Out of Network Coverage

Rules for obtaining out-of-network services

You generally must receive your care from a network provider. In most cases, care you receive from a non-network provider (a provider who is not part of our plan’s network) will not be covered. Here are two exceptions:

• The plan covers emergency care or urgently needed care that you get from an out-of-network provider.
• If you need medical care that Medicaid or, if applicable, Medicare 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, if authorized by your Team.

Community Care does not cover any care you receive outside of the United States or its territories.

Referral Rules

For most services you must get prior approval from your Team. You can get only a few types of covered services on your own without first getting approval from your Team, except in an emergency or for urgently needed care,.

You can get the services listed below without getting approval in advance from your Team.

• Routine women’s health care, which include breast exams, mammograms (x-rays of the breast), Pap tests, and pelvic exams, as long as you get them from a network provider.
• Family planning services.
• Flu shots and pneumonia vaccinationsas long, as you get them from a network provider.
• Emergency services from network providers or from non-network providers.
• Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or, e.g., when you are temporarily outside of the plan’s service area.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.