Transition of care when you change carriers: keeping employees in treatment from being disrupted.
Who is most at risk when a group switches carriers, how to ask for continuity-of-care help, what to collect from employees ahead of time and how to plan the timeline. Written for the owner or HR lead.
A New Carrier Means a New Network
A switch can save money, and it can also disrupt care for employees in the middle of treatment.
Who Is Affected
Employees in cancer treatment, pregnancy, dialysis, behavioral health care, or after recent surgery are most affected. Their care is often scheduled months ahead, so a mid-treatment network change can mean cancelled appointments or higher bills. Identify these needs before the decision, without asking anyone to disclose a diagnosis to the employer.
Prescriptions Too
A new formulary can change coverage, prior authorization and cost for ongoing medications. Compare the medications employees use with the new drug list, and look at which ones need approval first or have changed tiers. A drug that is covered can still cost far more under a different tier.
Disruption Becomes a Retention Issue
Employees remember who was in charge when their treatment was interrupted. A long wait for approval or an unexpected bill during treatment is remembered long after the plan year. Build a transition plan into the decision so employees in ongoing care know what to do before the effective date.
What to Ask the New Carrier
Many carriers offer a transition period for members in active treatment, but rules differ.
Transition Period Rules
Ask how long the carrier will cover an out-of-network provider after the switch, and which conditions qualify. Carrier policies vary on length and on which conditions qualify, and some require the provider to join the network. Get the answer in writing, and ask whether the period resets when a member changes plans.
The Request Process
Ask whether members or providers file the request, what form is used and how long approval takes. A request process that is hard to find can make an approved right useless. Ask who files it, how soon it must be submitted and whether the member can follow its status, then tell employees where to start.
Get It in Writing
Ask for the transition-of-care policy as part of the proposal, not after enrollment. Verbal assurances from a sales representative do not help if a claim is denied later. Review the written policy with your broker, and keep a copy to share with employees who ask.
Prescription Continuity
Formulary differences are one of the most common sources of complaints after a switch.
Compare Formularies Early
Check the top medications your employees use against the new formulary before deciding. Run the list of common drugs, and the most expensive ones, against the formulary before you sign. Ask the carrier about coverage tiers, limits on quantity and step therapy, since a drug on the list can still be hard to get.
Transition Fills
Ask whether the carrier provides a one-time supply of a drug that is not covered or needs prior authorization. Ask how long the supply lasts, how the member requests it and whether it applies only to new members. Have employees contact the pharmacy ahead of time so a first fill does not become a last-minute problem.
Specialty Drugs
Specialty medications deserve a line-by-line review, with attention to who dispenses them. Ask which specialty pharmacy the carrier requires, how members change over, and whether there is a copay assistance program in the plan. Employees on these drugs need a named contact to coordinate the transfer.
Build a Transition Plan
A few steps well before the effective date prevent most problems.
Survey Employees Confidentially
Ask employees who are in ongoing treatment to contact a designated person, without requiring them to give medical details to the employer. Make participation voluntary and name a person outside the employee’s chain of command, such as an HR contact or a benefits adviser. Explain that the information is used to help with the transition, not to make employment decisions.
Share Information with the Carrier Properly
Health information goes through the member and carrier case management channels, not through the employer. Employees can work with the carrier’s care management team to protect their treatment plans. HR should provide the contact information and avoid collecting diagnoses, since health information has special privacy protections.
Set a Support Contact
Name one person or number who can help employees during the first 90 days. Make sure the person is trained and has access to the carrier contacts and the new plan details. Tell employees how to reach them, and share the contact in every message about the change.
Claims Run-Out and Overlap
Coverage ends under one carrier and starts under another, with claims still in motion.
Run-Out Period
Claims incurred under the old carrier are processed after termination within a run-out period. Know the deadline. Confirm with the old carrier or administrator how long claims can be submitted, and tell providers and employees who ask. Missing the deadline can leave members with bills, so mark the date in your calendar and share it with HR.
Deductible Credit
Some carriers give credit for amounts already paid toward the deductible. Others do not. Ask. Credits are not automatic, and the rules vary on timing and documentation. Ask what proof members need and who submits it, then tell employees so they keep their statements from the old plan.
Communicate Both Dates
Tell employees the end date of the old coverage and the start date of the new one. Include both dates in every notice, along with what to do with old cards and where to find new ones. Employees who see a gap on the calendar will ask, so address it up front.
The questions that come from carrier changes.
Six questions employers bring us about transition of care.
What is transition of care?
A carrier arrangement that lets members keep seeing a provider for a limited time after a network change.
Is it standard across carriers?
Practices differ. Ask for the policy in writing.
Who requests the transition?
Often the member or provider, through the carrier’s process. Confirm the steps.
Will deductibles carry over?
Not always. Some carriers credit amounts already paid, others do not.
Should employees tell us their diagnosis?
No. They should contact the carrier directly and the employer should only name a contact.
When should we start planning?
Before you choose the carrier, so the transition rules can be part of the decision.
Ready? Send us your renewal, or talk it through with someone first. No cost, no obligation.
General information about continuity of care, not legal advice. Transition protections vary by carrier and state, so confirm them in writing before you sign.
Related guides.
Changing Carriers
What to compare when you move a group.
Formulary Strategy
Reviewing drug coverage before a switch.
Denied Claims and Appeals
Helping employees with claim problems.
Send us your renewal.
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The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
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