Out-of-Network Care

Medicare Out-of-Network Care

Health issues don’t always happen in your insurance network. At CHRISTUS Health Plan, we want to help you receive the best, most convenient care possible.

CHRISTUS Health Plan Generations and Generations Plus (HMO) members can receive care either in-network or out-of-network as long as the services are covered benefits and medically necessary.

If you opt to receive out-of-network care, know that your costs for the covered services may be higher. Here are additional details to keep in mind:

  • In most cases, the out-of-network provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible. The member would then be responsible for the full cost of these services. Check with your provider before receiving care to confirm their eligibility.
  • Before getting care, you may want to ask for a pre-visit coverage decision to confirm that the out-of-network services you’re getting are covered and medically necessary. This isn’t required but can be important in case we later determine that the services were not covered or medically necessary. In this instance, coverage may be denied, and you will be responsible for the full cost. If this happens, you have the right to appeal our decision not to cover your care.
  • It’s best to ask an out of network provider to bill the plan first. If you’ve already paid for the covered services, CHRISTUS Health Plan will reimburse you for our share of the cost. If an out-of-network provider sends you a bill that you think we should pay for, you can send it to us.
  • For emergency care, urgently needed care or out-of-area dialysis, you may not have to pay a higher cost-sharing amount.

H1189_MM143 pending approval
Last Updated: 2/23/17