New 2025 Individual Exchange Plans and Updated Prior Authorization Guidelines
On January 1, 2025, UnitedHealthcare will launch Individual Exchange plans in four new states, while continuing to offer these plans in the 26 states where they are currently available. Additionally, thirteen of the existing states will see expanded access, covering 119 new counties.
New States for 2025:
- Indiana
- Iowa
- Nebraska
- Wyoming
Existing States:
- Alabama
- Arizona
- Colorado (Rocky Mountain Health Plans)
- Florida
- Georgia
- Illinois
- Kansas
- Louisiana
- Maryland
- Massachusetts (Navigate)
- Michigan
- Mississippi
- Missouri
- 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
As of January 1, 2025, the Rocky Mountain Valley and Rocky Mountain Sky health plans, along with their respective provider networks, will merge and expand into additional counties. The newly combined network will be named Rocky Mountain Valley.
Prior Authorization Information: Providers in the new states should review the list of codes that require prior authorization.
Preparing for the New Plans: To ensure readiness for 2025, providers are encouraged to visit the Individual Exchange plans page, which offers access to:
- A self-paced, interactive guide on the new 2025 plans
- State-specific plan details
- Coverage determination guidelines
- Medical and reimbursement policies
- Pharmacy information
- Prior authorization/notification and referral requirements
Additional Preparation Recommendations:
- Inform staff with an update on the participation and referral information.
- In most of these states, the plans do not require the member to visit an in-network primary care provider before visiting a specialist of the member’s choice.
- Members must select a PCP to help coordinate their care, or one will be assigned after 30 days.
- Organize business processes where some plans require referrals, if possible.
- Make sure staff are capable of submitting and checking the status of referrals in case it is needed.
- Review the prior authorization list available at “Advance Notification and Clinical Submission Requirements.”
- Get acquainted with the UnitedHealthcare Individual Exchange Medical & Drug Policies, as it is important to note that any medical necessity review for a service/procedure/code will incorporate site of service analysis.
For further assistance, please go to the Individual Exchange plans page, call a provider advocate or chat live with the representatives anytime through the UnitedHealthcare Provider Portal.