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. 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.