Out-of-Area Care

Your Preferred Care health plan provides coverage for emergency or urgent care when you are outside the Preferred Care service area. This is called out-of-area care. The Preferred Care service area includes Monroe and the eight surrounding counties – Genesee, Orleans, Wyoming, Livingston, Wayne, Yates, Seneca, and Ontario.

Emergency care does not need to be approved before you get care. An emergency is the start of a severe medical or behavioral condition that begins suddenly, with symptoms serious enough that a person with a basic understanding of medicine and health would think the following might happen if urgent medical help is not received:

• the health of the person is in danger;
• in the case of a behavioral condition, the health of the person or others is in danger;
• serious harm to a person's bodily functions;
• serious injury to organs or another part of the person; or
• serious disfigurement to the person.

An example of an emergency is chest pains. If you think you are facing an emergency, go to a hospital right away or call 911.

Urgent care is to treat minor illness or injury. An example of an urgent situation is the flu or a minor cut. You may not consider these situations an emergency but believe you need to get care quickly. You do not need to get a referral for urgent care if you receive care at an urgent care center. If you need to get urgent care at a doctor’s office, make sure to call your PCP for a referral before visiting the doctor’s office.

Routine or elective care received outside the Preferred Care service area is not covered by your health plan. An example of routine care is an annual check-up. Preferred Care needs to arrange and authorize any routine care you may get outside of the service area.

Certain Preferred Care health plans offer added out-of-network benefits. Routine care may be covered outside the service area if you have a plan that offers this benefit. Check your contract or certificate for more information.

Out-of-Area Care for College Students

Students who are Preferred Care members and attend school outside the service area are covered for emergency and urgent care only. It is important for the student to have his or her Preferred Care member ID card.

In an emergency situation, the student should go to the emergency room right away or call 911. If a student needs care but is not sure emergency care is needed, he/she should go to the school medical center first. The doctor will send the student to the hospital emergency room if necessary. If urgent care is appropriate, the doctor will direct the student to an Urgent Care Center. Preferred Care will cover the urgent or emergency care in both cases.         

If urgent care is needed, the student will have to choose a local doctor (near their school) to visit for this care. If the student wishes to go to a doctor’s office for treatment, a referral from their PCP is necessary.

The student needs to call his/her Primary Care Physician (PCP) if post-emergency follow-up care is needed. The PCP will call the medical team at Preferred Care for a decision about whether out-of-area follow-up care will be covered.

College students that attend school outside the service area may be covered for necessary and pre-approved follow-up care like allergy shots or physical therapy.

Last updated: July 19, 2006