UnitedHealthcare insurance exchange plans: What you need to know

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Insights:

UnitedHealthcare, the country’s largest health insurance company, offers marketplace plans in 11 states and hopes to expand into other states in 2022.

A few years ago, UnitedHealthcare, the largest health insurance company in the U.S., pulled back from providing Obamacare health plans on the Affordable Care Act (ACA) health insurance marketplace, otherwise known as the exchange.

However, UnitedHealthcare is back offering exchange plans again in some states and hopes to roll out plans in additional states soon.

Learn more about UnitedHealthcare exchange plans, how they work, and what they cover. By doing your homework, you may be able to enroll in one of these health insurance plans and save money.

Key Takeaways

UnitedHealthcare plans usually offer wide provider networks.
The marketplace plans assign members a primary care physician and they must get referrals from that doctor to see specialists.
Health insurance marketplace plans have comprehensive coverage, including essential health benefits.
UnitedHealthcare exchange plans may require that you receive all health care within the plan’s provider network.
Open enrollment for marketplace plans is Nov. 1 to Dec. 15 in most states.

What is a UHC exchange health plan?

UnitedHealthcare is now offering more health care insurance plans available on the ACA health insurance marketplace. These plans provide comprehensive care for members and offer access to a wide network of providers.

On its website, UnitedHealthcare states that its exchange benefit plans “are built on patient-centered care, with the goal of enhancing the patient-doctor relationship and promoting better health and lower costs.”

Members get a primary care provider

Members who have one of these marketplace plans are assigned a primary care physician (PCP). The PCP oversees health care needs and services and is required to provide referrals when members need to see specialists.

“UnitedHealthcare ACA plans are private insurance plans that have a similar benefit structure to other ACA plans,” explains John Bartleson, owner of Health Benefits Connect in Englewood, Colorado.

Unlike some other ACA insurance plans, “UnitedHealthcare plans have typically wider provider networks. Also, and most importantly, UnitedHealthcare is a trusted name in the health insurance marketplace among both health care members and health care providers,” Bartleson adds.

UnitedHealthcare benefit plans for exchanges

Currently, UnitedHealthcare exchange plans are available in the following states:

Arizona
Colorado
Maryland
Massachusetts
Nevada
New York
North Carolina
Oklahoma
Tennessee
Virginia
Washington

“UnitedHealthcare has filed and is awaiting approval from regulators to participate on the health insurance exchanges in Alabama, Florida, Georgia, Illinois, Louisiana, Michigan, and Texas for plan year 2022, expanding its footprint to 18 states offering exchange plans,” says Christina Witz, a spokesperson for UnitedHealthcare.

What do UnitedHealthcare health insurance marketplace plans cover?

Every UnitedHealthcare exchange plan includes coverage for the 10 essential health benefits, which include:

Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Emergency services
Hospitalization (like surgery and overnight stays)
Pregnancy, maternity, and newborn care (both before and after birth)
Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
Prescription drug coverage
Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
Laboratory services
Preventive care and wellness services and chronic disease management
Pediatric services, including oral and vision care

Every UHC exchange plan is provided in three different metal levels: Bronze, Silver, and Gold. Marketplace plans differ by metal tier. Bronze and Silver plans have lower premiums but higher deductibles, while Gold plans have higher premiums and lower out-of-pocket costs.

In Washington state, the carrier is also offering Select Gold, Silver, and Bronze plans under its Cascade Care Program.

Many exchange plan members can count on receiving three virtual care visits with no copay due on most plans within a plan year, as well as no-cost primary care visits on at least one Silver plan and most markets within a plan year.

“As an exchange participant offering ACA-compliant plans, UnitedHealthcare can’t deny coverage due to pre-existing conditions or other circumstances prohibited by the Affordable Care Act,” says Brian Martucci, finance editor for Minneapolis-headquartered Money Crashers. “Also, be aware that UnitedHealthcare exchange plan participants generally can’t be reimbursed for out-of-network care, except for emergency services, where required.”

How to get a UnitedHealthcare exchange plan

You can buy a plan through your state’s insurance marketplace. Another way to get one of these plans is to contact a licensed health insurance broker.

“A broker will be able to easily navigate the federal health care marketplace and/or state-based marketplaces,” Bartleson adds. “Seeking insight from a licensed broker can save you time, and they can also make plan recommendations based on your medical needs and budget.”

When does benefit coverage begin?

Members must pay their first month’s premium before coverage becomes effective. If you’ve not paid your premium during your second or third month, your claims will remain pending until payment is received.

The ACA requires that health insurers offer a three-month grace period before terminating coverage for members with unpaid premiums. This grace period covers those who received an advance premium tax credit and have paid a minimum of one full month’s premium within the past benefit year.

Who is eligible for a UHC exchange plan?

Anyone eligible to obtain health insurance coverage on federal or state health insurance exchanges can apply for a UnitedHealthcare exchange plan.

To be eligible for any exchange plan, you must:

Live in the U.S.
Be a U.S. citizen or national
Not be incarcerated

What is the role of the primary care physician for exchange benefit plans?

To help manage health care needs and treatment, UHC exchange plans require that members are assigned a primary care physician (PCP) within their service area. The PCP has to submit electronic referrals if members want to see a network specialist physician. Any specialists have to be located within the defined service area for your plan.

“A primary care physician will be assigned to you based on your health needs, geographical location, and other factors,” Martucci says.

How do members choose a primary care physician?

Unlike other ACA plans, a UnitedHealthcare exchange plan doesn’t allow you to choose your primary care physician. Each member is assigned a PCP upon enrollment.

Additionally, every member of your family may be assigned a different PCP, depending on their needs. Once your PCP is assigned, you can view information about this healthcare provider on the UnitedHealthcare website.

Frequently Ask Questions

Do exchange health plans require advance notification or prior authorization?

Prior authorization and advance notification are required for particular plan services because UnitedHealthcare wants to determine if those services are covered under your benefits. Prior authorization approval is given only for services that UnitedHealthcare deems are medically necessary, per the member’s benefit plan and applicable policies and guidelines.

Is UnitedHealthcare under Medicaid?

UnitedHealthcare exchange plans are separate and distinct from Medicaid, a government-run public health insurance program. Private insurance companies can offer Medicaid and Medicare plans, but those aren’t sold in the health insurance marketplace. Instead, you have to go through the Centers of Medicare and Medicaid Services or your state.

How do you know what’s considered in-network for exchange benefit plans?

Each ACA plan has its own network directory that lists its in-network medical providers and medical facilities. Use UnitedHealthcare’s Find a Provider online tool to determine if your preferred provider or specialist is in-network.

“Providers must have locations within your service area — usually the state in which your plan is offered — to be eligible for in-network status,” says Martucci.

When is open enrollment for marketplace plans?

Open enrollment is Nov. 1 to Dec. 15 in most states. Some states have longer enrollment periods. During open enrollment, you get buy a marketplace plan or change to another exchange plan.

What is the special enrollment period?

There is another time when you may be able to sign for a marketplace plan. If you have a qualifying life event, you can get a health plan during a special enrollment period.

Qualifying events include getting married, losing health coverage, a spouse dying, and having a child. If you have a qualifying event, you have 60 days from that event to sign up for a marketplace plan.

Erik Martin

Contributing Researcher

Erik J. Martin is a Chicago area-based freelance writer whose articles have been published by AARP The Magazine, The Motley Fool, The Costco Connection, USAA, US Chamber of Commerce, Bankrate, The Chicago Tribune, and other publications. He often writes on topics related to insurance, real estate, personal finance, business, technology, health care, and entertainment. Erik also hosts a podcast and publishes several blogs, including Martinspiration.com and Cineversegroup.com.