Close to home or far away.

Understanding your out-of-network coverage.

Whether you are traveling or simply need fast care close to home, the US Family Health Plan includes coverage for emergency and urgent care services at in-network levels, even when received from out-of-network providers. Learn what types of care are covered out of network, and what to know about payment, reimbursement, and routine care.

Urgent care (in-person and telehealth).

Out-of-network urgent care services for minor illnesses and injuries are covered at the in-network level in the U.S. and internationally. These services do not require a referral. Examples may include urgent care for:

• Earaches
• Sore throats
• Minor cuts or burns
• Sprains
• Rashes
• Urinary tract infections

Telehealth may also be an option for certain non-emergency medical needs. Included Health, Inc. is a convenient way to receive high-quality care from a licensed health care provider by video 24/7 with little to no wait time. Register for Included Health.

Emergency care within the U.S.

Within the U.S., out-of-network emergency care for serious or life-threatening conditions is covered at the in-network level, including related hospitalization when medically necessary.

Emergency care outside the U.S.

Outside of the U.S., emergency care and related hospitalization required to stabilize the emergency condition is covered at the in-network level. Contact Member Services if you would like more coverage information before international travel.

Payment/reimbursement for out-of-network urgent/emergency care.

When receiving services from out-of-network providers, present your US Family Health Plan member ID card as some providers may bill Martin’s Point directly for services. If not, you may be asked to make full payment at the time services are received, particularly for international care. If you paid out of pocket for covered emergency or urgent care services with an out-of-network provider, you may request reimbursement from the plan.

To request reimbursement, you will need to submit a completed Medical Reimbursement Form and copies of:

• Itemized bill
• Proof of payment
• Medical Records

Follow-up care after an emergency or hospitalization.

Some follow-up care related to a covered emergency visit or hospitalization may also be covered when received outside of the network. Coordinate with your primary care provider (PCP) for ongoing care or additional services.

Routine and non-emergency care

Routine care is generally expected to be provided by your network PCP or other network specialist(s) for coverage. If medically necessary care is not available in the network, your provider can seek prior authorization for care outside of the network. This may be waived if medically necessary services are not available in-network in your area. Your provider will need to seek prior authorization for coverage in this situation.

If you would like to receive non-urgent/non-emergency services from an out-of-network provider, even when an in-network provider is available to deliver those services, you may have coverage under your plan’s Point-of-Service (POS) benefit with higher out-of-pocket member costs. For information about the POS benefit and receiving specialty care outside of the network, visit martinspoint.org/pos.

Coverage for college students.

College students enrolled in the US Family Health Plan must continue to receive routine care through their network PCP. If they need to see out-of-network providers for urgent/emergency care while at school, the coverage rules noted above apply.

Call Member Services if you have questions at 1-888-674-8734 (TTY: 711).