How The CIGNA Plans Work

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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