United Healthcare Insurance Plan Guide for Texas
All You Need to Know About UnitedHealthcare Plans for 2023 in Texas
We know we all need health coverage, but which company should you select? Who has the best coverage, with the best options, and is most affordable? That is what we at Cover Mile are here to assist you with. We find the insurance company that best fits your situation. We take the confusion out of the process and guide you to the company that fits your family’s needs. Through this review, we aim to show you what UnitedHealthcare offers. We will explain their coverage charts and what their benefits mean to you.
Health Insurance Terms to Understand
Before we dive in, let’s go over a few terms you will frequently see when researching health insurance. Understanding these terms will aid you in selecting the best insurance plan for you and your family.
Deductible – This 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 deductibles from $0 up to $9100, depending on the plan. Deductibles are based on the calendar year and start over each year. They are one of the main determiners of 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 co-insurance portion kicks in. You can read more about deductibles through the link above.
Co-insurance – Co-insurance 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, you will see it in the Summary of Benefits as 80/20, 70/30, and 60/40 based on the ACA metal levels. This refreshes each year.
Out-of-Pocket Max – All 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 co-insurance and reach the 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 co-insurance recycle.
Primary Care Physician – Your 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. Meaning if you want or need to see a Specialist, you first visit your PCP, then, with their recommendation, you receive UHC approval.
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; 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 deductible, co-insurance, 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 in Texas groups its plans into four categories. Essential, Value, Advantage, and Virtual First. 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.
Essential: These plans will have lower deductibles, thus, have higher premiums. They will help provide basic coverage for serious illness or injury.
Value: These are their primary plans they sell. 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.
Virtual First: These plans will also have low premiums but include 24/7 access to $0 virtual primary, urgent, and specialty care.
Not all metal levels carry each category. Bronze does not have an Advantage plan. However, only the Bronze metal offers the Essential category.
UnitedHealthcare Bronze has five plans within its four categories; all are offered on the Marketplace and through their website. Each has a different deductible and out-of-pocket max. Most share the 40% co-insurance level. Four are below. The fifth plan is a higher deductible Standard plan.
|Bronze||UHC Bronze Essential||UHC Bronze Virtual First||UHC Bronze Value||UHC Bronze Standard|
|Primary Care Visit||0%, after deductible||$100 Copay||$0 copay||$50|
|Specialist Visit||0%, after deductible||50%||50%||$100|
|Emergency Room||0%, after deductible||50%||50%||50%|
|Urgent Care||0%, after deductible||$75 Copay||$75 copay||$75 copay|
|Inpatient Hospital||0%, after deductible||50%||50%||50%|
|Outpatient Hospital||0%, after deductible||50%||50%||50%|
|Prescription (Pharmacy)||$3/$0/$0/$0/$0*||$3/$35/50%/50%/50%*||$3/$30/50%/50%/50%*||$25/$50/$10$/500/ N/A*|
*Prescriptions are Tiered 1 through 5. 1 being low-cost, Generic; 5 being Brand and higher cost.
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. In most cases, to receive the cost-sharing benefits, one must apply for a Silver-level plan. See the Marketplace website for details.
|Silver||UHC Silver First||UHC Silver Value||UHC Silver Advantage||UHC Silver Standard|
|Primary Care Visit||$100 copay||$0||$0||$40|
|Specialist Visit||$100 copay||$80 copay||$100 copay||$80|
|Emergency Room||40%||40%||$1000 copay||40%|
|Urgent Care||$75 copay||$75 copay||$75||$60|
|Inpatient Hospital||40%||40%||$375 copay||40%|
|Outpatient Hospital||40%||40%||$1500 copay per day||40%|
|Prescription (Pharmacy)||$15/$30/$60//40%/50%*||$3/$30/$60/40%/50%*||$3/$30/$85/40%/50%*||$20/$40/$80$350/ N/A|
*Prescriptions are Tiered 1 through 5. 1 being low-cost, Generic; 5 being Brand and higher cost.
UHC Silver 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.
UHC Silver Value HSA: A Silver Value HSA (Health Savings Account) is a health insurance policy that uses a special savings account to pay for medical expenses to meet your $5400/$10,800 deductible. However, after that is met, most medical costs are zero-copay or zero-coinsurance.
UnitedHealthcare Gold has six plans, all of which are offered on the Marketplace. We have three listed below. The primary difference between the unlisted plans is the deductible amounts. Another difference on the Gold level is that it does not have a Virtual First as the other two levels had. 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. These 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.
|Gold||UHC Gold Value||UHC Gold Advantage||UHC Gold Standard|
|Primary Care Visit||$0||$0||$30 copay|
|Specialist Visit||$75 copay||$60 copay||$60 copay|
|Emergency Room||40%||$500 copay||25%|
|Urgent Care||$75 copay||$75 copay||$45 copay|
|Inpatient Hospital||20%||$1500 copay||25%|
|Outpatient Hospital||20%||$75 copay||25%|
|Prescription (Pharmacy)||$1/$15/$50/30%/40%*||$1/$15/$50/30%/40%*||$15/$30/$60/$250/ N/A*|
*Prescriptions are Tiered 1 through 5. 1 being low-cost, Generic;5 being Brand and higher cost.
UHC Gold Advantage Plus: This plan is identical to the 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. As we learned earlier, you are required to visit them first before you seek treatment from a Specialist. You also have the option to use your Virtual Visit benefit included in all UnitedHealthcare plans. Most plans have a $0 copay for a virtual visit. You can search for a doctor, specialist, or facility through their website.
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 4-5: 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 offer access to virtual primary and specialist care. Members must have a smartphone or tablet, and data rates may apply.
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 Program – OptumRx 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.
- 90-day Supply – Depending 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.
UnitedHealthcare can help you find a pharmacy in your area through its website.
At Cover Mile, 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
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.
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.
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.
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.
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.
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.
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.
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.
Does UnitedHealthcare cover adjustable beds?
UnitedHealthcare covers adjustable beds under its Durable Medical Equipment provision within its policies. Deductibles and co-insurance apply.
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.