Choosing a PPO plan means you can choose to receive care from out-of-network providers. Our plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher. Here are other important things to know about using out-of-network providers:
- You can get your care from an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before receiving services to confirm that they are eligible to participate in Medicare.
- You don’t need to get a referral or prior authorization when you get care from out-of-network providers.
- Out-of-network/non-contracted providers are under no obligation to treat Care N’ Care members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call your Customer Experience Team or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
- It is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered services, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider sends you a bill that you think we should pay, you can send it to us for payment.
- The pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
When you select a Care N’ Care in-network primary care physician, you’ll have a dedicated doctor who will focus on your individual healthcare needs and coordinate your care with other in-network providers if needed. This allows you to keep your out-of-pocket costs lower and more predictable.