Out-of-Network Coverage (Part C)

In most cases, you must receive your care from a Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan) provider. There are some exceptions, however, when care you receive from an out-of-network provider will be covered. Those exceptions are:

• Emergency care or urgently needed care that you get from an out-of-network provider
• If you need care that cannot be adequately provided by a network provider, including need for continuity of care, you can get this care from an out-of-network provider.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area
• The plan covers out-of-network care in unusual circumstances, so long as those services are authorized in advance by your primary care provider or Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan). Please remember that without that authorization, you will be responsible for payment of the service.

In some cases your doctor may send you to an out-of-network doctor. Your doctor will need to get prior approval from the health plan. Some of those times may be because:

• You have a unique medical condition and the services are not available from network providers.
• Services are available in-network but are not available as soon as you need them
• Your primary care provider determines that a non-network provider can best provide the service.

See the Benefits Chart in your Summary of Benefits.

For more information, please refer to your Member Handbook or call Member Services at 1-866-549-8289. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned the next business day. TTY users call 711.

Out-of-Network Coverage

In most cases, you must receive your care from a Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan) provider. There are some exceptions, however, when care you receive from an out-of-network provider will be covered. Those exceptions are:

• Emergency care or urgently needed care that you get from an out-of-network provider
• If you need care that cannot be adequately provided by a network provider, including need for continuity of care, you can get this care from an out-of-network provider.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area
• The plan covers out-of-network care in unusual circumstances, so long as those services are authorized in advance by your primary care provider or Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan). Please remember that without that authorization, you will be responsible for payment of the service.

 Examples of unusual circumstances that may lead to out-of-network care are:

• You have a unique medical condition and the services are not available from network providers.
• Services are available in-network but are not available as soon as you need them
• Your primary care provider determines that a non-network provider can best provide the service.

In most cases, you must receive your care from a Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan) provider. There are some exceptions, however, when care you receive from an out-of-network provider will be covered. Those exceptions are:

• Emergency care or urgently needed care that you get from an out-of-network provider
• If you need care that cannot be adequately provided by a network provider, including need for continuity of care, you can get this care from an out-of-network provider.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area
• The plan covers out-of-network care in unusual circumstances, so long as those services are authorized in advance by your primary care provider or Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan). Please remember that without that authorization, you will be responsible for payment of the service.

In some cases your doctor may send you to an out-of-network doctor. Your doctor will need to get prior approval from the health plan. Some of those times may be because:

• You have a unique medical condition and the services are not available from network providers.
• Services are available in-network but are not available as soon as you need them
• Your primary care provider determines that a non-network provider can best provide the service.

See the Benefits Chart in your Summary of Benefits.

For more information, please refer to your Member Handbook or call Member Services at 1-866-549-8289. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned the next business day. TTY users call 711.

Out-of-Network Coverage

In most cases, you must receive your care from a Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan) provider. There are some exceptions, however, when care you receive from an out-of-network provider will be covered. Those exceptions are:

• Emergency care or urgently needed care that you get from an out-of-network provider
• If you need care that cannot be adequately provided by a network provider, including need for continuity of care, you can get this care from an out-of-network provider.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area
• The plan covers out-of-network care in unusual circumstances, so long as those services are authorized in advance by your primary care provider or Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan). Please remember that without that authorization, you will be responsible for payment of the service.

 Examples of unusual circumstances that may lead to out-of-network care are:

• You have a unique medical condition and the services are not available from network providers.
• Services are available in-network but are not available as soon as you need them
• Your primary care provider determines that a non-network provider can best provide the service.