How The CIGNA Plans Work
All three CIGNA medical plan options provide comprehensive medical coverage. The Plans provide benefits for your covered medical expenses when you are diagnosed and treated for a non-occupational illness or accidental injury.
If you are injured or become ill as of a result of a work-related incident, you may be eligible for Worker's Compensation benefits, including medical benefits. If you suffer a work-related illness or injury, you should contact your manager. He or she will arrange medical care for you and report the incident. For more details, see Survivor and Disability.
However, the Plans differ in several significant areas, as outlined in the following sections.Back to Top
Choice Of Doctor Or Provider
CIGNA Low Option PPO Open Access Plus (OA+) Plan and CIGNA High Option PPO Open Access Plus (OA+) Plan—Individuals enrolled in one of these plans may visit any qualified medical provider. However, the Plans pay higher benefits when a "network" provider is used. Both PPO Plans use the Open Access Plus network, and you can keep your out-of-pocket costs down when you use providers in the network.
CIGNA Network HMO Plan—Individuals enrolled in this Plan must use network providers and/or have their care coordinated by their primary care physician (PCP). Female participants may obtain services directly from their obstetrician/gynecologist without having to confer with their PCP. No benefits are paid for unapproved non-network care. There is one exception: Benefits will be paid if emergency care is received outside the HMO network due to medical necessity.Back to Top
Pre-Existing Condition Limitations
A pre-existing condition limitation is an injury or illness for which you or a covered dependent receives treatment, incurs expenses, or receives a diagnosis within 90 days prior to the coverage effective date under this Plan. Charges relating to a pre-existing condition are not covered until you or your dependents have been covered by the Plan for one year. Pregnancy is not considered a pre-existing condition.
Under the PPO Plans, the pre-existing condition limitation applies for a one-year period. If you were covered by another health care plan within 63 days of becoming covered under the applicable PPO Plan, your prior health coverage will count toward the Plan's one-year pre-existing condition limitation period. In order to reduce a pre-existing condition limitation period, you will need to submit proof of prior coverage along with your enrollment material.
No pre-existing condition limitations apply under the Network HMO Plan. Once your coverage takes effect, the Plan will begin paying benefits for any eligible charges.
If you leave A&B, you will be entitled to receive a certificate of prior coverage, which can be used to offset any pre-existing condition limitations that may apply under your new coverage. For details, see When Coverage Ends.Back to Top
To determine what benefits you may be eligible to receive, it's important you understand the following payment provisions that apply to the administration of the Plans. These provisions include...
These payment provisions are explained in the sections below. The following table summarizes the major payment provisions.
The deductible feature applies only to the PPO Plans. The deductible is the amount you pay each calendar year before the Plan starts to pay benefits for network or non-network care.
For example, under the CIGNA Low Option PPO OA+ Plan, benefits for network and non-network care are not payable until you have met the deductible. The deductible for network services is $1,000 per individual, up to a family maximum of $3,000. If you use non-network providers, there is a separate deductible of $2,000 per individual, up to a family maximum of $6,000. Similar provisions apply to the CIGNA High Option PPO OA+ Plan, with different deductible amounts as described in the table above. Once you have satisfied your deductible, the coinsurance amounts as described below will apply, unless otherwise noted.Back to Top
Maximum Family Deductible Feature
The maximum family deductible limits the number of individual deductibles your family has to meet each year. Under the CIGNA Low Option PPO OA+ Plan, for example, when three family members satisfy the family maximum deductible, the plan will treat all family members as if they had satisfied the individual deductible. No single family member can apply more than their individual deductible amount in eligible expenses to the family deductible.Back to Top
Under the PPO Plans, a separate hospital deductible applies when a covered individual receives covered services in a non-participating hospital. This hospital deductible applies for each admission to a non-participating hospital. This deductible is separate from, and does not apply toward, the annual deductible or annual out-of-pocket maximum as described below.
The hospital deductible for non-participating hospitals is $1,000 for the CIGNA Low Option PPO OA+ Plan, and $400 for the CIGNA High Option PPO OA+ Plan.Back to Top
"Copayments" are flat dollar amounts you pay for certain covered services. After you pay the required copayment, the Plan will pay the remainder of all eligible charges. In general, when you visit the doctor, your copayment is $20. For specialist visits under the CIGNA High Option PPO OA+ (network only), your copayment is $35. Under the HMO Plan, your copayment for specialist visits is $30. Keep in mind that different plans may have different copayment levels for specialist office visits, urgent care and emergency room care.Back to Top
"Coinsurance" is the percentage of covered expenses both you pay and the Plan pays. The Plans' share of covered expenses generally range from 50% to 100%, depending on the Plan you elect. If you are enrolled in one of the PPO Plans, the coinsurance amount also depends on whether you use network or non-network providers.
The coinsurance percentages will apply until you reach your annual out-of-pocket maximum—at which point the Plan pays 100% of your covered expenses for the rest of the calendar year.
Note that the PPO and HMO plans pay benefits based on a negotiated charge when you use network providers—any charge above this amount made by the provider is not your responsibility.
In contrast, if you are enrolled in the one of the PPO Plans and use non-network providers, the Plan will pay benefits based on 110% of the maximum reimbursable charge (MRC) designated by CIGNA.Back to Top
The out-of-pocket maximum includes any copayments and coinsurance amounts you pay for your share of eligible charges. Once your share of eligible charges reaches the out-of-pocket maximum, the Plan pays 100% of most eligible expenses for the rest of that calendar year.
The following expenses do not apply toward your out-of-pocket maximum...
Lifetime Maximum Benefits
Some medical plans used to limit the amount of benefits the plans would pay in a covered individual's lifetime. In compliance with federal healthcare reform legislation, all of the CIGNA Medical Plans have an unlimited lifetime maximum for most benefits.Back to Top
When you receive eligible medical services, you or your provider must file a claim with CIGNA for benefits to be paid. In general, claims will be filed automatically when you use network providers. If you use non-network providers, you must send your medical bills and completed claim form to CIGNA for reimbursement at the address listed on the back of your ID card. You may obtain a claim form from your local Human Resources representative or online via the Company intranet.
When you complete your claim, be sure to follow the form's instructions, and include the following information...
If you seek covered services outside the United States, you will also need to include the following information with your claim...
Feel free to contact CIGNA directly at 1-800-CIGNA-24 or the toll-free number listed on the back of your ID card if you need assistance in filing a claim.
Claims-Filing Deadline And Payments
To claim benefits, you must provide written notice within 30 days after the date the illness or injury began. No benefits are payable for claims submitted after this 30-day period, unless you can show that proof was given to the Claims Administrator as soon as was reasonably possible.
Upon receiving notice of your claim, CIGNA will send you or the Company the necessary claim forms. If you do not receive the claim forms within 15 days after CIGNA receives your claim, the 30-day requirement noted above will be waived. You will then have 90 days (or as soon as reasonably possible) to provide written proof of loss that describes the occurrence, details, and extent of the loss.
The Plan has the right to request an examination of anyone filing a claim. If a medical exam is required, you will not have to pay for it.
All benefits will be paid after the Claims Administrator receives satisfactory proof of claim. Payment will be made directly to network providers, or to you when you use non-network providers. You may request that payment be made directly to the provider if you make such a request when you complete your claim form.
Note: If you are financially responsible for a dependent's medical care as specified by a court order (QMCSO), the Claims Administrator will pay the provider directly.
In the event a claim is denied you can request a review by submitting a request to the Claims Administrator within 365 days after you received notice of the denied claim. The Claims Administrator will forward your claim to the Plan Administrator for review. See What If Your Benefits Are Denied for details.Back to Top
The utilization review (UR) process is used to certify the medical necessity and length of stay for any hospital confinement. Specifically, UR applies to:
Pre-Admission Certification (PAC) must be requested prior to each hospital stay. For hospital stays that required an extension, Continued Stay Review (CSR) should be requested before the end of the original certified length of stay.
You are responsible for ensuring the UR process is completed for services requiring review and to follow up with your network provider to confirm the process has been completed. However, this process is usually handled automatically under the...
If you are enrolled in one of the PPO Plans and use non-network providers, you must handle the UR process by following the notification process as outlined below.
Note, however, that regardless of the type of provider you use, you are ultimately responsible for ensuring that the UR process is completed for any services requiring such a review.
In general, to complete the UR process you (or your provider) must notify CIGNA's Review Organization. The Review Organization is a dedicated unit with whom CIGNA contracts to perform the UR process. The Review Organization is made up of Registered Graduate Nurses (R.N.s) and other trained staff members who work with consulting physicians.
The guidelines for notifying the Review Organization are as follows...
You may contact the Review Organization by calling the number printed on your ID card. When you call, have the following information ready...
The results of the UR will be sent to you, your physician and CIGNA.
It's important to keep in mind that you and your physician ultimately decide on the type of medical care you receive. UR only determines the medical necessity of a service or supply according to the Plan benefits and provisions. UR approval does not mean the service or supply is automatically covered. To be covered, the service or supply must also qualify as a covered expense. To find out if a service or supply is a covered expense, see What The CIGNA Plans Cover. If you have questions, contact CIGNA directly at the number listed on your ID card.Back to Top
If you fail to contact the Review Organization and complete a required UR, a $250 "non-notification deductible" will apply, regardless of whether the confinement occurs in a network or non-network hospital. This deductible is separate from any other deductible and will not apply toward the out-of-pocket maximum.
In addition, benefits will be reduced by 50% for:
Case management is a voluntary program CIGNA provides to assist individuals with treatment needs that extend beyond the acute care setting. The program is intended to ensure that patients receive appropriate care in the most effective setting possible, whether at home, as an outpatient, or as an inpatient. Case management professionals can offer quality, cost-effective treatment alternatives, as well as assistance with obtaining needed medical resources.
To request case management services, you, your dependent, or your physician may call the toll-free number on your medical ID card during normal business hours, Monday through Friday.Back to Top