If you have a Medicare Advantage Plan, your plan likely has a network of providers. A network consists of doctors, hospitals, and medical facilities that contract with a plan to provide services. When you receive non-emergency, non-urgent services from an out-of-network provider, you will likely be responsible for paying higher cost-sharing or for paying the full cost of the services out-of-pocket.
However, your Medicare Advantage Plan is required to cover emergency and urgent care anywhere in the U.S. without imposing additional costs or coverage rules (such as prior authorization). This means that if you seek emergency care from an out-of-network provider, your Medicare Advantage Plan must cover the care as if you had gone to an in-network provider. Medicare Advantage Plans define an emergency by the prudent person standard. Prudent means acting with care or thought about the future. This standard ensures that even if your condition turns out not to be a medical emergency, it will still be covered as long as a prudent person would have assumed it was an emergency at the time you got care.
If your Medicare Advantage Plan denies coverage of an emergency or urgently needed service because you saw an out-of-network provider or failed to get a referral or prior authorization, you should appeal their denial. You should ask your doctor to provide medical documentation that the services you received met the definition of emergency or urgently needed services (see number 1). If you need assistance appealing the denial, contact your State Health Insurance Assistance Program (SHIP). If you do not know how to contact your SHIP, call 877-839-2675 or visit www.shiptacenter.org.
Read More: What If I Receive Emergency or Urgently Needed Services from an Opt-Out Provider?
Learn About: Does Medicare Cover Emergency Medical Services that I Receive in Another Country?
Return to: Medicare In-Depth
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