Your UnitedHealthcare Choice Plus plan, in plain words
What to do so you pay less
- Stay in-network. Your plan pays 80% of in-network care but only 60% out of network, and out-of-network providers can bill you for the rest. Check that a doctor or hospital is in your plan at myuhc.com before you go.
- Show your ID card every time. If you do not, the provider may not know you have this plan and can bill you for the full cost.
- Get prior approval when your plan requires it. Some care must be approved by your plan before you get it. In-network providers usually handle this. If you go out of network, you must get it yourself, or your plan pays only half, or nothing.
- File out-of-network claims in time. If an out-of-network provider does not bill your plan for you, send the claim yourself within 90 days. After 15 months your plan can refuse to pay.
If you remember only two things: use in-network providers, and show your ID card. Those two habits prevent most surprise bills.
Watch out: if care needs prior approval and you skip it, your plan can pay only 50% of the cost, or nothing at all. When in doubt, call your plan before you get the care.
How you and your plan split the cost
Amounts shown are per person, in-network. A family pays more before the plan takes over. See the family numbers below.
Here is the order it works in for in-network care:
A quick example. Say you have surgery that costs $20,000 in-network. You pay your $1,000 deductible, then 20% of the rest, which would come to $4,800. Your yearly cap stops you at $3,500. Your plan pays the other $16,500, and everything else for the rest of the year.
For in-network care that uses your deductible and 20% coinsurance. It does not include fixed copays (like $30 office or $250 emergency room visits) or free preventive care.
How your share is figured, from your plan's schedule of benefits: you pay the first $1,000 of in-network care as your deductible, then 20% of the cost above that. Your total for the year is capped at $3,500, which already counts what you paid toward the deductible. Once you reach $3,500, your plan pays 100% of covered in-network care for the rest of the year. This estimate covers coinsured care only; fixed copays and free preventive care are separate.
Two rules change every number above. First, the plan only pays for care it calls care your plan agrees you need; a doctor recommending or prescribing it is not enough on its own. A doctor recommending a service, or it being the only treatment available, does not by itself make it covered. Second, out-of-network the plan pays its percentage of the the amount your plan decides a service is worth, not the amount the provider charges, which is its own allowed amount, not the provider's bill. The provider can bill you the entire difference on top of your share.
What common visits cost you (in-network)
| Care | You pay |
|---|---|
| Preventive care (checkups, shots, screenings) | $0 |
| Primary doctor visit | $30 |
| Specialist visit | $60 |
| Mental health or substance use visit | $30 |
| Urgent care visit | $100 |
| Emergency room visit | $250 |
| Outpatient lab and X-ray | $0 |
The $250 emergency room charge is waived if you are admitted to the hospital straight from the ER. Preventive care and outpatient lab and X-ray are covered at 100% in-network, with no deductible.
Prescription drug costs
What you pay depends on the drug's tier. Your plan sets the tier for each drug, and it can change. Check your drug at myuhc.com.
| Where | Tier 1 | Tier 2 | Tier 3 |
|---|---|---|---|
| Pharmacy, up to 31 days | $10 | $35 | $60 |
| Mail order, up to 90 days | $25 | $87.50 | $150 |
| Specialty, up to 31 days | $10 | $100 | $300 |
Preventive care medications have no copay. Everyday pharmacy drugs are covered under a separate drug rider, not under the main medical benefits.
Family amounts and out-of-network amounts
| In-network | Out of network | |
|---|---|---|
| Deductible, per person | $1,000 | $2,000 |
| Deductible, per family | $3,000 | $6,000 |
| Plan pays | 80% | 60% |
| Yearly cap, per person | $3,500 | $7,000 |
| Yearly cap, per family | $7,000 | $14,000 |
Out of network you pay more, and the provider can bill you for the difference between their charge and what your plan allows. The yearly cap includes your deductible.
What is covered, and what is not
Care is covered when three things are true. It is care your plan agrees you need to prevent, find, or treat an illness or injury. It is on the covered list. It is not on the excluded list. Here are the common ones.
Covered. Doctor and specialist visits, preventive care, hospital stays, and emergency and urgent care. Lab, imaging, and surgery. Maternity, mental health, and substance use care. Physical and other therapy, home health, hospice, and ambulance. Diabetes care, medical equipment, prosthetics, and transplants.
Not covered. You pay in full. Eyeglasses, contact lenses, and LASIK. Most dental and braces. Cosmetic procedures. Weight-loss programs and obesity surgery. Infertility and IVF. Acupuncture, massage, and other alternative therapy. Over-the-counter items. Care in another country, unless it is an emergency.
Something can be excluded even if your doctor recommends it. When something is not covered, you pay the full cost. Some of these have exceptions. Breast reconstruction after a mastectomy is covered, and so is surgery that restores how your body works. See the full lists below.
What this means for you
The single biggest thing you control is staying in-network. In-network your plan pays 80% and the provider cannot bill you extra. Out of network your plan pays 60%, and the provider can send you a bill for whatever your plan does not cover.
Preventive care is free in-network, with no deductible. That includes checkups, recommended screenings, and immunizations. Use it.
If your plan denies care or a payment and you disagree, you can push back, and there are deadlines. The steps and dates are below.
More detail, if you want it
Everything your plan covers
Your plan lists 35 covered service categories. Each is covered only when it is medically necessary and not excluded.
- Doctor visits for sickness and injury; specialist care; surgeon and other physician fees
- Preventive care: checkups, screenings, immunizations
- Hospital inpatient stays; skilled nursing and inpatient rehab facilities
- Emergency care; urgent care; ambulance (emergency, and some non-emergency transfers)
- Lab, X-ray, and imaging (including CT, PET, MRI, MRA, nuclear medicine)
- Outpatient surgery; scopic procedures such as colonoscopy and endoscopy
- Maternity and pregnancy care; newborn care
- Mental health and substance use care (inpatient and outpatient)
- Physical, occupational, speech, cardiac, pulmonary, and cognitive therapy
- Home health care; hospice care
- Diabetes care and supplies; kidney disease treatment and dialysis
- Chemotherapy, radiation, and other therapeutic treatments; transplants
- Durable medical equipment; prosthetic devices; ostomy supplies; hearing aids
- Reconstructive procedures; congenital heart disease surgery; TMJ treatment
- Accident-related dental; hospital dental with anesthesia for certain patients
- Routine vision exam; provider-administered drugs; qualifying clinical trials
- Autism spectrum disorder services (Wisconsin law)
Everything your plan does not cover
Your plan will not pay for these, even if a doctor recommends them. You pay the full cost.
- Alternative treatments: acupuncture, acupressure, massage, aromatherapy, hypnosis, Rolfing, art, music, or dance therapy
- Most dental care and braces (except accident-related and certain medical cases)
- Eyeglasses, contact lenses, their fitting, and vision-correction surgery such as LASIK
- Cosmetic procedures: scar or tattoo removal, liposuction, wrinkle or spider-vein treatment, hair removal or replacement, wigs. But reconstructive surgery is covered when it treats a medical condition or restores how your body works. Breast reconstruction after a mastectomy is also covered, including reconstruction of the other breast to match (Section 1, Reconstructive Procedures)
- Weight-loss programs and obesity surgery
- Infertility treatment and IVF; surrogacy, donor eggs, sperm, or embryos; reversing sterilization
- Everyday pharmacy drugs (covered under the separate drug rider instead); over-the-counter drugs; growth hormone therapy
- Experimental, investigational, or unproven services
- Routine foot care, shoe orthotics, arch supports, treatment of flat feet
- Most medical supplies: compression stockings, Ace bandages, gauze, catheters
- Personal-comfort items: TVs, phones, air conditioners, exercise equipment, home or vehicle changes
- Care in another country, unless it is an emergency; travel costs
- Services by a family member or by someone who lives at your address
- Custodial care, respite care, private-duty nursing, rest cures
- Care received after your coverage ends; war or active-military-duty injuries
- Nutrition counseling and supplements (with limited exceptions); autopsy; sex-transformation surgery
Care that needs prior approval
Your plan must approve these before you get them. In-network, your provider usually handles it. Out of network, you must do it yourself, or your plan pays only 50%, or nothing.
- Planned hospital stays; maternity stays longer than 48 hours (vaginal) or 96 hours (cesarean)
- Skilled nursing and inpatient rehab; home health care; inpatient hospice
- Inpatient mental health and substance use care; intensive outpatient programs; psychological testing; longer outpatient visits
- Non-emergency ambulance (air and ground)
- Durable medical equipment and insulin pumps over $1,000
- Reconstructive surgery; congenital heart disease surgery; TMJ services; transplants; kidney disease treatment
- Certain outpatient surgery, therapy, genetic testing (BRCA), clinical trials, and autism services
To get approval, call the number on your ID card. This starts the plan's review.
Yearly limits on certain benefits
Hearing aids for children under 18 are not subject to the dollar cap. Wound vacuums are not subject to the equipment limit.
If your plan says no and you disagree
You can challenge a denial. It is free. There are deadlines.
- Ask questions or complain first. Call the number on your ID card. Your plan answers a written complaint within 30 days.
- File a grievance. Your plan confirms it within 5 business days and decides within 30 days. Urgent cases are decided within 72 hours. You may appear before the review committee.
- Ask for an outside review. After the grievance, request an independent review in writing within 4 months. An independent organization decides within 30 business days, or 72 hours if urgent. Their decision is binding on your plan.
- Contact the state. You can also file a complaint with the Wisconsin Office of the Commissioner of Insurance at 1-800-236-8517 or [email protected].
When your coverage starts and stops
Starts: after you enroll through your employer and pay any required amount. Enroll within 31 days of becoming eligible. Your plan does not pay for care you get before your start date.
Stops: when the plan ends, when you are no longer eligible, when your employer tells the plan to end your coverage, or at retirement. It ends on the last day of that month. Your plan still pays for covered care you got before your coverage ended, but not for care after.
If you are in the hospital on the day your coverage starts, tell your plan within 48 hours.
Special cases: new babies, adoption, and adult children
A new baby or adopted child. Coverage starts the moment your baby is born, and it includes birth defects and birth-related problems. But you must tell your plan, and pay any required amount, within 60 days of the birth. If you miss the 60 days, coverage does not continue. To keep it, you must pay everything you owe, plus 5.5% interest, within one year of the birth. The same 60-day and 31-day windows apply to a child you adopt or take in for adoption. They also apply to a child you gain through marriage, guardianship, or a court order (Section 3, Enrollment).
Your child can stay on your plan until age 26. Any child under 26 counts as a dependent (Section 9, Defined Terms).
Wisconsin adds an extension to age 27. An unmarried child who is 26 but not yet 27 can stay on your plan in two cases. Either their own employer offers no health insurance, or the employer's plan would cost them more than staying on yours. A child who is unmarried and became disabled can stay on past 26 with no age limit. A child called to federal active duty from the National Guard or reserves while a full-time student can also stay, whatever their age (Section 9, Defined Terms, Wisconsin).
If someone else caused your injury
Say someone else caused your injury and your plan paid for your care. If you later get money for that injury, the plan can take back what it spent. This is called subrogation and reimbursement.
It applies when a third party pays you. That includes a lawsuit, a settlement, car insurance, homeowner's insurance, or workers' compensation. Your plan has the first right to be repaid out of that money, before you keep the rest. You are expected to help the plan and not do anything that weakens its right to be repaid (Section 7, Subrogation and Reimbursement).
If you have another health plan too
If you are covered by more than one plan, the two plans coordinate so they together pay up to 100% of the allowed cost, not more. If Medicare is your primary payer, the prior-approval rules here do not apply to you. Call the number on your ID card for how your plans work together.