Did you know all City of Houston’s Cigna Health Plans provide a Transition of Care and Continuity of Care provision that can be applied when a Cigna Plan participant is in the middle of care with a plan provider whose Cigna contract has terminated? This special provision allows Cigna Plan participants to request in-network benefits/cost sharing from an out-of-network provider.
What is Transition of Care?
With Transition of Care, you may be able to continue to receive services for specified medical and behavioral conditions with health care providers who are not in our network at in-network coverage levels. This care is for a defined period of time until the safe transfer of care to an in-network provider or facility can be arranged.
You must apply for Transition of Care at enrollment.
You must apply no later than 30 days after the effective date of your coverage.
What is Continuity of Care?
With Continuity of Care, you may be able to receive services at in-network coverage levels for specified medical and behavioral conditions in certain circumstances. These include when your health care provider leaves your plan’s network or if/when you have been notified by your employer that you may qualify for Continuity of Care or your employer changes health care plans and the immediate transfer of your care to another provider would be inappropriate and/or unsafe. This care is for a defined period of time. You must apply for Continuity of Care within 30 days of your health care provider’s termination date. This is the date that he or she is leaving your plan’s network.
How they both work
- You must already be under treatment for the condition identified on the Transition of Care/Continuity of Care request form.
- If the request is approved for medical or
- You will receive the in-network level of coverage for treatment of the specific condition by the health care provider for a defined period of time, as determined by us.
- If your plan includes out-of-network coverage and you choose to continue care out-of-network beyond the time frame approved by us, you must follow your plan’s out-of-network provisions. This includes any precertification requirements.
- Transition of Care/Continuity of Care applies only to the treatment of the medical or behavioral condition specified and the health care provider identified on the request form. All other conditions must be cared for by an in-network health care provider for you to receive in-network coverage.
- The availability of Transition of Care/Continuity
- Does not guarantee that a treatment is
- Does not constitute precertification of medical services to be provided.
- Does not guarantee that a treatment is
- Depending on the actual request, a medical necessity determination and formal precertification may still be required for a service to be covered.
Examples of acute medical conditions that may qualify for Transition of Care/Continuity of Care include, but are not limited to:
- Pregnancy in the second or third trimester at the time of the plan effective date or of the health care provider termination.
- Pregnancy is considered high risk if mother’s age is 35 years or older, or patient has/had:
- Early delivery (three weeks) in previous pregnancy.
- Gestational diabetes.
- Pregnancy induced hypertension.
- Multiple inpatient admissions during this pregnancy.
- Newly diagnosed or relapsed cancer in the midst of chemotherapy, radiation therapy or reconstruction.
- Transplant candidates, unstable recipients or recipients in need of ongoing care due to complications associated with a transplant.
- Recent major surgeries still in the follow-up period, that is generally six to eight weeks.
- Acute conditions in active treatment such as heart attacks, strokes or unstable chronic conditions.
- “Active treatment” is defined as a provider visit or hospital stay with documented changes in a therapeutic regimen. This is within 21 days prior to your plan effective date or your health care provider’s termination date.
- Hospital confinement on the plan effective date (only for those plans that do not have extension of coverage provisions).
- Behavioral health conditions during active treatment.
Examples of conditions that do not qualify for Transition of Care/Continuity of Care include, but are not limited to:
- Routine exams, vaccinations and health assessments.
- Stable chronic conditions such as diabetes, arthritis, allergies, asthma, hypertension and glaucoma.
- Acute minor illnesses such as colds, sore throats and ear infections.
- Elective scheduled surgeries such as removal of lesions, bunionectomy, hernia repair and hysterectomy.
What time frame is allowed for transitioning to a new in-network health care provider?
If we determine that transitioning to an in-network health care provider is inappropriate or unsafe for the conditions that qualify, services by the approved out-of- network health care provider will be authorized for a specified period of time (usually 90 days). Or, services will be approved until care has been completed or transitioned to an in-network health care provider, whichever comes first.
If I am approved for Transition of Care/Continuity of Care for one illness, can I receive in-network coverage for a non-related condition?
In-network coverage levels provided as part of Transition of Care/Continuity of Care are for the specific illness or condition only and cannot be applied to another illness or condition. You need to complete a Transition of Care/Continuity of Care request form for each unrelated illness or condition. You need to complete this form no later than 30 days after your plan becomes effective, your health care provider leaves your plan’s network or you have been notified by employer that you may qualify for Continuity of Care.
Can I apply for Transition of Care/Continuity of Care if I am not currently in treatment or seeing a health care provider?
You must already be in treatment for the condition that is noted on the Transition of Care/Continuity of Care request form.
How do I apply for Transition of Care/Continuity of Care coverage?
Requests must be submitted in writing, using the Transition of Care/Continuity of Care request form. This form must be submitted at the time of enrollment, change in medical plan, or when your health care provider leaves the our network. It cannot be submitted more than 30 days after the effective date of your plan, your health care provider’s termination or after you have been notified by your employer that you may qualify for Continuity of Care. After receiving your request, we will review and evaluate the information provided. Then, we will send you a letter informing you whether your request was approved or denied. A denial will include information about how to appeal the determination.
If you have questions about Transition or Continuity of Care or would like to learn more about the process to apply, please reach out directly to your dedicated City of Houston’s Cigna On-Site Representative or Customer Service line as listed below. Please note Cigna On-Site Representatives are assigned based on plan participant’s last name.
- A-F: Walter Ariel Iriarte - 832-393-6305
- G-M: Maria Rodriguez - 832-393-6193
- N-Z: Ivan Flake - 832-393-6191
- Team Lead - LaKeitha Johnson - Escalations Only 832-393-6192
- 800-997-1406 (same number on the back of your Cigna ID Card)