Out-of-Network Coverage

Except for a few limited situations, you must use network providers for your care while enrolled in our plan. The primary exceptions are:

• Emergencies
• Urgently needed care when you can’t access the network (for example, when you’re out of the area)
• Out-of-area dialysis at a Medicare-certified facility
• Services from out-of-network providers that Community Advantage Plus has authorized in advance
  

If you obtain non-authorized care from an out-of-network provider, you are responsible for the full cost of those services.

You must get care from network providers.

Usually, the plan will not cover care from a provider who does not work with the health plan. Here are some cases when this rule does not apply:

• You need emergency or urgent care and the provider is out of network (see definitions below).
• Our network can’t provide a covered service you medically need and you obtain prior authorization to see an out-of-network provider. In these cases, your care is covered at no cost to you.
• You require kidney dialysis while temporarily outside the service area and receive it at a Medicare-certified dialysis facility.
• Continuity of care when you first join the plan: you may request to continue seeing your current providers. With certain exceptions and if an existing relationship is verified (see Member Handbook), we must approve this request. You can generally continue for up to 12 months while a care coordinator helps transition you to in-network providers. After 12 months, services with out-of-network providers are no longer covered.

How to get care from out-of-network providers

In specific circumstances, you may have the right to finish a course of covered services with a provider or facility whose contract has ended. Newly enrolled members may also have continuity-of-care rights with a non-contracted provider if they were in treatment when CHPIV coverage began. See the Member Handbook for details.Important: Any out-of-network provider must be eligible to participate in Medicare and/or Medi-Cal. We cannot pay providers who are not eligible. If you see a provider who is not Medicare-eligible, you must pay the full cost. Providers are required to inform you if they are not eligible to participate in Medicare.

Getting care when you have a medical emergency

What counts as a medical emergency?

A medical emergency is a sudden medical condition (including severe pain or serious injury) such that a reasonable person with average health knowledge would expect that without immediate care it could result in:

• Serious risk to your health or your unborn child’s health
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part

For a pregnant member, active labor is an emergency when either:

• There isn’t enough time to safely transfer to another hospital before delivery, or
• A transfer would endanger the member or the unborn child.

What should you do if you have a medical emergency?

If you have a medical emergency:

• Get help as fast as possible. Call 911 or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.
• As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours. However, you will not have to pay for emergency services because of a delay in telling us. The phone number is listed on the back of your Member ID Card, we are open 24 hours a day, 7 days a week to assist you.

What is covered if you have a medical emergency?

Worldwide emergency services ($50,000 Max) are covered, excluding transportation back to the U.S.After your condition is stabilized, you may need follow-up care. We cover necessary follow-up care and will transition you to network providers as soon as possible if your emergency care began out of network.

What if it wasn’t a medical emergency after all?

Sometimes it can be hard to know if you have a medical emergency. You might go in for emergency care and have the doctor say it wasn’t really a medical emergency. As long as you reasonably thought your health was in serious danger, we will cover your care.

However, after the doctor says it was not an emergency, we will cover your additional care only if:

• You go to a network provider, or
• The additional care you get is considered “urgently needed care” and you follow the rules for getting this care. (See the next section.) 

Getting urgently needed care

What is urgently needed care? Care for a sudden illness, injury, or condition that isn’t an emergency but requires prompt attention (e.g., a flare-up of a chronic condition).

Getting urgently needed care when you are in the plan’s service area

In most situations, we will cover urgently needed care only if:

• You get this care from a network provider,
• You follow the other rules described in this chapter.

In most cases, urgently needed care is covered when:

• You receive care from a network provider, and
• You follow the other requirements in this chapter.

If you cannot reasonably reach a network provider, we will cover urgently needed care from an out-of-network provider.

You also have access to Urgent Care Centers. For information on the Urgent Care Centers available please contact the Member Services staff at 1-888-484-1412 (TTY: 711), our Member Services staff is available to assist you 24 hours a day, 7 days a week.

Getting urgently needed care when you are outside the plan’s service area

If you’re outside the service area and can’t access the network, urgently needed care from any provider is covered. Care received outside the United States is not covered (urgent or otherwise).

Please refer to your Member Handbook for full information on out-of-network medical coverage, or you may also contact the Member Services staff at 1-888-484-1412 (TTY: 711). Our Member Services staff is available to assist you 24 hours a day, 7 days a week.