You must receive your care from a Commonwealth Care Alliance network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our network) will not be covered.
Here are exceptions when care you receive from an out-of network provider will be covered:
- Emergency care or urgently needed care that you get from an out-of-network provider.
- If you need medical care that Medicare or MassHealth (Medicaid) requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Your primary care provider/primary care team must authorize care you receive from an out-of-network provider prior to seeking care. In this situation, we will cover these services at no cost to you. If you do not get authorization for seeing an out-of-network provider in advance, you will have to pay for the service.
- Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.
- The plan covers out-of network care in unusual circumstances. Your primary care provider/primary care team must authorize care you receive from an out-of-network. provider prior to seeking this care. In such a situation, we will cover these services at no cost to you. If you do not get authorization for out-of-network care in advance, you will be responsible for payment for the service. Some examples of unusual circumstances which may lead to out-of-network care are the following:
- You have a unique medical condition and the services are not available from network providers.
- Services are available in network but are not available timely as warranted by your medical condition.
- Your primary care provider/primary care team determines that a non-network provider can best provide the service.
For detailed information on out-of-network coverage rules, see your Evidence of Coverage (Member Handbook): Using the Plan’s Coverage for your Medical and Other Covered services.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, and/or pharmacy network may change on January 1 of each year.
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Last Updated 07/29/2013