Network Only benefits
To receive In-Network Medical Benefits, services must be provided by a Cigna Network Provider. A Cigna Network Provider is an institution, facility, agency or health care professional, which has contracted directly or indirectly with Cigna. Providers qualifying as Participating Providers may change from time to time. A list of the current Participating Providers is located online at www.mycigna.com. The Provider Organization is a network of Participating Providers.
If you see a doctor who does not participate in the Cigna Network, you’ll be responsible for all associated costs.
If you have a life-threatening medical emergency, go to your nearest hospital emergency department. Emergency services are covered at the In-Network benefit level until your medical condition is stabilized.
If you are unable to locate a Cigna Network Provider in your area who can provide you with a service or supply that is covered under the Cigna OAPIN option, you must call your Cigna Customer Services to obtain authorization for Out-of-Network Provider coverage. If you obtain authorization for services provided by an Out-of-Network Provider, those services will be covered at the In-Network benefit level.
You share in the cost of most medical services and supplies. For some services and supplies, such as doctor’s visits, your share of the cost is a fixed dollar amount. This is called a copayment or copay. Your copay amount is printed on your plan ID card.
You won’t always pay a copay for medical services or supplies. Some services and supplies, such as preventive medications and your annual physical, are at no additional cost to you. And some services are subject to coinsurance.
For some medical services and supplies, such as hospital stays and outpatient surgeries, your share of the cost is a percentage of the negotiated fees for services received. This is called coinsurance. The Plan pays 90% of the allowable expense and you pay 10%, until your annual out-of-pocket limit is reached.
The allowable expense or allowed amount is the portion of billed charges for medical services and supplies that is considered eligible for payment by the Plan, before this amount is reduced by your copayment or coinsurance amount.
For most covered services, the allowed amount is the contracted rate between the Provider Organization and the participating Network Provider. Contracted rates vary among providers in the same service area. You can find network providers and compare costs on MyCigna.com or by calling Cigna Customer Service.
Note: You are responsible for any billed charges above the allowed amount, for example the difference in cost between a private and semi-private hospital room, and these additional charges do not accumulate towards your annual out-of-pocket limit.
Annual out-of-pocket limit
Your out-of-pocket limit is the maximum amount you could pay for covered expenses in a Contract Year. Your out-of-pocket limit includes your portion of the allowable expenses for covered medical services, supplies, and medications, including copays and coinsurance. Once your out-of-pocket maximum has been reached, benefits for covered expenses are payable at 100%.
Note: Monthly contributions, charges above the allowed amount for covered services, and charges for services that are not covered under the Cigna option do not accumulate towards your annual out-of-pocket limit.
Balance bill protection
Sometimes covered services are performed by a Non-Network Provider without your knowledge or ability to choose a participating provider, for example in an emergency situation or when you receive care in a network facility but a network physician is unavailable. When this happens, covered expenses are payable at the In-Network benefits level, and the allowable expense is limited to what is reasonable and customary for similar services in the same geographic area.
Most non-network charges will fall within reasonable and customary limits. However, if you receive a balance bill for the difference between a Non-Network Provider’s billed charges and what is considered reasonable and customary for covered services under the Cigna option, and you did not voluntarily elect to receive services from the Non-Network Provider, call Cigna Customer Service. The full or partial balance bill may qualify as a “hidden” allowable expense eligible for payment by the Plan.
Lifetime maximum benefit
The total maximum benefit per covered person is unlimited.
Contract Year means a period from January 1 to December 31 each calendar year.
Benefits for in-network medical care
This Cigna OAPIN option pays the following benefits for in-network care:
- 100% Coverage for Preventive Care Services
Medically-necessary preventive care services, including screenings and immunizations, as well as certain maintenance medications, including statins and contraception, will be covered at no additional cost.
- Copay for Physician Visits
The copays per visit for physician visits are $25 for primary care and $40 for specialists.
- Copays for Urgent Care and Emergency Room Visits
The copays per visit for Urgent Care are $60 and $150 for Emergency Room visits.
- 90% Coverage for Inpatient and Outpatient Care
Inpatient and outpatient care, including surgeries and other pre-scheduled medical procedures, will be covered at 90% of the negotiated network fee for service. You are responsible for paying 10% of the cost of covered inpatient and outpatient medical services, until the combined medical/pharmacy annual out-of-pocket maximum is reached.
- Combined Out-of-Pocket Maximum
The combined annual out-of-pocket limit for 2021 is $3,000 per individual and $6,000 per family. Out-of-pocket expenses for both covered medical and pharmacy will count towards the same annual maximum, after which the Plan will pay for covered services and prescriptions at no additional cost.
Your PCP will provide your primary care and, when medically necessary, your PCP may refer you to other in network doctors or facilities for treatment. The referral is important because it is how your PCP arranges for you to receive necessary, appropriate care and follow-up treatment. While your plan does not require a referral from your PCP for you to see specialty doctors, you will want to coordinate such care with your PCP. Also, certain services do require prior authorization from Cigna. In such case, your doctor will coordinate the prior authorization process with Cigna on your behalf. You will not be required, nor expected, to manually track the prior authorization.
The term Prior Authorization means the approval that a Participating Provider must receive from Cigna in order for certain services and benefits to be covered under the Cigna OAPIN Option. Your PCP is responsible for obtaining authorization from Cigna for in-network covered services.
Services that require Prior Authorization include, but are not limited to:
- Inpatient Hospital Services,
- Inpatient Services at any Other Participating Healthcare Facility,
- Outpatient Facility Services,
- Magnetic Resonance Imaging (MRI),
- Nonemergency Ambulance,
- Organ Transplant Services,
- Mental Health/Substance Abuse Treatment
Direct access for obstetric/gynecological services
You are allowed direct access to a licensed/certified Participating Provider for covered obstetric/gynecological services. There is no requirement to obtain an authorization of care from the Plan or from your Primary Care Physician for visits to a Participating Provider of your choice for pregnancy, well-woman gynecological exams, primary and preventive gynecological care, and acute gynecological conditions. Make sure that the OB/GYN is a Participating Provider prior to each visit and that any services that the OB/GYN requests will be In-Network under the Cigna OAPIN option.