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How to continue treatment when your health plan changes

Say you are five months pregnant and, uh-oh, your employer is changing health insurance plans. Your obstetrician is no longer part of your health plan's network. A reason to panic? Not necessarily, health insurance experts say.

If you take the proper steps, chances are you will be able to continue seeing your doctor until you deliver, and for any post-pregnancy follow-up you need.  Your new health plan should treat these remaining medical bills as if you received in-network care.

Not all health insurance plans are the same and you should check your policy and with your health insurer, says Anjanette Coplin, a spokesperson for Aetna. Here's what would happen in this scenario if, for example, you had Aetna:

  • If your plan changes and you want to stay with your doctor, you will need to apply for transition of care. "The member must submit a transition of care request, typically signed by her doctor, before the change in plans is made," Coplin says.

Transition of careThere are some caveats to be eligible to apply for transition of care for pregnancy:

  • You need to be at least 20 weeks pregnant unless your state or plan requirements are different.
  • Or, you are less than 20 weeks but are considered and documented to be high risk by your providers.

Pregnancy isn't the only reason you might apply for a transition of care from your health insurer. Transition of care applies to treatments for a diagnosed condition that has a defined number of services or periods of treatment and includes a qualifying situation, Coplin says.

Here are examples of situations that are likely to qualify for transition of care and allow you to remain with your original doctors or other providers even when they are no longer in your health plan:

  • Chemotherapy or radiation therapy.
  • Out-patient intravenous therapy for a resolving condition.
  • Surgeries that are performed in stages.
  • Treatment for a mental illness or for substance abuse.
  • Post-surgical care.
  • An organ or bone marrow transplant.

If your transition of care request is granted, you will be able to continue to see the health care providers who started your treatment. You will receive the treatments without penalty at your preferred plan benefit level. For example, if your request is approved and you have an HMO, you would be covered at the in-network benefit level regardless of whether your doctor is still part of your HMO network.

Transition of care requests

You’ll likely start the process by filling out your insurer’s transition of care request form. Here’s an example of one for Aetna.

Each request is reviewed on a case-by-case basis, Coplin says. Requests are reviewed by the insurer's staff in consultation with the medical director. After the review is complete, you will receive a letter confirming whether your request for coverage under transition of care has been approved.

You can continue to see your doctors for a transitional period only. You won't be granted an exemption forever, Coplin says.

As with pregnancy, you must be undergoing an "active course of treatment" that started prior to the enrollment date of your new plan. Coplin explains that an active course of treatment is a program of planned services provided by a specialty provider. The date the treatment starts is the day you receive a service or treatment for your diagnosed condition.

Get approval before you continue treatments

Your health insurance company is likely to ask your doctor to sign your transition of care request. It is important that you follow these steps before you continue your treatment. "In order for claims to be paid at the in-network level during the transition of care process, Aetna must approve any treatment prior to the treatment being rendered," Coplin says.

It may take some time to get the approval (in some cases 15 days for non-urgent care, depending on your health plan and your state), so be sure to allow for that. Apply for transition of care as soon as you can.

Get your doctor to help

Martin Rosen, executive vice president of Health Advocate in Plymouth Meeting, Pennsylvania, a health care advocacy and assistance company, suggests you ask your doctors to go to bat for you if you want to continue receiving care from them.

"The reality is that expertise really matters," Rosen says. That's why having your doctor explain to your insurance company why you need to stay under his or her care is better than trying to do it yourself, he says. "Most physicians are more than aware and understand this challenge. They have lots of experience with it."

Also, you are more likely to win the battle if your case is well documented and you have determined that you are seeking benefits to which you would be entitled had your plan not changed, says Rosen.

Rosen says most insurance companies do as Aetna does and allow women, if they are in their third trimester, to continue to see the provider with whom they started. "If your obstetrician is not in your new network, the insurance company will likely make arrangements for you in large part because of the general view that it would be deleterious to the health of the mother if you didn't continue with the same care."

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