Description Of Covered Services

The following is a summary of additional services covered under the CIGNA Medical Plans; this section also provides more details on some of the covered services outlined previously.

In general, the benefit payment provisions apply to these services. For additional details, refer to the CIGNA plan booklet available from your local Human Resources representative, or contact CIGNA directly at the number on your medical ID card.

Acupuncture

To receive network benefits, treatment must be performed by a physician.

Allergy Injections

Covered when administered at a physician's office.

Ambulance

See Transportation Services later in this section.

Ambulatory Surgical Center Charges (or Free-Standing Surgical Center)

Includes treatment, services, and supplies performed in an ambulatory surgical center for services in connection with the surgical procedure.

Anesthetics

Includes both the anesthetics and the charges for administering them.

Appliances

Includes any appliance that replaces a lost body organ or part, or helps an impaired one to work, such as an artificial limb or eye. Only the first charge for the first appliance is covered.

Assistant Surgeon Services

The expenses for the services of an assistant surgeon will be covered at 20% of the amount of the covered expenses for the surgeon's charges for the surgery. An assistant surgeon is a physician with the designation of M.D., D.O., D.M.D, or D.P.M. Surgical assistant's services are not covered.

Birth Center Charges

Includes room and board, other services and supplies, and anesthetics as described above.

Birth Control Devices

Covered when provided in a doctor's office; note that oral contraceptives are covered under the prescription drug portion of the medical plan.

Blood or Blood Derivatives

Only if not donated or replaced.

Chemical Dependency Treatment

Includes both inpatient and outpatient services.

Chemotherapy

Covered as any other expense.

Chiropractic Care

When performed by a physician, such as a licensed Doctor of Chiropractic (D.C.). Benefits are limited to $1,500 per calendar year, per covered individual.

The plan does not cover charges for:

• Chronic conditions.

• Vitamin therapy.

• Maintenance or preventive treatment.

• Treatment of children under 12 years old unless the chiropractor obtains a signed consent form from the parent or guardian of the child before rendering care. A copy of this consent form must accompany the bill or the claim will be denied.

Dental Services

Most dental services are covered if needed as a necessary, but incidental, part of a larger service in the treatment of an underlying medical condition. Dental expenses are eligible if they are charges...

• For a continuous course of dental treatment that started within six months of an injury to sound natural teeth.

• Made by a hospital for room and board or necessary services and supplies.

• Made by the outpatient department of a hospital for surgery.

• Made by a physician for any of the following surgical procedures:

  • Excision of epulis (a benign gingival mass)

  • Excision of unerupted impacted tooth, including removal of alveolar bone and sectioning of the tooth

  • Removal of residual root (when performed by a dentist other than the one who extracted the tooth)

  • Intraoral drainage of acute alveolar abscess with cellulitis

  • Alveolectomy

  • Gingivectomy, for gingivitis or periodontitis

Additional dental benefits are provided under the FlexSolutions Dental Plans, which are described under the About The Dental Plans section.

Durable Medical Equipment

Includes appliances that replace a lost body organ or part, or helps an impaired one to function; orthotic devices, such as arm, leg, neck, or back braces; hospital-type beds; equipment needed to increase mobility, such as a wheelchair; respirators or other equipment for the use of oxygen; and monitoring devices. The equipment must be for repeated use and cannot be a consumable or disposable item. It must be used primarily for medical purposes and it must be appropriate for use in the home. The equipment may be purchased or rented, as determined by the Claims Administrator. Only the first charge for the first appliance is covered.

Emergency Room Visits

Covered only if it is determined that the services are medically necessary and the individual could not have used a less-intensive or more appropriate place of service, diagnostic or treatment alternative. Non-emergency use of an emergency room is not covered. For a definition of emergency services, see Emergency Services.

Foot Care

Care and treatment of the feet, if needed due to severe systemic disease. Routine care such as removal of warts, corns or calluses; the cutting and trimming of toenails; and foot care for flat feet, fallen arches and chronic foot strain are covered services only if due to severe systemic disease.

Health Care Provider's Services

Includes the services of a licensed or certified Health Care Provider, while acting within the scope of that license or certification. Such services are payable as any other eligible expense.

Hearing Aids/Hearing Exams

Benefits are limited to $1,500 every 36 months. This benefit does not include repairs, replacements or batteries.

Home Health Care

Includes temporary or part-time nursing care by (or supervised by) a registered graduate nurse (R.N.); temporary or part-time care by a home health aide; and physical, occupational and/or speech therapy. To be eligible for payment, home health care services must be:

• Received from a licensed home health agency,

• Part of a home health care plan, and

• Performed while you are under the continuing care of a physician.

Services are not covered if they are provided by a person who is related to you by birth or marriage or who lives with you or your dependents.

Hospice Care Charges

Hospice care is an integrated program of care that provides comfort and support services for terminally ill patients ("terminally ill" generally means that the patient has a prognosis of six months or less to live). Coverage for hospice care includes:

• Semi-private room and board and other services and supplies provided while the patient is confined in a hospice facility, hospital, skilled nursing facility, home health care agency, or any other licensed facility or agency under a hospice care program

• Services provided by a hospice facility on an outpatient basis

• Professional physician services

• Services provided by a psychologist, social worker, family counselor, or ordained minister for individual and family counseling, including bereavement counseling within one year after the person's death

• Pain relief treatment, including drugs, medicines, and medical supplies

• Services provided by a home health agency for:

  • Part-time nursing care by (or supervised by) a registered graduate nurse (R.N.)

  • Part-time care provided by a home health aide

  • Physical, occupational, and speech therapy

  • Medical supplies, physician-prescribed medications, and laboratory services to the extent that such charges would have been payable if the person had been confined in a hospital or hospice facility

The following charges are not considered eligible expenses under the Plan:

• Services provided by a person who is related to you by birth or marriage, or who lives with you or your dependents

• Charges for any period when you or your dependent is not under the care of a physician

• Services or supplies not listed in the hospice care program

• Any healing or life-prolonging procedures

• Any services that are also payable under another portion of this Plan

• Any services or supplies that are mainly to aid a person in daily living

• Charges for more than three bereavement counseling sessions

Hospital Charges

Includes room and board charges, whether the charges are for a ward, semi-private room or an intensive care unit. Charges made for a private room are eligible as a covered expense up to the hospital's regular daily charge for a semi-private room. Also includes other services and supplies.

Hospital Charges/Well Baby Care

Includes routine care during a covered newborn's initial hospital confinement, such as nursery care, physician visits, and charges for circumcision and other services and supplies.

Inpatient Rehabilitation Therapy

Inpatient rehabilitative therapy is covered only if intensive and multidisciplinary rehabilitation is necessary to improve the patient's ability to function independently. Covered services include services of a hospital or rehabilitation facility (such as skilled nursing facilities, rehabilitation hospitals and sub-acute facilities) for room, board, care, and treatment during confinement. Benefits are limited to 120 days per calendar year, per covered individual.

Laboratory Tests and X-rays

Includes X-rays or tests for diagnosis or treatment of an illness or injury, performed either on an inpatient or outpatient basis.

Licensed Counselor Services

Services of a licensed counselor (including a social worker) provided for the treatment of a mental or nervous disorder or chemical dependency are covered as long as you obtain a referral before the covered expenses are incurred. To obtain services, you must coordinate your care through CIGNA by calling the 800 number indicated on your ID card.

Mammography

Available to covered employees and spouses/domestic partners under the Plans' preventive health care services (and also includes breast examinations). Under the Plans, mammograms provided as part of preventive/routine care are limited to...

• One baseline mammogram between the ages of 35 and 39

• One mammogram every year for women age 40 or older, or as required due to medical necessity

Maternity Services

Includes both office visits and hospital services.

Note: Federal law protects the benefit rights of mothers and newborns related to any hospital stay in connection with childbirth. In general, group health programs and health insurance issuers may not:

• Restrict benefits for the length of hospital stay for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).

• Require that a provider obtain authorization from the program or the insurance issuer for prescribing a length of stay of up to 48 hours (or 96 hours).

For a hospital delivery, the hospital length of stay begins at the time of delivery (or at the time of the last delivery in the case of multiple births). For a delivery outside the hospital, the hospital length of stay begins at the time the mother or newborn is admitted as a hospital patient in connection with childbirth by the attending physician.

Medical Supplies

Includes blood or blood derivatives, only if not donated or replaced, and surgical supplies, such as bandages and dressings. Surgical supplies given during surgery or a diagnostic procedure are included in the overall cost for that surgery or diagnostic procedure.

Multiple Surgical Procedures

When more than one surgical procedure is performed during the same operative session, the covered expenses for the subsequent procedures are limited to 50% of the covered expenses for those procedures when they are performed on their own.

Nursing Services

Includes the services of a trained nurse. This includes services of a Registered Graduate Nurse (R.N.), a Licensed Practical Nurse (L.P.N.), or a Licensed Vocational Nurse (L.V.N.).

Organ/Tissue Transplants

Note: Benefits for organ/tissue transplants are covered only when you obtain services in-network.

Includes evaluation, donor search, organ procurement/tissue harvest, transplant procedures, and hospital and physician fees, but only if CIGNA is notified before the scheduled date of any of these activities, and the transplant procedures are performed at a designated CIGNA Lifesource Center. Benefits include the replacement of tissue and/or organ for heart, lung, heart/lung, liver, kidney, pancreas, kidney/pancreas, and bone marrow/stem cell transplants, immunosuppressive medication, and donor's medical costs.

Donor charges are considered covered only if the recipient is covered under this Plan. Expenses for a donor will be reduced by the Plan if they are payable from another plan.

The Plan also provides benefits for travel and lodging expenses for the patient and one companion when traveling to a Lifesource facility as directed by CIGNA (limitations may apply).

Other Hospital Services

Includes room and board, surgeon charges and physician visits.

Outpatient Short-Term Rehabilitative Therapy

Services for treatment and medical care by an occupational therapist, speech therapist or physical therapist provided the therapy is ordered and monitored by a physician. It must be given in accordance with a written treatment plan, submitted by a physician and approved by the Plan. Progress reports may be requested by the Plan at various intervals to ensure treatment is medically necessary. Benefits are limited to 90 visits per calendar year combined.

Oxygen

Includes charges for administering oxygen, as well as the rental of any required equipment.

Pap Smear/Pelvic Examination

Available annually to covered employees and spouses/domestic partners under the Plans' preventive health care services.

Physical Therapy

See Outpatient Short-Term Rehabilitative Therapy.

Physician Services

Includes hospital, office and home visits, and emergency room treatment services. Also includes surgery, reconstructive surgery, assistant surgeon services, and multiple surgical procedures as defined elsewhere in this section.

Prescribed Drugs and Medicines

Includes drugs and medicines provided on an inpatient basis. For information regarding the outpatient prescription drug benefits available under the Plans, see Prescription Drug Benefits.

Preventive Health Care

The following services are covered up to Plan limits as long as they are provided by network physicians (under the PPO Plans) or by your PCP (under the HMO Plan)...

• Annual routine physical exams for adults (including pap smears, pelvic exams and mammograms for women as outlined elsewhere in this section); and

• Well baby/well child care services for children through age five.

The HMO Plan also provides benefits for chromosome testing based on medical necessity.

Private Duty Nursing

Covered as part of a home health care plan if approved by CIGNA; not covered while confined in a facility.

Psychiatric Treatment

Includes inpatient and outpatient treatment for mental and nervous disorders, as well as alcoholism and drug abuse, up to the maximum benefits. Treatment must be performed by a licensed psychiatrist (M.D.) or licensed psychologist. Benefits for outpatient treatment are limited to 35 visits per calendar year; inpatient treatment is limited to 30 days per calendar year.

Radiation Therapy

Covered as any other expense.

Reconstructive Breast Surgery

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• All stages of reconstruction of the breast on which the mastectomy was performed,

• Surgery and reconstruction of the other breast to produce a symmetrical appearance,

• Prostheses, and

• Treatment of physical complications of all stages of the mastectomy, including lymphedemas.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this program.

Reconstructive Surgery

Includes reconstructive surgery to improve the function of a body part when the malfunction is the direct result of a birth defect, illness, accidental injury, or a prior surgery performed to treat an illness or accidental injury that occurs while the individual is covered under this Plan.

Rehabilitation Therapy

Includes services of a hospital or rehabilitative facility. Inpatient therapy is limited to 120 days per confinement (either in a hospital, rehabilitation facility or both) each calendar year. Outpatient therapy is limited to 90 days each calendar year (combined with occupational, physical and speech therapy), regardless of whether the services are performed in a hospital or rehabilitative facility.

Rentals

Includes rental of a durable medical equipment, such as a wheelchair, hospital-type bed or device to help with breathing when paralyzed. CIGNA's approval is required.

Routine Physical Exam

See Preventive Health Care.

Second Surgical Opinion

Includes services of a physician to provide a second opinion to confirm the need for elective surgery ("elective surgery" meaning a surgical procedure that is not considered an emergency and that may be avoided without undue risk to the patient).

Skilled Nursing Facility

Includes room and board, and other services and supplies. Covered expenses are limited to the facility's regular daily charge for a semi-private room. Payment limited to the first 120 days of confinement each calendar year.

Social Worker's Services

Includes the services of a clinical social worker for psychological testing and psychotherapy only. To receive network benefits under the PPO Plans, or to be covered under the HMO Plan, you must coordinate your care through CIGNA. You can do so by calling the 800 number indicated on your ID card and accessing the mental health benefits information.

Speech Therapy

Includes the services of a licensed speech therapist only when the services must be given to restore speech lost or impaired that occurs while the individual is covered under this Plan. The therapy must be ordered and monitored by a physician, and be given in accordance with a written treatment plan, submitted by a physician and approved by the Plan. Progress reports may be requested by the Plan at various intervals to ensure treatment is medically necessary. Benefits are limited to 90 visits per calendar year combined with occupational, rehabilitative and physical therapy.

Speech therapy is not covered if such therapy is...

• Used to improve speech skills that have not fully developed

• Considered custodial or educational

• Intended to maintain speech communication

• Not expected to improve the patient's ability to speak

Surgery

Includes physician services for surgery, reconstructive surgery, assistant surgeon services, and multiple surgical procedures as defined elsewhere in this section.

Surgical Supplies

Includes bandages and dressings.

Transportation Services

Includes services provided by a professional ground ambulance service to and from the nearest medical hospital qualified to provide the required treatment. Benefits are paid only for a true emergency.

Well Baby/Well Child Care

See Preventive Health Care.

Well Woman Care

See Preventive Health Care.