CareAdvantage Dual Eligible Special Needs Plan (D-SNP) 2024

Emergency Medical Care

What is a medical emergency?

A medical emergency is a medical condition that could result, without immediate medical attention, in any of the following:

• Severe pain or injury posing a danger to health 
• Critical dysfunction of any bodily functions, organs or parts
• For a pregnant woman in labor, when transfer to another hospital could endanger the health or safety of the mother or child

Follow-up care

The doctors who give you emergency care will decide when your condition is stable and the medical emergency is over. Then they may want you to stay in the hospital a while longer for "post-stabilization services" until you are healthy enough to go home. A Care Manager will talk with the doctors who gave you emergency care to help manage and follow up on your care. If you get emergency care from out-of-network providers, we will try to get network providers to take over your care as soon as possible. 

• It is important that you carry your CareAdvantage ID card at all times so a non-contracted hospital can get approval for your post-stabilization care
• CareAdvantage may not pay for unauthorized post-stabilization care or related transport provided by a non-contracted hospital or provider
• If your doctor says you can be safely moved to a network hospital, we will arrange and pay for your transfer to a CareAdvantage network hospital or nursing facility

What if it wasn't a medical emergency after all?

Sometimes you might go in for emergency care and the doctor will say it wasn’t a medical emergency. As long as you reasonably thought your health was in serious danger, we will cover your care. However, after the doctor says it was not an emergency, we will cover your follow-up care only if you go to a network provider or it is considered urgently needed care.

Urgently needed care

Urgently needed care is care you get for a sudden illness, injury or condition that isn't an emergency but needs care right away. For example, you might have a flare-up of an existing condition and need immediate treatment. The preferred way to access urgent care is to contact your PCP, who will tell you where to go. If you cannot contact your PCP in a timely manner, you may go straight to an urgent care center.

Outside of the CareAdvantage Service Area

In most situations, we will cover urgently needed care only if you get this care from a network provider and you follow the other rules described in this section. However, if you can't get to a network provider in a timely manner, we will cover urgently needed care from an out-of-network provider.

If you are outside of the CareAdvantage service area, we will cover urgently needed care you get from any provider. 

Getting Care During a Disaster

If the state or federal government declares a state of disaster or emergency in your geographic area, CareAdvantage will cover care from out-of-network providers and prescriptions filled at non-network pharmacies.

Search for a provider

Use the online provider search form to find the latest information for in-network primary care providers (PCP), specialists, pharmacies, clinics or hospitals. This directory is updated weekly.  You may need a referral from your PCP before making an appointment with a specialist for non-emergency care. Call your PCP to find out if a referral is required.