UnitedHealthcare Announces Expanded 2026 Individual Exchange Plan
UnitedHealthcare has confirmed significant changes in its Individual Exchange plans in 30 states. They plan to expand services in 11 states.
Expanded 2026 Service Areas
- Alabama
- Arizona*
- Colorado (Rocky
- Mountain Health Plans)*
- Florida
- Georgia
- Illinois*
- Indiana
- Iowa
- Kansas
- Louisiana*
- Maryland
- Massachusetts (Navigate)
- Michigan*
- Mississippi
- Missouri
- Nebraska
- Nevada (Sierra Health and Life/Health Plan of Nevada)*
- New Jersey (Oxford Metro)
- New Mexico (Choice)
- New York (Compass)
- North Carolina
- Ohio
- Oklahoma*
- South Carolina
- Tennessee*
- Texas*
- Virginia*
- Washington (Charter)*
- Wisconsin
- Wyoming
Visit the UnitedHealthcare Individual Exchange plan resources for the latest information.
Important News for Texas Providers
Sanitas Medical Group will introduce new capitated primary care plans in the San Antonio region in Texas. The Kelsey-Seybold capitated plans will still be in the Houston market. Further plan and network information can be found in the Interactive Guide or the Texas Quick Reference Guide for Exchanges
Platform Migration for Massachusetts and New York Plans
The Massachusetts (Navigate) and New York (Compass) Individual Exchange plans of the UnitedHealthcare will move to a new claims platform as of Jan. 1, 2026. This will lead to altered remittance formats, and new addresses of the appeal submission have been provided.
New Appeals Address for Medical, OBH, Dental, and Vision Cases
For Massachusetts and New York medical, OBH, dental, or vision cases, submit appeals to:
- UnitedHealthcare
- P.O. Box 6111
- Mail Stop CA-0197
- Cypress, CA 90630
- Standard fax: 888-404-0949
- Expedited fax: 888-808-9123
- UnitedHealthcare Provider Portal
Massachusetts and New York Pharmacy Appeals
For pharmacy cases, if the appeal or non-formulary exception is before Jan. 1, 2026, and the member doesn’t have coverage after Jan. 1, 2026, submit appeals to:
- UnitedHealthcare
- P.O. Box 6111
- Mail Stop CA-0197
- Cypress, CA 90630
- Standard fax: 888-404-0949
- Expedited fax: 888-808-9123
- UnitedHealthcare Provider Portal
For pharmacy cases, if the appeal or non-formulary exception is before Jan. 1, 2026, and the member has coverage after Jan. 1, 2026, submit appeals to:
- Optum Rx
- c/o Appeals Coordinator
- P.O. Box 2975
- Mission, KS 66201
- Pharmacy fax: 877-239-4565
- Pharmacy portal (If the initial prior authorization was originally submitted on CoverMyMeds)
You can go to the list of codes requiring prior authorization for more info.
Provider Readiness for 2026 Members
UnitedHealthcare has published revised materials for providers as mentioned below:
- Self-paced interactive guide chapter 2026,
- State-specific plan information
- Coverage determination guidelines
- Medical and reimbursement policies
- Pharmacy information
- Prior authorization/notification and referral requirements
Providers are advised to:
- Notice employees of participation.
- Check referral required plans.
- Re-examine the prior authorization list at: Advance Notification and Clinical Submission Requirements
- Make sure employees are able to place and follow up on referrals where / when necessary.
- It is important to note that in-network PCPs are not required to make specialist referrals in most states, but PCPs have to be chosen within 30 days.
- You should also go through the UnitedHealthcare Individual Exchange Medical & Drug Policies for medical necessity review of codes.
The providers have the option of seeking assistance via the provider advocate, the UnitedHealthcare Provider Portal, or the Individual Exchange plans resource center.
