Out-of-Network Coverage Rules
Usually, ICS Community Care Plus FIDA-MMP will not cover services or items from a provider who has not joined ICS Community Care Plus FIDA-MMP’s network. There are, however, certain circumstances under which this rule does not apply, listed below. To learn about getting approval to see an out-of-network provider, see the Participant Handbook for complete information.
- The plan covers emergency or urgently needed care from an out-of-network provider in certain situations.
- If you need care that our plan covers and our network providers cannot give it to you, you can get the care from an out-of-network provider. In this situation, we will cover the care as if you got it from a network provider and at no cost to you.
- The plan covers services and items from out-of-network providers and pharmacies when a provider or pharmacy is not available within a reasonable distance from your home.
- The plan covers kidney dialysis services when you are outside the plan’s service area for a short time. You can get these services at a Medicare-certified dialysis facility.
When you first join ICS Community Care Plus FIDA-MMP, you can continue seeing the providers you see now during the “transition period.” In most cases, the transition period will last for 90 days or until your Person-Centered Service Plan is finalized and implemented, whichever is later. However, your out-of-network provider must agree to provide ongoing treatment and accept payment at our rates. After the transition period, we will no longer cover your care if you continue to see out-of-network providers.
If you are a resident of a nursing facility, you can continue to live in that nursing facility for the duration of the FIDA Program, even if the nursing facility does not participate in ICS Community Care Plus FIDA-MMP’s network.
If you are receiving services from a behavioral health provider at the time of your enrollment, you may continue to get services from that provider until treatment is complete, but not for more than two years.