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New York Commercial Health Plans

The following commercial health plans are offered in New York. Open any section below to view more information.

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Surest is a UnitedHealthcare company that administers health plans without deductibles or coinsurance. Members have access to the nationwide UnitedHealthcare and Optum® Behavioral Health networks and can check costs and care options in advance.

If you participate in UnitedHealthcare commercial plans, you automatically participate in Surest benefit plans at the existing commercial reimbursement rates per your participation agreement.

A small number of members have the Surest Flex plan, which includes the feature of flexible coverage. For a fixed list of plannable tests, procedures or treatments, the member must activate coverage at least 3 business days in advance of the service, or the member may not have coverage for the service.

Claims: Please send claims to us electronically using Surest Payer ID 25463 or by mail to Surest, P.O. Box 211758, Eagan, MN 55121. Include the subscriber ID and rendering address on the claim to help us confirm the copay/member price. Check the status of your claims in the UnitedHealthcare Provider Portal.

Eligibility and benefits: To check member eligibility and benefits, visit the provider portal or call Surest Provider Services at 844-368-6661. If you’re requesting information about a dependent, we’ll need the subscriber ID.

Variable copays: You can receive variable copay information through electronic data interchange (EDI) 270/1 transaction responses. For more information, see the 270/271 EDI Surest guide and Digital Solutions page.

For more information, please visit UHCprovider.com/surest.

The Empire Plan is a health insurance program developed by New York State and its employee unions for employees of New York State and their families. It is the most selected group health insurance option under the New York State Health Insurance Program (NYSHIP), covering more than 1 million employees, retirees and eligible dependents from more than 740 participating employers and agencies. Members live nationwide, with larger concentrations in New York, Arizona, California, Connecticut, Delaware, Florida, Georgia, Massachusetts, Maryland, North Carolina, New Jersey, Nevada, Pennsylvania, South Carolina, Tennessee, Texas and Virginia.

Multiple stakeholders are involved in plan administration:

  • The Medical/Surgical Program is administered by UnitedHealthcare. Certain outpatient hospital services are included in this coverage, and there is a PPO network for its Participating Provider Program. This includes providers contracted by UnitedHealthcare specifically for The Empire Plan, as well as providers contracted for other UnitedHealthcare commercial plans who see Empire Plan patients. All use the UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage, which includes an Empire Plan supplement section.
  • Hospitalization and Related Expense coverage is administered by Anthem Blue Cross
  • The Mental Health and Substance Use Program is administered by Carelon Behavioral Health Solutions
  • The Prescription Drug Program is administered by CVS Caremark

Tools and resources

UnitedHealthcare Charter 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. The UnitedHealthcare Charter network is narrowed in states where the product is sold.

  • UnitedHealthcare Charter members must receive a referral from their PCP to see a network specialist for services to be covered. There is out-of-network coverage for emergency services only.
  • UnitedHealthcare Charter Balanced members may see a network specialist at a reduced benefit level when there is no referral. There is out-of-network coverage for emergency services only.
  • UnitedHealthcare Charter Plus members may see a network specialist at a reduced benefit level when there is no referral.  Charter Plus also provides out-of-network coverage.

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

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 Tier 1 UnitedHealth Premium® Care Physicians.

UnitedHealthcare Choice Advanced and UnitedHealthcare Choice Advanced Plus build on Choice and Choice Plus plans with additional features for both members and employers.

UnitedHealthcare Compass 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.

  • UnitedHealthcare Compass 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.
  • UnitedHealthcare Compass Balanced members must receive a referral from their PCP to see a network specialist for benefits to be covered. Lower network coverage applies when there is no referral. There is out-of-network coverage for emergency services only.
  • UnitedHealthcare Compass Plus members need a referral from their PCP to see a network specialist for benefits to be covered. Lower network coverage applies when there is no referral or for services from an out-of-network care provider.

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.

UnitedHealthcare Compass plans are offered as Individual Exchange plans in certain states with off-Exchange versions when required by state law.

Tools and resources

UnitedHealthcare® Core and Core Essential

UnitedHealthcare Core health plans allow members to choose a network physician or specialist without a referral (open access). The UnitedHealthcare Core network is narrowed in some states.

  • UnitedHealthcare Core Essential members must receive care from network providers for benefits to be covered.
  • UnitedHealthcare Core plans cover out-of-network providers at a lower benefit level.

An array of health and wellness resources are available to members including the Online Health Assessment, Personal Health Record and Online Health Coaching modules.

Tools & Resources

UnitedHealthcare Navigate®

The UnitedHealthcare Navigate 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. The UnitedHealthcare Navigate network is narrowed in some states.

  • UnitedHealthcare Navigate 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.
  • UnitedHealthcare Navigate Balanced members may see a network specialist at a reduced benefit level when there is no referral.   There is out-of-network coverage for emergency services only.
  • UnitedHealthcare Navigate Plus members may see a network specialist at a reduced benefit level when there is no referral.  Navigate Plus also provides out of network coverage.

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.

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

Other Forms