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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that when you become a member of our plan, you must choose a plan provider to be your primary 
care physician (PCP). Your PCP is a provider who meets state requirements and is trained to give you basic 
medical care. Your Provider Directory will indicate which providers may act as your PCP. As we explain 
below, you can get your routine or basic care from your PCP. Your PCP can also coordinate the rest of the 
covered services you get as a plan member. For example, in order to see a network specialist, you usually need 
to get your PCP's approval first (this is called getting a "referral "to a specialist). This includes: 
 X-rays 
 Laboratory tests 
 Therapies 
 Care from doctors who are specialists 
 Hospital admissions 
 Follow-up care 
 
"Coordinating" your services includes checking or consulting with other plan providers about your care and 
how it is going. If you need certain types of covered services or supplies from network providers, you must get 
approval in advance from your PCP (such as giving you a referral). In some cases, your PCP will need to get 
prior authorization (prior approval). Chapter 4 has more information on which services require prior 
authorization.  
 
Since your PCP can provide and coordinate your medical care, you should have all of your past medical 
records sent to your PCP's office. Chapter 8 tells you how we will protect the privacy of your medical records 
and personal health information. 
 
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are 
many kinds of specialists. Here are a few examples: 
 Oncologists care for patients with cancer 
 Cardiologists care for patients with heart conditions 
 Orthopedists care for patients with certain bone, joint, or muscle conditions 
 When your PCP thinks that you need specialized treatment, he/she can give you a referral to see a specialist or 
certain other providers in the plan's network. If you are seeing a network specialist for your care, you may need 
to return to your PCP for a referral for additional services. For some types of services, your PCP may need to 
get approval in advance from our plan (this is called getting "prior authorization"). See Chapter 4, Section 2.1 
for information about which services require prior authorization. 
 
It is very important to get a referral (approval in advance) from your PCP before you see a specialist or certain 
other providers in the plan's network (there are a few exceptions, including women's health care that we 
explained earlier in this section). If you don't have a referral (approval in advance) before you get services from 
a network specialist, you may have to pay for these services yourself. If the network specialist wants you to 
come back for more care, check first to be sure that the referral (approval in advance) you got from your PCP 
for the first visit covers more visits. If there are specific specialists in the plan's network you want to use, find 
out whether your PCP sends patients to these specialists. Each plan PCP has certain network specialists they 
use for referrals. This means that the PCP you select may determine the specialists you may see. You may 
generally change your PCP at any time if you want to see a network specialist that your current PCP can't refer 
you to. Earlier in this section, under Changing your PCP," we explained how to change your PCP. If there are 
specific hospitals you want to use, you must first find out whether your PCP, or the doctors you will be seeing, 
uses these hospitals. You can find these rules on pages 31-35 of the Plan's 2023 EOC. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.