This section is a user guide to your LM HealthWorks Plan that takes you step-by-step through the process of seeking care and using your benefits

How to Seek Care, In Network

Follow these steps for in-network care

Show your medical ID card.`
In most cases, you pay nothing at the time of your visit.
Some doctors may ask for payment at the time you receive services. Here’s what you should know — and what you can do — if this happens.
In order for benefits to be paid, a claim must be filed. Your in-network provider takes care of this for you.
Once your provider’s office files a claim, you will receive a Monthly Claims Summary by mail or online that shows the total charge for care and the amount the plan will pay. It also shows how much of the deductible you’ve met including any amount from your HealthFund applied, and how much remains to be met.
You pay your share of covered expenses as shown on your EOB when your provider’s office sends you the bill. Here’s how it is determined what your share of covered expenses would be:
If there’s a balance in your HealthFund, the appropriate amount is withdrawn automatically to pay your share of the expense. This amount is also applied toward your calendar year in-network deductible.
If your HealthFund balance is depleted before the deductible is met, you pay for care out of your own pocket until it’s met. This is also true if there’s a zero balance in your HealthFund at the time an expense is incurred.
After the deductible is met, you and the plan share in the cost of your care. You pay a percentage of your expense (called coinsurance). For covered preventive care services, the plan typically pays 100% with no deductible. The Benefits Summary chart shows how you and the plan share expenses.

Remember: Once you’ve met your annual deductible and met the out-of-pocket maximum, the plan pays 100% for covered expenses.*

Once you become a member of the LM HealthWorks Plan and register for the Aetna member website, you can check the status of a claim and progress toward your deductible at the Aetna member website. If the provider bill and your EOB are not showing the same amount you should pay out of pocket, call the LM HealthWorks Plan at 1-877-458-4975 for further clarification.

* Excludes prescription drugs. You do not have to meet a deductible before the plan pays prescription drug benefits.

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