The following commercial health plans are offered in West Virginia. Click the "+" sign to view more information on each.
Mid-Atlantic Health Plan
UnitedHealthcare® Maryland Independent Physician Association (M.D.IPA) Plan
The UnitedHealthcare Maryland Independent Physician Association (M.D.IPA) health plan encourages members to use their primary care provider (PCP) to coordinate care across a wide spectrum of health services and enter electronic referrals to network specialists.
- Members must receive a referral from their PCP to see a network specialist for benefits to be covered. There is out-of-network coverage for emergency services only.
- This health maintenance organization (HMO) individual practice plan emphasizes preventive care, including immunizations and preventive exams and health screenings.
For a detailed description of MS.IPA benefits, exclusions and limitations, please refer to FEHB brochure #73-100 uhcfeds.com.
Optimum Choice®, Inc. (OCI)
The Optimum Choice, Inc. (OCI) health plans encourage members to use their primary care provider (PCP) to coordinate care across a wide spectrum of health services and enter electronic referrals to network specialists.
- An optional health savings account (HSA) can pay for qualifying medical expenses, including the annual deductible.
- An optional health reimbursement arrangement (HRA) can offer a type of employer-funded health benefit plan that reimburses employees for out-of-pocket medical expenses.
If services are delivered outside of the local network, the plan will not cover the cost except in an emergency.
Forms, Tools & Resources
These resources are available to care providers with members in M.D.IPA, M.D.IPA Preferred, Optimum Choice, Inc., and Optimum Choice Preferred health plans unless otherwise noted.
- Capitated Radiology Procedures as of Jan. 1, 2020
- Chiropractic Services Extension Form
- Emergency Room Auto-Pay List - Effective October 1, 2019
- Emergency Room and Urgent Care Reimbursement Protocol
- Laboratory Services Protocol
- Maryland Capitated Radiology Vendors for Routine Diagnostic Radiology Services
- Ophthalmology and Optometry Protocol
- Preferred Radiology Care Providers for Routine Outpatient Diagnostic Radiology Services (Frederick, Maryland, Northern Virginia, Washington D.C.)
- Preferred Referral Protocol for M.D.IPA and OCI
- Primary Care Physician (PCP) Selection and Panel Closure Protocol
- Primary Care Physician Referral Form Effective Jan 1. 2020
- Radiology Services Prior Authorization Quick Reference Guide
- Radiology Services Protocol
- Rehabilitation Services Extension Request Form
The UnitedHealthcare Choice and Choice Plus health plans allow members to choose a physician or specialist from the UnitedHealthcare Choice networks but do not need a referral to receive benefits.
- UnitedHealthcare Choice members must receive care from network care providers for benefits to be covered. There is out-of-network coverage for emergency services only.
- UnitedHealthcare Choice Plus members are covered at a lower benefit level for services provided by out-of-network care providers.
Preventive care, including immunizations and preventive exams and health screenings, is covered at 100 percent in our UnitedHealthcare Choice and UnitedHealthcare Choice Plus networks.
UnitedHealthcare Choice Advanced health plans allow members to choose a physician or specialist in the UnitedHealthcare Choice networks and do not need a primary care physician or referral to receive benefits. There is out-of-network coverage for emergency services only.
- UnitedHealthcare Choice Advanced members must receive care from network care providers for benefits to be covered. Members are encouraged to choose lower cost, freestanding network health care facilities rather than hospitals for radiology services and outpatient surgery.
- UnitedHealthcare Choice Advanced Plus members are encouraged to seek care from the network care providers but don’t need a referral to receive benefits; members are covered for out-of-network care provider visits at a lower benefit level.
UnitedHealthcare Choice Advanced members have lower copays and/or greater coinsurance when they use UnitedHealth Premium® Tier 1 2-star care providers.
UnitedHealthcare Choice Advanced and UnitedHealthcare Choice Advanced Plus build on Choice and Choice Plus plans with additional features for both members and employers.
UnitedHealthcare® NexusACO®
The UnitedHealthcare NexusACO suite of products offers cost-saving opportunities to members when they seek care providers from a select group of Accountable Care Organizations (ACO) nationwide. There is out-of-network coverage for emergency services only.
UnitedHealthcare NexusACO Plans – Open Access
- UnitedHealthcare NexusACO OA plans offer network-only coverage for care providers.
- UnitedHealthcare NexusACO OAP plans offer both network and non-network coverage.
UnitedHealthcare NexusACO Plans – Referral Required
- UnitedHealthcare NexusACO R plans offer network-only coverage for care providers.
- UnitedHealthcare NexusACO RB plans offer network coverage when the PCP refers a member to a network specialist, and lower coverage applies when there is no referral.
- UnitedHealthcare NexusACO RP plans offer network coverage when the PCP refers a member to a network specialist, and lower coverage applies when there is no referral or with an out-of-network specialist.
All UnitedHealthcare NexusACO members are required to select a primary care provider (PCP) within the network to provide their preventive care, treat chronic conditions, manage medications and enter specialist referrals.
Changes to PCP selection are permitted once per month. Changes submitted on or before the 31st of the month will be effective on the first day of the following month.
Tools & Resources
UnitedHealthcare Options PPO health plans allow members to choose a network physician or specialist without a referral (open-access).
- It is the member's responsibility to obtain prior approvals for both network and non-network services. No referral is required to see a specialist.
- If a non-network physician is chosen, out-of-pocket member costs will be higher and it is the member’s responsibility to obtain approvals and submit claims.
UnitedHealthcare Options PPO offers two levels of coverage: a higher level of benefits for in-network services, and a lower level of benefits for non-network services, with somewhat higher deductibles and coinsurance.