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How to Get Care from Out-of-Network Providers

You must receive your care from providers that are in the Commonwealth Care Alliance network. But there are some cases when we will cover care from a provider who is not in our plan’s network:

Emergency care and urgently needed care is covered when providers in our network are unavailable.

Medicare or MassHealth (Medicaid) requires our plan to cover some types of care. If the providers in our network cannot provide this care, we will cover care from an out-of-network provider. Your primary care provider must approve the care you receive from an out-of-network provider first.

We will cover kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

Examples of unusual circumstances which may lead to out-of-network care include:

  • You have a unique medical condition and the services are not available from network providers
  • Services are available in-network but are not available in a timely way as warranted by your medical condition
  • Your primary care provider determines that an out-of-network provider can best provide the services

Your primary care provider must approve the care you receive from an out-of-network provider first.

For detailed information on out-of-network coverage rules, see your Evidence of Coverage: Using the plan’s coverage for your medical and other covered services (Chapter 3).

The benefit information provided here is a brief summary, not a complete description of benefits. Benefits, formulary, and pharmacy and/or provider networks may change on January 1 of each year. Limitations, copayments, and restrictions may apply. You will be covered for all services listed above as long as they are approved and/or coordinated by your primary care provider, your care team, or Commonwealth Care Alliance (CCA). For more information, call CCA Member Services or review your CCA Senior Care Options Evidence of Coverage.

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