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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 before you seek 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 care.

For detailed information on out-of-network coverage rules, see your Member Handbook: How to get care from out-of-network providers (Chapter 3, Section D4).

The benefit information provided here is a brief summary, not a complete description of benefits. Benefits, formulary, 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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