Your UnitedHealthcare Choice Plus plan, in very simple words
Four things to do so you pay less
- Use doctors in your plan. They are called in-network. Your plan pays more for them. Other doctors cost you a lot more. Check first at myuhc.com.
- Show your plan card every time. If you do not, they may charge you the full price.
- Get a yes from your plan first, when it asks. Some care needs your plan to say yes before you get it. In-network, your doctor asks for you. If you skip this, your plan may pay only half. Or it may pay nothing.
- Send bills in on time. Sometimes you must send a bill to your plan yourself. Send it fast, within 90 days. Say you got care in January. You have until about April. Wait past 15 months and your plan can say no.
Two things matter most. Use doctors in your plan. Show your plan card. These two habits stop most surprise bills.
Watch out. Say your care needs a yes from your plan first. If you skip that, your plan may pay only half. Or it may pay nothing. When you are not sure, call your plan before you get care.
What you pay
The 20¢ means this: for each $1 of care, you pay 20 cents. These numbers are for one person, in-network. A family pays more. Family numbers are lower down.
Here is how it works, in three steps:
- You pay the first $1,000 each year. This first money is called your the first money you pay for care each year, before your plan starts to pay. You may see that word on your papers.
- Then you pay a small part of each bill. You pay 20 cents of every dollar. Your plan pays the other 80 cents. Example: a $100 visit costs you $20. Your plan pays $80.
- There is a top limit. The most you pay in one year is $3,500. After you reach it, your plan pays it all.
An example with a big bill. Say you have surgery. It costs $20,000. First you pay your $1,000. Then you would pay 20 cents on the rest. That comes to $4,800. But your top limit is $3,500. So you pay just $3,500. Your plan pays the rest: $16,500.
This is for in-network care. It uses your first $1,000 and your 20-cent share. It does not count set fees. A set fee is like $30 for an office visit. Or $250 for the emergency room. It does not count free checkups.
How your share is worked out, from your plan's list of benefits: you pay the first $1,000 of in-network care. Then you pay 20 cents of every dollar above that. The most you pay in a year is $3,500. That $3,500 already counts the first $1,000 you paid. Once you reach $3,500, your plan pays it all for the rest of the year. This covers your 20-cent share only. Set fees and free checkups are not counted here.
Two rules can change every number above.
First, your plan only pays for "medically necessary" care; a doctor saying you need it is not enough on its own. This is true even if your doctor says you need it. It is true even if it is the only choice. Your plan still has to agree.
Second, out-of-network can cost a lot more. Your plan pays part of the price it allows. The doctor may charge more than that. You pay the extra. This can be a big bill.
What you pay for a visit (in-network)
These are set fees. You pay them each time you go.
| Care | You pay |
|---|---|
| Checkups, shots, and screenings | $0 |
| Your family doctor | $30 |
| A specialist doctor | $60 |
| Mental health or drug or alcohol help | $30 |
| Urgent care | $100 |
| Emergency room | $250 |
| Lab tests and X-rays | $0 |
You do not pay the $250 emergency room fee if you go straight into the hospital from there. Checkups, lab tests, and X-rays are free in-network. You do not pay the first $1,000 for them.
What you pay for medicine
What you pay depends on the drug's group. Your plan puts each drug in a group. This can change. Check your drug at myuhc.com. Group 1 is the cheapest.
| Where you get it | Group 1 | Group 2 | Group 3 |
|---|---|---|---|
| Drug store, up to 31 days | $10 | $35 | $60 |
| By mail, up to 90 days | $25 | $87.50 | $150 |
| Special drugs, up to 31 days | $10 | $100 | $300 |
Some drugs that keep you well are free. Everyday drug store medicine is paid a different way, not with your main plan.
Numbers for a family, and out of network
In-network means a doctor in your plan. Out of network means a doctor who is not.
| In-network | Out of network | |
|---|---|---|
| First money, one person | $1,000 | $2,000 |
| First money, a family | $3,000 | $6,000 |
| Plan pays, of each $1 | 80¢ | 60¢ |
| Most in a year, one person | $3,500 | $7,000 |
| Most in a year, a family | $7,000 | $14,000 |
Out of network you pay more. The doctor can also bill you the extra. The most-in-a-year number counts your first money too.
What is covered, and what is not
Your plan pays for care your plan agrees you need. Here are the common things it pays for. And here are things it does not.
Covered. Doctor visits. Checkups. Hospital stays. Emergency and urgent care. Lab tests, X-rays, and surgery. Having a baby. Mental health, drug, and alcohol help. Physical therapy. Care at home. Diabetes care. Wheelchairs and other equipment. Transplants.
Not covered. You pay the full price. Glasses, contacts, and eye surgery to see better. Most dentist care and braces. Care to look better, not to fix a health problem. Weight-loss plans. Help getting pregnant. Massage and acupuncture. Drug store items you buy on your own. Care in another country, unless it is an emergency.
Some care is not covered even if your doctor wants it. Then you pay the full price. A few have exceptions. If you lose a breast to cancer, your plan pays to rebuild it. It also pays for surgery that fixes how your body works. See the full lists below.
The big things to remember
The best way to pay less is simple. Use doctors in your plan. In-network, your plan pays more. The doctor cannot bill you extra.
Out of network, your plan pays less. The doctor can send you a bill for the rest.
Checkups are free in-network. You do not pay the first $1,000 for them. Use them.
Say your plan tells you no. You can fight it, and it is free. The steps are below.
More detail, if you want it
Everything your plan covers
Your plan pays for these kinds of care. It pays only when your plan agrees you need it. The care must also not be on the "not covered" list.
- Doctor visits when you are sick or hurt. Specialist doctors. Surgery.
- Checkups, screenings, and shots
- Hospital stays. Care in a nursing home to get better.
- Emergency care. Urgent care. Ambulance rides.
- Lab tests, X-rays, and scans
- Surgery you do not stay overnight for. Scope tests, like a colonoscopy.
- Having a baby. Care for a new baby.
- Mental health help. Drug and alcohol help.
- Therapy: physical, speech, heart, lung, and more
- Care in your home. Comfort care near the end of life.
- Diabetes care and supplies. Kidney care and dialysis.
- Cancer care. Transplants.
- Wheelchairs and other equipment. Fake body parts. Hearing aids.
- Surgery to fix your body. Heart surgery for a defect you were born with. Jaw care.
- Dentist care after an accident. Hospital dental care for some people.
- Eye exams. Drugs a doctor gives you. Some medical studies.
- Care for autism (Wisconsin law)
Everything your plan does not cover
Your plan will not pay for these. This is true even if a doctor wants them. You pay the full price.
- Massage, acupuncture, hypnosis, and art, music, or dance therapy
- Most dentist care and braces. But it does pay after an accident, and in some health cases.
- Glasses, contacts, and eye surgery to see better, like LASIK
- Care to look better, not to fix a health problem: scar or tattoo removal, liposuction, wrinkle care, hair removal, wigs. But your plan does pay to fix your body when there is a health need. If you lose a breast to cancer, your plan pays to rebuild it. It also pays to match the other breast (Section 1, Reconstructive Procedures).
- Weight-loss plans and weight-loss surgery
- Help getting pregnant, like IVF. Using another person's eggs, sperm, or womb. Undoing surgery that stopped you from having children.
- Everyday drug store medicine (paid a different way). Medicine you buy on your own. Growth hormone.
- New care that is still being tested
- Routine foot care. Shoe inserts and arch supports.
- Most small supplies: support stockings, bandages, gauze, tubes
- Comfort items: TVs, phones, air conditioners, exercise gear, changes to your home or car
- Care in another country, unless it is an emergency. Travel costs.
- Care from a family member, or from someone who lives with you
- Day-to-day help with living. Round-the-clock private nurses.
- Care after your plan ends. Hurts from war or active army duty.
- Food advice and food supplements (a few cases are covered). Autopsy. Sex-change surgery.
Care that needs a yes from your plan first
Your plan must say yes to these before you get them. In-network, your doctor asks for you. Out of network, you must ask yourself. If you skip this, your plan may pay only half, or nothing.
- Planned hospital stays. A long stay after having a baby.
- A nursing home stay. Care at home. A hospice stay.
- A hospital stay for mental health or drug or alcohol help. Some longer visits and tests.
- An ambulance ride that is not an emergency
- Equipment and insulin pumps that cost more than $1,000
- Surgery to fix your body. Heart surgery for a defect. Transplants. Kidney care.
- Some surgery, therapy, gene tests, medical studies, and autism care
To get a yes, call the number on your plan card. This starts the plan's review.
Yearly limits on some care
Your plan pays for these only up to a limit each year.
Kids under 18 have no dollar limit on hearing aids. Wound pumps have no equipment limit.
If your plan says no and you do not agree
You can fight a no. It is free. But there are time limits.
- Ask or complain first. Call the number on your plan card. Your plan answers a written complaint within 30 days.
- Then make it formal. Your plan writes back within 5 work days. It decides within 30 days. Urgent cases take 72 hours. You can speak to the group that reviews it.
- Ask for an outside review. Do this in writing within 4 months. An outside group decides within 30 work days, or 72 hours if urgent. Their answer is final. Your plan must follow it.
- Tell the state. You can also complain to the state of Wisconsin. Call 1-800-236-8517. Or email [email protected].
When your plan starts and stops
It starts after you sign up through your job and pay your part. Sign up within 31 days of when you can. Your plan does not pay for care before your start day.
It stops when the plan ends, when you can no longer be on it, when your job ends it, or when you retire. It ends on the last day of that month. Your plan still pays for care you got before it ended. It does not pay for care after.
Are you in the hospital on the day your plan starts? Tell your plan within 48 hours.
Special cases: new babies, adoption, and older children
A new baby or an adopted child. Your plan covers your baby from the moment of birth. This covers health problems the baby is born with. But you must tell your plan, and pay your part, within 60 days of the birth. Miss the 60 days, and the plan stops. To keep it, you must pay all you owe. You must also pay a late fee of 5.5% on top. Do this within one year. The same rules cover a child you adopt. They also cover a child who joins your family through marriage, guardianship, or a court order (Section 3, Enrollment).
Your child can stay on your plan until age 26. Any child under 26 can be on your plan (Section 9, Defined Terms).
Wisconsin lets some children stay until age 27. An unmarried child who is 26 but not yet 27 can stay in two cases. One: their job gives them no health plan. Two: their job's plan would cost them more than yours. A child who cannot work due to a disability can stay past 26, with no age limit. A full-time student called to active army duty can also stay, at any age (Section 9, Defined Terms, Wisconsin).
If someone else caused your injury
Say someone else hurt you, and your plan paid for your care. Later you get money for that injury. Then your plan can take back what it spent. This is called getting paid back.
It works when someone else pays you. That can be a court case, a deal, car insurance, home insurance, or a work injury payout. Your plan gets paid back first, before you keep the rest. You must help your plan and not block it (Section 7, Subrogation and Reimbursement).
If you have a second health plan
Say you are on two health plans. The two plans work together. Together they pay up to the full allowed cost, and no more. Is Medicare your main plan? Medicare is the government health plan for people 65 and up. If it is your main plan, the "yes from your plan first" rules here do not apply to you. Not sure how your two plans work together? Call the number on your plan card.