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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 (CCA) network. But there are some cases when we will cover care from a provider who is not in our plan’s network:

One Care members are covered at any hospital emergency department, no matter if the hospital is in- or out-of-network.

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 before you seek that care.

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
  • Your medical condition requires care sooner than will be possible in-network
  • 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 before you seek that care.

For detailed information on out-of-network coverage rules, see your Member Handbook.

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. For more information, call Commonwealth Care Alliance Member Services or read the Commonwealth Care Alliance Member Handbook.

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