2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 62
AETNA INSTITUTE OF EXCELLENCE (IOE) PROGRAM
The Institute of Excellence (IOE) is a facility that contracted with Aetna to furnish particular services and supplies
to you in connection with one or more highly specialized medical procedures. The maximum charge made by the
IOE for such services and supplies will be the amount agreed to between Aetna and the IOE. Your Participating
Provider should confirm if there is an Institute of Excellence (IOE) for your condition.
Transplant Expenses
Once it has been determined that you or one of your eligible Dependents may require an organ transplant, you or
your Physician must call the Medical Management and Precertification Program Administrator to discuss
coordination of your transplant care. Aetna will coordinate all transplant services. In addition, you must follow any
precertification requirements. Organ means solid organ; stem cell; bone marrow and tissue.
Benefits may vary if an IOE facility or a non-IOE facility is used. In addition, some expenses listed below are payable
only within the IOE network. The IOE facility must be specifically approved and designated by Aetna to perform the
procedure you require. A transplant will be covered at the Participating Provider level only if performed in a facility
that has been designated as an IOE facility or that is an Aetna Participating Provider facility that has a single case
rate agreement between an Aetna Participating Provider and Aetna for the type of transplant in question. Any
treatment or service related to transplants that are provided by a facility that is not specified as an IOE network
facility or that is not an Aetna Participating Provider facility that has a single case rate agreement between an Aetna
Participating Provider and Aetna, even if the facility is considered a Participating Provider for other types of services,
will be covered at the Non-Participating Provider level. Please read each section below carefully.
Covered Transplant Expenses
Covered transplant expenses include the following:
(1)
Charges for activating the donor search process with national registries.
(2)
Compatibility testing of prospective organ donors that are immediate family members. For purposes of this
section an “immediate” family member is defined as a first-degree biological relative. These are your biological
parent, sibling or child.
(3)
Inpatient and outpatient expenses directly related to a transplant.
(4)
Charges made by a Physician or a transplant team.
(5)
Charges made by a Hospital, outpatient facility or Physician for the medical and surgical expenses of a live
donor, but only to the extent not covered by another plan or program.
(6)
Related supplies and services provided by the IOE facility during the transplant process. These services and
supplies may include: physical, speech and occupational therapy; bio-medicals and immunosuppressants;
home health care expenses and home infusion services.
Covered transplant services are typically Incurred during the 4 phases of transplant care described below.
Expenses Incurred for one transplant during these 4 phases of care will be considered one transplant occurrence.
A transplant occurrence is considered to begin at the point of evaluation for a transplant and end either: (1) 180
days from the date of the transplant; or (2) upon the date the patient is discharged from the Hospital or outpatient
facility for the admission or visits related to the transplant, whichever is later.
The 4 phases of one transplant occurrence and a summary of covered transplant expense during each phase are
as follows:
(1)
Pre-transplant evaluation/screening. Pre-transplant evaluation screening includes all transplant-related
professional and technical components required for assessment, evaluation and acceptance into a transplant
facility’s transplant program.
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