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.

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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.

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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.

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Payment Provisions

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...

  • Deductibles

  • Copayments

  • Coinsurance

  • Out-of-Pocket Maximums

  • Lifetime Maximum Benefits

These payment provisions are explained in the sections below. The following table summarizes the major payment provisions.

The CIGNA Medical Plans... At a Glance
Payment  Provisions CIGNA Low Option PPO OA+ Plan CIGNA High Option PPO OA+ Plan CIGNA
Network HMO Plan

 

Network Providers

Non-Network Providers

Network Providers

Non-Network Providers

Network Providers Only

Deductible

$1,000/individual,
$3,000/family

$2,000/individual,
$6,000/family

$300/individual,
$600/family

$500/individual, $1,200/family

None

Copayment Amount

Not applicable

Not applicable

A $20 copayment applies for many routine services ($35 copayment applies to specialists)

None; coinsurance amount applies

A $20 copayment applies for many routine services ($30 copayment applies to specialists)

Coinsurance Amount

80% after deductible for most services

50% after deductible for most services

100% after $20 copayment for many routine services; 90% after deductible for most other services

70% after deductible for most services

100% (after any applicable copayment)

Out-of-Pocket Maximum

$4,000/individual,
$8,000/family

$6,000/individual,
$12,000/family

$2,000/individual, $4,000/family

$4,000/individual, $8,000/family

$1,500/individual,  $3,000/family

Lifetime Maximum

Unlimited

Unlimited

Unlimited

Unlimited

Unlimited

Deductibles

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.

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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.

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Hospital Deductible

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.

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Copayments

"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.

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Coinsurance

"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.

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Out-Of-Pocket Maximums

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.

Out-Of-Pocket Maximums

CIGNA Low Option PPO OA+ network providers

$4,000 per individual/$8,000 per family

CIGNA Low Option PPO OA+ non-network providers

$6,000 per individual/$12,000 per family

CIGNA High Option PPO OA+ network providers

$2,000 per individual/$4,000 per family

CIGNA High Option PPO OA+ non-network providers

$4,000 per individual/$8,000 per family

HMO providers

$1,500 per individual/$3,000 per family

The following expenses do not apply toward your out-of-pocket maximum...

  • Amounts you pay over reasonable and customary charges

  • Charges for the treatment of mental or nervous disorders, or alcoholism and drug abuse

  • Charges for non-covered services

  • Any penalty amounts you must pay for failing to obtain required pre-certification

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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.

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Filing Claims

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...

  • Your name and Social Security Number,

  • The Employer's name and Account Number (your Account Number is the seven-digit policy number shown on your medical ID card),

  • The patient's name (if different than yours),

  • Copies of the itemized medical bills (including dates of service), and

  • The diagnosis and specific services or supplies provided (if not noted on the bill).

If you seek covered services outside the United States, you will also need to include the following information with your claim...

  • The name of the country where services were received,

  • The currency of the country were services were received,

  • The exchange rate on the date services were received,

  • A written English translation of the claim and itemization of services rendered (if possible), and

  • The receipt showing the out-of-pocket payment (if applicable).

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.

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Utilization Review

The utilization review (UR) process is used to certify the medical necessity and length of stay for any hospital confinement. Specifically, UR applies to:

  • Initial inpatient hospital admissions

  • Extended inpatient hospital stays

  • Other inpatient stays at facilities such as skilled nursing facilities, rehabilitative hospitals, and sub-acute facilities

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...

  • HMO Plan, and

  • PPO Plans when you use network providers.

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.

UR Notification

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...

  • For hospital admissions, call before the confinement begins (if there is no specific admission date when the confinement is planned, you must call as soon as the admission date is set).

  • For an extended length of stay, call before the initial certified hospital confinement ends.

  • For hospital admissions due to pregnancy, call at least three months prior to your delivery date (sooner if possible).

  • For emergencies that result in a hospital confinement, you (or a representative or your physician) must call within 48 hours of the date the confinement begins, or as soon as is reasonably possible.

You may contact the Review Organization by calling the number printed on your ID card. When you call, have the following information ready...

  • Your Employer's name

  • The Account Number shown on your medical ID card

  • Your name and Social Security Number

  • The name of the covered person receiving treatment (if different from yours)

  • Medical information concerning the proposed treatment

  • The physician's name, phone number and address

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.

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Benefit Reductions

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:

  • Hospital room and board charges, for stays that exceed the number of days authorized through PAC or CSR

  • Any hospital charges if the stay was requested through PAC but not certified as medically necessary

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Case Management

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.

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