Medical Transition of Care

"I’m currently in a course of treatment with a doctor who does not belong to the plan’s network. Can I stay with this doctor?"

Yes, you can in most cases. But because your doctor is an out-of-network provider, benefits will be paid at a lower level, meaning you may pay more for your care. However, there’s a plan provision called Transition of Care that may help. Under this provision, you may be able to continue a course of treatment with an out-of-network provider for a limited period of time — and receive benefits at the in-network level.

Here’s what you need to know and do:

• You must be in an active course of treatment that started before the day your coverage became effective under the LM HealthWorks Plan. An active course of treatment is a program of planned services that starts on the first day your doctor provided treatment for your condition and continues to cover a certain number of services or treatment period. The treatment you’re receiving also must be eligible for Transition of Care.

Here are some examples in which a person may be eligible for 
Transition of Care Coverage:

• In an ongoing treatment plan, such as chemotherapy or radiation therapy.
• Diagnosed with a terminal illness and expected to live six months or less.
• Needing more than one surgery, such as cleft palate repair.
• Having an ongoing or disabling condition that suddenly gets worse.
• Having had surgery recently.
• Receiving outpatient treatment for a mental illness or for substance abuse (must have had at least one treatment session within 30 days before the plan’s effective date).
• May need or have had an organ or bone marrow transplant.

You must apply for Transition of Care Coverage and be approved. Transition of Care Coverage may be contingent upon agreement between the LM HealthWorks Plan administrator and your existing physician.

How to apply for Transition of Care Coverage

If you meet one or more of the eligibility requirements listed above, you can apply for Transition of Care coverage in order to have benefits paid at the in-network level for out-of-network care for a limited period of time. You will need to complete** a Transition Coverage Request form within 90 days of enrolling or re-enrolling in the LM HealthWorks Plan. You can click here to download the form. Then follow these steps:

1. Be sure to complete Sections 1, 2 and 3 of the form, and sign and date the form.
2. Give the form to your doctor to complete Section 4.
3. Fax the completed form to Aetna, using the appropriate fax number printed on the form.

Aetna will outreach to you once the decision regarding your request has been processed and you’ll receive a coverage decision letter in the mail.

Consider nominating your doctor for network membership

If you are receiving ongoing care from an out-of-network doctor, you may want to consider nominating him or her for membership in the network. Learn more.

* Transition of Care coverage applies to services included in the plan only. Although you’ll receive benefits at the in-network level from an out-of-network provider, you will be responsible for any costs in excess of the recognized charge.
** You should also complete and submit the Transition of Care form within 90 days of the date your provider left the network or 90 days of a doctor’s Aexcel of IDF home host network status change.

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