United Healthcare Insurance Plan Guide for Texas 2023

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

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
Deducible	$9100/$18,200	$7250/$14,500	$7400/$14,400	$7500/$15,000
Co-insurance	0%	40%	40%	40%
Out-of-Pocket Max	$9100/$18,200	$9100/$18,200	$9100/$18,200	$9000/$18,000
Primary Care Visit	0%, after deductible	$100 Copay	$0 copay	$50
Virtual Visits	$0	$0	$0	$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

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
Deducible	$4000/$8000	$4000/$8000	$2000/$4000	$5000/$11,600
Co-insurance	30%	30%	30%	30%
Out-of-Pocket Max	$9100/$18,200	$9100/$18,200	$9100/$18,200	$8900/$17,800
Primary Care Visit	$100 copay	$0	$0	$40
Specialist Visit	$100 copay	$80 copay	$100 copay	$80
Virtual Visits	$0	$0	$0	$40
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

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
Deducible	$1900/$3800	$1500/$3000	$2000/$4000
Co-insurance	20%	20%	20%
Out-of-Pocket Max	$9100/$18,200	$9100/$18,200	$8700/$17,400
Primary Care Visit	$0	$0	$30 copay
Specialist Visit	$75 copay	$60 copay	$60 copay
Virtual Visits	$0	$0	$30
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. 

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 4-5: 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.