With limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which CommuniCare Advantage Cal MediConnect Plan authorizes use of out-of-network providers.
You are responsible for paying the full cost of services that were obtained out-of-network where not authorized.
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:
- The plan covers emergency or urgently needed care from an out-of-network provider. To learn more and to see what emergency or urgently needed care means, see below.
- If you need care that our plan covers and our network providers cannot give it to you, you can get the care from an out-of-network provider. An authorization should be obtained from the plan prior to seeking care. In this situation, we will cover the care at no cost to you. To learn more about getting approval to see an out-of-network provider, see below.
- The plan covers kidney dialysis services when you are outside the plan’s service area for a short time. You can get these services at a Medicare-certified dialysis facility.
- When you first join the plan, you can ask to continue to see your current providers. With some exceptions, we are required to approve this request if we can establish that you had an existing relationship with the providers (see Chapter 1, Section F, page 13 of the Member Handbook). If we approve your request, you can continue seeing the providers you see now for up to 12 months for services. During that time, a care coordinator will contact you to help you find providers in our network. After 12 months, we will no longer cover your care if you continue to see out-of-network providers.
How to get care from out-of-network providers
Under some conditions, a member may have a right to complete covered services with a doctor or hospital whose contract has ended. A newly covered member may also have a right to complete covered services with a non-contracted doctor if the member was receiving services from that doctor at the time coverage with CHG became effective. Please refer to the Member Handbook, Chapter 3, Section D, page 42, How to get care from specialists and other network providers.
- Please note: If you go to an out-of-network provider, the provider must be eligible to participate in Medicare and/or Medi-Cal. We cannot pay a provider who is not eligible to participate in Medicare and/or Medi-Cal. If you go to a provider who is not eligible to participate in Medicare, you must pay the full cost of the services you get. Providers must tell you if they are not eligible to participate in Medicare.
Getting care when you have a medical emergency
What is a medical emergency?
A medical emergency is a medical condition with symptoms such as severe pain or serious injury. The condition is so serious that, if it doesn’t get immediate medical attention, you or any prudent layperson (meaning a person with an average knowledge of health and medicine) could expect it to result in:
- Serious risk to your health; or
- Serious harm to bodily functions; or
- Serious dysfunction of any bodily organ or part; or
In the case of a pregnant woman, an active labor, meaning labor at a time when either of the following would occur:
- There is not enough time to safely transfer the member to another hospital before delivery.
- The transfer may pose a threat to the health or safety of the member or 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?
You may get covered emergency care whenever you need it, anywhere in the United States or its territories. If you need an ambulance to get to the emergency room, our plan covers that. To learn more, see the Benefits Chart in Chapter 4, Section D, page 59.
After the emergency is over, you may need follow-up care to be sure you get better. Your follow-up care will be covered by us. If you get your emergency care from out-of-network providers, we will try to get network providers to take over your care as soon as possible.
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?
Urgently needed care is care you get for a sudden illness, injury, or condition that isn’t an emergency but needs care right away. For example, you might have a flare-up of an existing condition and need to have it treated.
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, and
- You follow the other rules described in this chapter.
However, if you can’t get to a network provider, we will cover urgently needed care you get 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 Customer Service staff at 1-888-244-4430, TTY users should call 1-855-266-4584, our Customer 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
When you are outside the service area, you might not be able to get care from a network provider. In that case, our plan will cover urgently needed care you get from any provider.
Our plan does not cover urgently needed care or any other non-emergency care that you get outside the United States.
Please refer to your Member Handbook for full information on out-of-network medical coverage, or you may also contact the Customer Services staff at 1-888-244-4430. Our Customer Services staff is available to assist you 24 hours a day, 7 days a week.
CommuniCare Advantage Cal MediConnect Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Enrollment in CommuniCare Advantage Cal MediConnect Plan depends on contract renewal.
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PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).
ملحوظة: اذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم
Last update 12/31/2019