Out-of-Network Coverage

If you need care when you are outside the service area, your coverage is very limited. The only services we cover when you are outside our service area are care for a medical emergency, urgently needed care, renal dialysis, and care that Capital Health Plan or a plan provider has approved in advance.

Capital Health Plan Medicare Advantage plans provide worldwide coverage for medical emergencies only. A "medical emergency" is when you reasonably believe that your health is in serious danger - when every second counts. A medical emergency includes severe pain, a bad injury, a serious illness, or a medical condition that is quickly getting much worse.

If you have a medical emergency, get medical help as quickly as possible. Call 911 for help or go to the nearest emergency room. You do not need to get permission first from your PCP (Primary Care Physician) or other plan provider.

Make sure that Capital Health Plan knows about your emergency, because we will need to be involved in following up on your emergency care. You or someone else should call to tell your PCP about your emergency care as soon as possible, preferably within 48 hours.

If you need to report an out-of-area emergency or have questions about what medical care is covered when you travel, please call us at one of the telephone numbers listed on this page.

For information about Out-of-Network Coverage for Prescription Drugs, please read about Out-of-Network Pharmacies.