Out of Network Care

Out-of-Network Care

As a member of MediGold Essential Care (HMO), MediGold Classic Preferred (HMO) or MediGold Medical Only (HMO), you must get your health care from MediGold’s network providers with the exception of emergency or urgently needed services and out-of-network renal dialysis, unless authorized in advance.

As a member of MediGold Network Choice (PPO) or MediGold Value Choice (PPO), both in- and out-of-network services are covered. Out-of-network services will cost more than in-network services with the exception of emergency or urgently needed services and out-of-network renal dialysis.

For information on out-of-network pharmacy benefits, please refer to your Evidence of Coverage document in the Medical Benefits section.

Last Updated 9/30/2011 10:51:09 PM

H1846 H3668_012Nov_12 CMS Approved 11/25/2011

*MediGold is the only Central Ohio Medicare Advantage program to receive a 5-star (Excellent) Member Satisfaction Rating according to the 2011 Medicare & You Handbook published by the Centers for Medicare and Medicaid Services (CMS).

**2011 Consumer Assessment of Health Plan Survey (CAHPS)

Health plan with a Medicare contract. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium, copays or co-insurance may change on January 1, 2013. Individuals must have both Part A and Part B to enroll. You must continue to pay your Medicare Part B premium. Limitations, copays and restrictions may apply. HMO members must use plan providers, except in emergency or urgent care situations or for out-of-area renal dialysis. If an HMO member obtains routine care from out-of-network providers, neither Medicare nor MediGold will be responsible for the costs. PPO members may use in- and out-of-network providers, although they may pay more for out-of-network care, except for urgent or emergent care or out-of-network renal dialysis. In general, beneficiaries must use network pharmacies to access prescription drug benefits, except under non-routine circumstances. Quantity limitations and restrictions may apply. Documents accessible on this website may be available in alternative formats or languages.