Out-of-Network Coverage Rules

 

It’s important to understand your benefits when receiving services from doctors who are outside of our provider network.

Freedom of Choice with our PPO Plans

At Clover Health, we understand that your relationship with your doctor is very important and we believe you have the right to receive care where you are most comfortable. That’s why we give you the opportunity to make choices for greater control of your healthcare costs.

You can choose a provider from the Clover PPO network and have low copays. Your costs will be easy to plan for with less need to worry about unexpected medical bills. But you also have the freedom to go to out-of-network doctors, specialists, or hospitals; you may have to pay higher costs. The choice is yours.

In-Network Versus Out-of-Network Providers

Using in-network doctors and facilities will allow you to take advantage of discounted rates. In-network health providers have agreed to a set price for each treatment or procedure.

You will still have insurance coverage for out-of-network providers, but you may have a higher cost-share.

Tip: When calling an out-of-network provider to see if they accept your Clover plan, ask, “Do you accept an out-of-network PPO Medicare plan?” If the answer is yes, they will know how to bill Clover.

Please note: providers that do not contract with us are under no obligation to treat you, except in emergency situations. Our plan will cover services from out-of-network providers, as long as the services are covered benefits and are medically necessary. “Medically necessary” means the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition, and meet all accepted standards of medical practice.

You may contact us in advance of any service or procedure to confirm it will be covered by our plan by calling 1-888-778-1478 (TTY 711) 8 am–8 pm (local time), 7 days a week*. Please note, if you use an out-of-network provider, your share of the costs for your covered services may be higher. In addition, if you move forward with a service or procedure that is not medically necessary with an out-of-network provider, you will be responsible for the full cost.

For HMO Plans

As a member of a HMO plan, you must use network providers to get your medical care and services. The only exceptions are emergency or urgently needed services, out-of-area dialysis services, and when Clover Health authorizes the use of out-of-network providers.

Please be advised, if you obtain routine care from an out-of-network provider without our authorization, you will be responsible for the full cost. For assistance locating a network provider, please call Member Services at 1-888-778-1478 (TTY 711), 8 am–8 pm local time, 7 days a week*, or visit our Provider Search page.