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Out-of-Network Providers

You must receive your care from a network provider

In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. Here are three exceptions:

  • The plan covers medical emergency care or urgently needed services that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed services means below.
  • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Authorization must be obtained from the plan prior to seeking care. In this situation, we will cover these services as if you got the care from a network provider.
  • The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside University of Maryland Health Advantage’s service area.

Medical emergencies

A “medical emergency” is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.  The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

Urgently needed services

“Urgently needed services” are non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. The unforeseen condition could, for Example, be an unforeseen flare-up of a known condition that you have.

You are covered only for emergency services, urgently needed care, and kidney dialysis services when you are temporarily traveling outside the plan’s service area.  The plan does not cover routine health care services or follow-up health care services for while you are outside of the service area.  This means outside the Maryland counties of Anne Arundel, Baltimore, Baltimore City, Caroline, Carroll, Cecil, Charles, Dorchester, Harford, Howard, Kent, Montgomery, Prince Georges, Queen Anne’s, and Talbot.

The plan will continue to provide coverage for your Part D prescription drugs so long as you continue to purchase them from network pharmacies.  Our network of pharmacies spans across the United States, so contact our Member Services Department at 1-844-786-6762 (TTY users please call 711), 24 hours a day, 7 days a week to see if the pharmacies in the area you are traveling to are in our network.

If you have a second home located outside of the plan’s service area that you travel to each year for a couple months, you are covered only for emergency services, urgently needed care, and kidney dialysis services when you are temporarily traveling outside the plan’s service area.  The plan does not cover routine health care services or follow-up health care services for while you are outside of the service area. 

The plan will continue to provide coverage for your Part D prescription drugs so long as you continue to purchase them from network pharmacies.  Our network of pharmacies spans across the United States, so contact our Member Services Department at 1-844-786-6762 (TTY users please call 711), 24 hours a day, 7 days a week to see if the pharmacies in the area you are traveling to are in our network.

It is important to understand that if you take a long trip and are going to be outside the plan’s service area for more than six (6) months, the plan must end your membership in accordance with federal regulations.

In order to receive all of your covered benefits, you must be within the plan’s service area and receive the care from our network of hospitals, providers, and ancillary vendors.  Our service area includes the following Maryland counties:  Anne Arundel, Baltimore, Baltimore City, Caroline, Carroll, Cecil, Charles, Dorchester, Harford, Howard, Kent, Montgomery, Prince Georges, Queen Anne’s, and Talbot.

You are only covered for emergency services, urgently needed care, and kidney dialysis services when you are temporarily traveling outside the plan’s service area.

When you are outside the service area and cannot get care from a network provider, University of Maryland Health Advantage will cover urgently needed services that you get from any provider.

We will cover prescriptions filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, you will have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost, if applicable, by submitting a paper claim. 

University of Maryland Health Advantage is a health maintenance organization, also known as a HMO with a Medicare contract.  In HMO Plans, you can't get your health care from any doctor, other health care provider, or hospital. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan's network (except emergency care, out-of-area urgent care, or out-of-area dialysis) with whom the plan has contracted to provide all covered services.  This enables the plan to pass on cost-savings to its members.

You should always try to obtain urgently needed services from network providers. However, if providers are temporarily unavailable or inaccessible and it is not reasonable to wait to obtain care from your network provider when the network becomes available, we will cover urgently needed services that you get from an out-of-network provider.