Out-of-Network (OON) Provider Access
In most cases, 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 the exceptions:
- The plan covers emergency care or urgently needed care that you get from an out-of-network provider. Suppose that you are temporarily outside our plan's service area, but still in the United States. If you have an urgent need for care, you probably will not be able to find or get to one of the providers in our plan's network. In this situation (when you are outside the service area and cannot get care from a network provider), our plan will cover urgently needed care that you get from any provider. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States
- 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 should be obtained from the plan prior to seeking care from an out-of-network provider. In this situation, you will pay the same as you would pay if you got the care from a network provider
- If you go to providers who are not in MeridianComplete's network without prior authorization or approval from us, you may have to pay the bill
- If you need services from an out-of-network provider, you or the out of network provider should contact your Care Coordinator at 1-855-580-1689 (TTY: 711), Monday - Sunday, 8 a.m. to 8 p.m. prior to receiving the services. Your Care Coordinator will assist you and/or the provider in getting the necessary information to obtain prior authorization
Please note: If you go to an out-of-network provider, the provider must be eligible to participate in Medicare and/or Medicaid. We cannot pay a provider who is not eligible to participate in Medicare and/or Medicaid. If you go to a provider who is not eligible to participate in Medicare, you must pay the full cost of the services you get. Providers must tell you if they are not eligible to participate in Medicare
- To learn more about Out-of-Network Coverage rules please reference Chapter 3 of your Member Handbook. For any questions regarding Out-of-Network coverage rules please call our Member Services Department at 1-855-580-1689 (TTY: 711), Monday - Sunday, 8 a.m. to 8 p.m.
MeridianComplete has a Continuity-of-Care Policy that allows members continued access to non-contracted practitioners in the following situations:
- Discontinuation of a contract between MeridianComplete and a practitioner or facility
- New member in an "active course of treatment" with a non-contracted practitioner at the time of enrollment
If this is your first time in a Medicare-Medicaid Plan MeridianComplete staff will arrange for continuation of care for up to 180 days. The lack of a contract with the physician of a newly enrolled member or discontinued contracts between MeridianComplete and a provider will not interfere with this option. MeridianComplete will work with the member and non-network provider to transition care to a provider within the MeridianComplete network during this continuity of care time period. Continuity of care will be administered within all applicable benefit limits.
If you changed to MeridianComplete from a different Medicare-Medicaid Plan you may continue to see your current providers for the first 90 days with our plan, at no cost, if they are not a part of our network. During the transition time, our care coordinator will contact you to help you find providers in our network. After that time, we will no longer cover your care if you continue to see out-of-network providers.
Exceptions to Policy:
- MeridianComplete staff may extend the 180 day period as long as necessary to meet unusual member needs
- MeridianComplete will not approve continued care by a non-participating provider if:
- The discontinued contract is based on a professional review action for provider incompetence or inappropriate conduct, and the welfare of the member would be in jeopardy
- The provider is unwilling to continue care of the member
- Care with the non-participating provider was initiated after the member has been enrolled with MeridianComplete
- The provider who would do the ongoing care either did not meet our Credentialing policies/criteria in the past or attempted to become credentialed while providing ongoing care and did not meet the credentialing policies/criteria
Out-of-Network (OON) Pharmacy Access
MeridianComplete reimburses members for Part D drug expenses incurred at out-of-network pharmacies in the following situations:
- The member is traveling outside of the MeridianComplete service area; runs out of or loses his or her covered Part D drug, or becomes ill and needs a covered Part D drug; and cannot access a network pharmacy
- The member cannot fill a prescription for a covered Part D drug in a timely manner within the service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24-hour-a-day/7-day-a-week service
- The member must fill a prescription for a covered Part D drug in a timely manner, and the particular covered Part D drug (for example, an orphan drug or other specialty pharmaceutical typically shipped directly from manufacturers or special vendors) is not regularly stocked at accessible network retail or mail-order pharmacies
- The member is provided covered Part D drugs dispensed by an OON institution-based pharmacy while he or she is a patient in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting, and as a result cannot get their medication filled at a network pharmacy
- The member is receiving a vaccine that is medically necessary but is not covered by Medicare Part B that is appropriately dispense and administered in a physician office
- During any state or federal disaster declaration or other public health emergency declaration in which the member is evacuated or otherwise displaced from their place of residence and cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy
- MeridianComplete applies OON policies for unexpected situations in which normal distribution channels are unavailable
Before obtaining a covered Part D drug through an OON pharmacy, it is the responsibility of the member:
- To contact MeridianComplete to ensure that there are no network pharmacies within reasonable distance where he/she can fill the prescription
When a member uses an OON pharmacy, the pharmacy may not be able to submit the claim directly to MeridianComplete. In this instance, the member is required to pay the OON pharmacy’s usual and customary (U&C) price at the point-of-sale and submit a written request for reimbursement to MeridianComplete. The pharmacy may also contact MeridianComplete to obtain an OON pharmacy override.
Note: If a member uses an OON pharmacy, the member may be financially responsible for the sum of:
- Any deductible or cost-sharing
- Any differential between the OON pharmacy’s U&C prices and the MeridianComplete negotiated in-network charge for the medication
MeridianComplete does not reimburse members for any prescriptions that are filled by pharmacies outside of the United States, even for a medical emergency.
MeridianComplete does not reimburse members for any fee or charge for vaccine administration that falls entirely outside the Part D cost sharing structure.