHC is the company for you.

Health Insurance Terms to Understand

Before we dive in, let’s review a few terms you will frequently see when researching health insurance. Understanding these terms will help you select the best insurance plan for you and your family.

DeductibleThis is the main one you will see. A deductible is the amount you pay out of pocket before your insurance kicks in. UnitedHealthcare (UHC) has individual deductibles from $0 up to $8,250, depending on the plan. Deductibles are based on the calendar year and start over each year. They are one of the primary factors that determine how much you will pay for your policy. The higher your deductible, the lower your premium; the lower your deductible, the higher your premium will be. A deductible is broken down into two parts:

            Individual: This is the per-person deductible.

            Family: This is the deductible for the entire family.

When you look at your Summary of Benefits, you will see this as a fraction. For instance, $7500 Individual/$15,000 Family. If you have a family policy, each member has their own $7500 out-of-pocket expense before the coinsurance portion kicks in. You can read more about deductibles through the link above.

CoinsuranceCoinsurance is where the insurance begins to pay its portion. This is a cost-sharing between you and the insurance company, usually based on a percentage. It begins when you meet your deductible. With UnitedHealthcare, it will usually be listed as “50% coinsurance” or just “50%”, whatever your policy’s coverage level is. This is the portion you will pay. It refreshes each year.

Out-of-Pocket MaxAll insurances have a failsafe called the out-of-pocket max. It is designed to assist those with high medical expenses due to chronic illness or those with larger families. When you reach your deductible, then pay your portion of your coinsurance and reach the out-of-pocket max specified in your policy, your insurance will begin to pay 100 percent of your medical expenses. This continues until the end of the year when your deductibles and coinsurance recycle.

Primary Care PhysicianYour Primary Care Physician (PCP) is the main doctor you visit for your medical care. With UnitedHealthcare being an HMO, you are required to coordinate all treatment through them. This means that if you want or need to see a Specialist, you first visit your PCP, and then, with their recommendation, you receive UHC approval to see a specialist to coordinate having tests and other procedures done.

Copay Copays are the amount you pay the doctor or facility for your visit. This can be a flat dollar amount or a percentage. It can vary by plan. Keep in mind this is for the office visit alone, not the treatment you receive. However, some treatments can be included within an office visit, like a well check-up and immunizations; see your medical plan for details.

Now that you know the basics of health insurance, let’s get into the plans UnitedHealthcare has to offer.

UnitedHealthcare and the Affordable Care Act

UnitedHealthcare is sold as part of the Affordable Care Act. All their plans are offered on the Marketplace website as well as the UHC website and are broken down into the Bronze, Silver, and Gold metal categories. Being part of the ACA, all plans sold offer all 10 of the Essential Benefits.

For the sake of space, we are only listing a handful of UnitedHealthcare’s plans. We will show benefits such as deductibles, coinsurance, and prescription levels. Also, to simplify our table, you will see deductibles abbreviated as a fraction. The Individual and Family deductibles and out-of-pocket maxes are shown as the first number will be the individual, and the second is the family. In addition, these numbers are for in-network doctors and facilities.

UnitedHealthcare Plan Names

UnitedHealthcare groups its plans into five categories. Essential, Value, Advantage, Virtual Plans and Copay Focus. Each has its benefits and targets a different insurance shopper. Review each, and you can find the best plan that fits you and your family’s needs. All five UHC health plan levels are eligible for premium tax credits and/or cost-sharing reductions.

Essential: These plans will have the highest deductibles and, thus, have the lowest premiums. They will help provide basic coverage for serious illness or injury. This coverage level is not available in Texas.

Virtual First: These plans will also have lower premiums but include 24/7 access to $0 virtual primary, urgent, and specialty care.

Value: These are the plans they sell most because they are middle of the road. While they have higher deductibles, they have additional benefits like $0 copay visits.

Advantage: Plans that will give the option for adult vision and dental. They will have a lower deductible and also carry higher premiums.

Copay Focus: These plans do not have a medical deductible. Your benefits kick in from day one. But with this type of benefit, you will generally pay more in premium.

Not all metal levels carry each category. Bronze does not have an Advantage or an Advantage+ plan. Also, the Essential level is no longer available in Texas.

UnitedHealthcare Bronze

UnitedHealthcare Bronze has expanded their coverage area for 2024. They have moved into 158 counties this year to cover 206 of the 254 Texas counties. This allows them to compete with larger companies like BCBS of Texas. UHC has five plans within its four categories; all are offered through the Marketplace and on their website. Each has a variety of deductibles and out-of-pocket max options. Most have a coinsurance level of 40% coinsurance, and new this year is a zero-dollar prescription tier on generic medications.

BronzeUHC Bronze ValueUHC Bronze Virtual FirstUHC Bronze StandardUHC Bronze Copay Focus $0 Indiv Med Ded
Out-of-Pocket Max$9450/$18,900$9100/$18,200$9400/$18,800$9450/$18,900
Primary Care Visit$0 Copay$0 Copay$50 Copay$40 Copay
Virtual Visits$0$0$50$0
Specialist Visit40%40%$100$120
Emergency Room50%50%50%$2250 copy/visit
Urgent Care$75 copay$75 Copay$75 copay$100 copay
Inpatient Hospital40%50%50%$3000 copay/ day
Outpatient Hospital40%50%50%$120 copay
Prescription (Pharmacy)$0/$3/$60/40%/ 45%/50%*$0/$3/$60/ 40%/45%/50%*$0/$25/$50/$100/ $500/ N/A*$0/$15/$65/45% 45%/45%*

*Prescriptions are Tiered 1 through 6. 1 being low-cost, Generic; 5 being Brand and higher cost.

UHC Bronze Value HSA: A Bronze Value HSA (Health Savings Account) is a health insurance policy that uses a special savings account to pay for medical expenses to meet your $6700/$13,400 deductible. However, after that is met, most medical costs are at a copay, depending on the policy you have.

UnitedHealthcare Silver

UnitedHealthcare Silver level has seven plans, all offered through the Affordable Care Act Marketplace. Silver plans are popular because many low-income individuals qualify for cost-sharing reductions and the premium tax credit. To receive the cost-sharing benefits, one must apply for a Silver-level plan. See the Marketplace website for details.

SilverUHC Silver Virtual FirstUHC Silver StandardUHC Silver ValueUHC Silver Advantage+
Out-of-Pocket Max$9100/$18,200$9100/$18,200$9450/$18,900$9450/$18,900
Primary Care Visit$100 copay$40$0$0
Specialist Visit$100 copay$8050% coinsurance$100 copay
Virtual Visits$0$0$0$0
Emergency Room40%40%50%$1000 copay
Urgent Care$100 copay$60$75 copay$100
Inpatient Hospital40%40%50%30%
Outpatient Hospital40%40%50%$750 copay per day
Prescription (Pharmacy)$0/$3/$30/$100// 40%/50%*$20/$40/$80 $350/ N/A$0/$3/$30/$100/ 45%/50%*$0/$3/$30/$85/ 40%/50%*

*Prescriptions are Tiered 1 through 6. 1 being low-cost, Generic; 6 being Brand and higher cost.

UnitedHealthcare Gold

UnitedHealthcare Gold has six Gold-tiered plans. All are offered through the Marketplace. The primary difference between the plans is the deductibles. Gold is the highest metal tier, providing the lowest deductibles, copays, and overall insurance cost. However, with the level of coverage comes the price tag. Gold-tiered plans are best suited for those who visit the doctor frequently, have chronic medical conditions, or expect to seek advanced medical care in the future.

GoldUHC Gold StandardUHC Gold ValueUHC Gold Virtual FirstUHC Gold Advantage
Out-of-Pocket Max$8700/$17,400$8500/$17,000$8400/$16,800$7000/$14,000
Primary Care Visit$30 copay$0$50 copay$5
Specialist Visit$60 copay20% coinsurance$100 copay$75 copay
Virtual Visits$0$0$0$0
Emergency Room25%20%25%$500 copay
Urgent Care$45 copay$50 copay$75 copay$50 copay
Inpatient Hospital25%20%25%45%
Outpatient Hospital25%20%25%$450 copay
Prescription (Pharmacy)$0/$15/$30/$60/ $250/ N/A*$0/$1/$15/$60/ 40%/50%*$0/$3/$30/$60/ 40%/50%*$0/$3/$30/$50/ 30%/40%*

*Prescriptions are Tiered 1 through 6. 1 being low-cost, Generic;6 being Brand and higher cost.

 UHC Gold Advantage Plus: This plan is identical to the Advantage plan above but adds Adult Dental with two exams per year and Adult Vision with one eye exam and one pair of glasses per year.

Finding a Provider in Your Network

Being an HMO, you will need to select a Primary Care Physician (PCP) to coordinate your medical care. If you do not choose a PCP, one will be selected for you. Also, as we learned earlier, you are required to visit them first before you seek treatment from a Specialist.

You also have the option to have a Virtual Visit with a doctor. This benefit is included with most UnitedHealthcare plans at a $0 copay. You can search for a doctor, specialist, or facility through their website.

Benefit Notices:

Keep in mind that the above is a summary of highlights only.

–The benefits above represent what a member would pay. When a non-participating provider is used, benefits are reduced, and out-of-pocket costs will increase.

–You are required to pay all the costs up to the deductible amount before your plan begins to pay for covered services. What is shown is the per-person deductible and out-of-pocket maximum.

–Prescription drug payment level tiers:  Tier 1: Lower cost, mostly generic drugs; some brand names may be included. Tier 2-3: Mid-range cost, mainly preferred Brand. Tier 4-6: highest cost, specialty drugs, primary brand name.

–Adult Dental and Vision: $0 cost-share for in-network periodic oral evaluation twice a year. There is a $1,000 benefit maximum. Routine vision exams and eyewear are also once a year.

–Virtual First health plans are offered 24/7 at a cost of $0 through the Galileo app. Members must have a smartphone or tablet, and data rates may apply. You may need referrals to see a Specialist.

–Members receive a $100 reward for completing 5 health benefit activities as well as free gym membership with some plans.

Prescription Coverage with UnitedHealthcare Insurance

All UnitedHealthcare plans have prescription coverage. Each plan has benefits that provide coverage based on a tier system.

  • Specialty Pharmacy ProgramOptumRx is UnitedHealthcare’s pharmacy provider. Optum can be used to refill a prescription, find a local pharmacy, or set up home delivery. UnitedHealthcare also has other options to save money on your prescriptions.
  • Prior Authorization– In some cases, you will need approval from UnitedHealthcare to fill certain prescriptions. They may find a more cost-effective drug instead of the suggested medication.
  • Step Therapy – Some drugs require step therapy before a prescribed medication is approved. UnitedHealthcare will suggest a more cost-effective alternative to a brand-name prescription. If you choose not to accept the step therapy drug, you may not have coverage.
  • Copay Cards – These are savings cards from drug companies that help lower the costs of specialty medications.
  • Smart RXAssist – Program to assist with patient costs with manufacturer copays.
  • 90-day SupplyDepending on the medication you are taking, you may be able to receive a 90-day supply of your prescription to save on your medication cost—for instance, a 90-day supply for the cost of a 60-day supply.

UnitedHealthcare can help you find a pharmacy in your area through its website.

At CoverMile, we desire to assist you in finding the health insurance in Texas that best suits you and your family. We will take the time to talk you through each plan, help you understand each UnitedHealthcare plan, and help you sign up for Affordable Care Act insurance. Contact us today.

Frequently Asked Questions

  1. Is UnitedHealthcare Medicaid?

    No. UnitedHealthcare is an insurance provider that offers health insurance through the Marketplace as well as off-market. When you enroll in Texas Medicaid, you may be given the option to enroll with an insurance plan; this is where UnitedHealthcare enters the picture. 

  2. Does UnitedHealthcare cover shingles vaccine?

    Shingles is a secondary infection that one carries after they have had chicken pox at a younger age. There is no guarantee one will come down with the infection. One does not usually come down with it until they are in their 60s. It manifests itself with pain and a rash. However, most plans do not cover the shingles vaccine until the plan member is 60 years old. 

  3. Is UnitedHealthcare good health insurance?

    UnitedHealthcare offers health insurance within forty-eight counties in Texas. They offer a variety of plans that include zero-dollar PCP visits, low-cost prescriptions, and adult dental/vision on some plans. All plans include Virtual Visits for members to consult with a doctor from the comfort of their home with a zero-dollar copay. 

  4. Does UnitedHealthcare Cover therapy?

    Yes. UnitedHealthcare covers behavioral health treatment as part of the 10 Essential Benefits. This would cover even if the condition were preexisting. There is also no dollar amount cap on services rendered under this benefit. 

  5. Does UnitedHealthcare cover cataract surgery?

    UnitedHealthcare Vision Insurance provides exams and glasses for children up to the age of eighteen. Advantage Plus plans extends that benefit to adults. However, this does not include cataract surgery or treatment. 

  6. Does UnitedHealthcare cover dental?

    UnitedHealthcare Dental plans, like Vision insurance, only cover children. The Advantage Plus plans covers adults but are limited to check-up exams only. And then there are two visits per year. Dental and Vision are considered Supplemental Insurance. UHC has a host of supplemental plans that include critical illness and accident insurance.

  7. Is UnitedHealthcare private insurance?

    Yes, UnitedHealthcare is considered private insurance. You can purchase their plans away from the Marketplace as well as through their website. UHC still must offer the 10 Essential Benefits and follow all the standards outlined within the Affordable Care Act.

  8. Is UnitedHealthcare a PPO or HMO?

    UnitedHealthcare is an HMO (Health Maintenance Organization). With an HMO, you must use the providers within their network. However, you may go out-of-network, if necessary, but only when your PCP recommends it and with UnitedHealthcare approval. 

  9. Does UnitedHealthcare cover adjustable beds?

    UnitedHealthcare covers adjustable beds under its Durable Medical Equipment provision within its policies. Deductibles and co-insurance apply. 

  10. What does UnitedHealthcare cover?

    UnitedHealthcare provides Texans with a variety of insurance plans. These include health insurance, dental and vision insurance, short-term health insurance, and health insurance for students and the self-employed. As we mentioned earlier, they also provide coverage for ancillary products like accident insurance and critical illness coverage.