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The Program » Services & Benefits » Out-of-Network Coverage

Out-of-Network Coverage

In most cases, you must receive your care from a Commonwealth Care Alliance provider. There are some exceptions, however, when care you receive from an out-of-network provider will be covered. Those exceptions are:

  • Emergency care or urgently needed care that you get from an out-of-network provider
  • If you need care that cannot be adequately provided by a network provider, including need for continuity of care, you can get this care from an out-of-network provider.
  • 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, so long as those services are authorized in advance by your primary care provider or Commonwealth Care Alliance. Please remember that without that authorization, you will be responsible for payment of the service. Examples of unusual circumstances that may lead to out-of-network care are:
    • You have a unique medical condition and the services are not available from network providers.
    • Services are available in-network but are not available as soon as you need them
    • Your primary care provider determines that a non-network provider can best provide the service.

See the Benefits Chart in your Member Handbook.

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations and restrictions may apply. For more information, call Commonwealth Care Alliance Member Services or read the Commonwealth Care Alliance  Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks may change on January 1 of each year.

Last Updated 08/26/2013