|Medical Plan |
How the Point-of-Service Plans Work
Both Point-of-Service Plans center around a network of physicians, hospitals and other health care providers who have agreed to provide care to patients at prenegotiated rates.
In-network primary care physicians are family or general practitioners, internists, and pediatricians, who contract with CIGNA to provide their services and charge only the contracted fee amount. Primary care physicians are responsible for coordinating all health care and, when necessary, for making referrals to in-network specialists. In-network primary care physicians and specialists also handle all inpatient and outpatient precertification.
Preventive care, like simple health screenings and immunizations, can help prevent or detect serious illnesses early - when they are less expensive to treat and you are more likely to fully recover. Primary care physicians provide a full range of preventive care based on recognized medical guidelines for a person’s age, gender, and personal and family health history. This care includes:
- annual well-woman exam
- well-child care
- cholesterol screenings
- prostate exams
- routine physical exams.
With a Point-of-Service Plan, you have a choice - at the "point-of-service” - each time you need health care, to use only in-network providers, or to use providers outside the network and receive less benefits.
Under the CIGNA Point-of-Service Plan:
- You must select a primary care physician for each covered family member.
- Your primary care physician must refer you to a specialist physician in order for you to receive in-network benefits (even in-network physicians). Otherwise, your benefits will be considered at the out-of-network rate. If the specialist refers you to another specialist, that referral must be made by the primary care physician. If you need more visits with the specialist than is approved, the primary care physician must get approval for more visits or the additional charges will be denied and you will have to pay them. Make sure you know how many visits are approved.
- A woman may "self-refer" to a network OB/GYN.
- For mental health/substance abuse care, you must contact the mental health/substance abuse number shown on your ID card. Although your primary care physician may make this call for you if you wish, you do not need a referral from your primary care physician to receive mental health/alcohol and drug abuse care.
- Emergency (as defined in the Glossary) care does not require a primary care physician referral. However, you will need to call your primary care physician within 48 hours after the emergency to ensure in-network benefits and have your primary care physician coordinate any follow-up care.
- You do not need a referral from a primary care physician to see an optometrist for a routine eye exam.
- You can change a primary care physician by calling CIGNA Member Services at the telephone number on your ID card.
Under the CIGNA Open Access Plan:
- You are not required to choose a primary care physician.
- If you select a primary care physician, the physician helps you get access to a specilatist and handles any required precertification for you. These services may help avoid mistakes that can reduce the amount of benefits you receive.
- For maximum coordination of your medical care, it is recommended that you choose a primary care physician.
- You may see a specialist without a referral from a primary care doctor.
Deductibles, Copayments and Coinsurance
You and your Eligible Dependents may be required to pay a portion of the covered expenses for services and supplies. That portion is the deductible, copayment, or coinsurance:
- Copayments and Deductibles are those expenses to be paid by you or your Eligible Dependents for the services received.
- Deductible amounts are separate from, and not reduced by, copayments.
- Copayments and deductibles are in addition to any coinsurance.
- Coinsurance means the percentage of charges for covered expenses that you are required to pay under the plan.
For deductibles, copayments or coinsurance amounts, refer to the Summary of Benefits for your plan.
If You Have an Emergency
If you have an Emergency, go to the nearest emergency facility for treatment - even if it is not a network facility. After you pay the copayment required by the plan, the plan pays 100% of the cost of emergency room treatment. The copayment is waived if you are admitted to the hospital from the emergency room.
Someone must contact your primary care physician or CIGNA Member Services within 48 hours of your emergency treatment to ensure that in-network benefits are paid and to arrange for follow-up care.
If you go to the emergency room for a nonemergency, your expenses will not be covered.
If the situation is urgent, but not an emergency, you should contact your primary care physician first and follow his or her directions.
Definitions for "Emergency" and "Urgent Care" can be found in the Glossary.
The Network Credentialing Process
All network doctors - primary care physicians and specialists - must meet certain educational and professional requirements before they are admitted into the network. CIGNA has a regular credentialing process to ensure that the doctors in the network meet certain standards, such as:
- medical degree and current unrestricted state license
- admitting privileges at a network hospital
- board certification or board eligibility
- malpractice criteria
- good reputation among peers
- 24-hour emergency availability
- sufficient office hours to meet patient demand
- on-site review of office facilities.
CIGNA reviews its physicians regularly. If any physician does not meet the requirements, that physician will be dropped from the network. Network hospitals are also credentialed. Hospitals are selected based on their facilities, services, medical outcomes, staff quality measures, and reputation in the community.
CIGNA has the right to change network doctors and network hospitals at any time and without advance notice.
The Point-of-Service Plans have certain provisions that apply to special circumstances. If you have any questions about these situations or others not described here, please contact CIGNA Member Services or the Benefit Plans Office.
If you need care while traveling outside your network area
You are covered for Emergency Care or Urgent Care on an in-network basis, as long as you call your primary care physician or CIGNA Member Services within 48 hours of receiving the emergency or urgent treatment. If you are traveling outside the U.S. you may wait until you return home to contact your primary care physician. You must file a claim for reimbursement as soon as possible when you return. For other types of care, call your primary care physician to determine your best options.
Residing in another location
If you or your Eligible Dependents will be residing temporarily in another location where there are in-network providers, you may be eligible for Point-of-Service benefits at that location. If you will be permanently residing outside the Point-of-Service network, refer to the "CIGNA Indemnity Plan” portion of the "Medical Plan” section and contact the Benefit Plans Office for more information.
When you go out-of-network, you can use any physician or facility you like. After you meet an annual deductible, the plan pays the Reasonable and Customary Charges for most kinds of medically necessary services, until the annual out-of-pocket maximum has been reached, depending on which medical plan option you have selected.
The out-of-pocket maximum protects you from excessive medical costs by establishing a ceiling on the amount you pay for covered medical expenses during a year. Once you reach the out-of-pocket maximum, the plan pays 100% of the Reasonable and Customary Charges for the rest of that year.
You must file claims to be reimbursed for out-of-network expenses. Claim forms are available from CIGNA Member Services or the Benefit Plans Office.
If your physician recommends any nonemergency hospitalization or surgery, you are responsible for calling CIGNA Member Services for hospital precertification at least seven days, or as soon as reasonably possible, before you are admitted to the hospital. If you do not call for precertification, your benefit will be reduced by 50%.
Reasonable and Customary Charges
Any charges above the Reasonable and Customary Charge are not covered by the plan and you will not be reimbursed for that amount. Also, these amounts will not count toward the deductible or out-of-pocket maximum.
"Reasonable and Customary Charge" is defined in the Glossary.
The Family Deductible
Although the deductible applies separately to each covered family member, the plan contains a provision - called the family deductible - that limits the amount your family pays in deductibles each year.
You can also meet the family deductible with any combination of individual expenses. However, once one family member meets his or her individual deductible, any further expenses incurred by that person may not be applied to the family deductible. Once the family deductible is met, no other family member needs to meet the deductible for that year.
The Out-of-Pocket Expenses and Your Maximum Expenses
The out-of-pocket expenses are covered expenses incurred for in-network and out-of-network charges for which no payment is provided because of any applicable coinsurance. The out-of-pocket maximum limits the amount you pay for medical expenses in one year.
ONCE YOU REACH THE OUT-OF-POCKET MAXIMUM, THE PLAN PAYS 100% OF COVERED EXPENSES.
Certain expenses do not count toward the out-of-pocket maximum:
- expenses for substance abuse treatment (under the CIGNA Open Access Plan)
- non-compliance penalties for not following precertification requirements
- charges above Reasonable and Customary Charge
- care that is received but not covered by the plan.
Precertification helps ensure that all inpatient and certain outpatient services are medically necessary and, in the case of hospital confinement, that the length of stay is appropriate.
If you stay in-network, you do not have to worry about precertification. Your in-network primary care physician or specialist will handle it for you. But, if you go out-of-network for care, you are responsible for calling CIGNA Member Services at least seven days, or as soon as possible, before you are admitted to the hospital or receive outpatient diagnostic testing or procedures. If you do not call, your benefit will be reduced by 50%.
When you call CIGNA Member Services for precertification, you need to provide the following information:
- your name, address and telephone number
- your physician’s name and telephone number
- the date of your admission or services
- the reason for your admission or services.
For mental health and substance abuse admissions, whether in-network or out-of-network, you must call the mental health/substance abuse (MH/SA) number listed on your ID card. You do not call CIGNA Member Services.
Mental Health/Alcohol and Substance Abuse Treatment
Under the Point-of-Service Plans, you must have mental health/alcohol and drug abuse treatment reviewed and authorized by calling the mental health/substance abuse (MH/SA) number listed on your ID card.
If you prefer, your primary care physician can make the call for you. A primary care physician referral is not necessary.
CIGNA Member Services
CIGNA Member Services is a customer service line staffed by experienced and courteous representatives trained to answer your questions and provide information about your Point-of-Service Plan participation and benefits. CIGNA Member Services can help you:
- find out more about in-network primary care physicians, specialists and facilities
- get more information about plan features and procedures
- change primary care physicians
- order replacement ID cards
- register comments about network providers and services
- request out-of-network claim forms.
In addition to Member Services:
You may locate participating providers in your CIGNA network by accessing www.cigna.com. Click on the "Provider Directory" link and follow the instructions for locating providers in your area.
As a CIGNA member, you have access to your benefit information through your own personalized CIGNA website - www.mycigna.com. There you can:
- locate participating providers
- change your PCP
- print a temporary ID card
- order a new ID card
- access your benefit information
- check the status of your claims.
If you go out-of-network, you must also call CIGNA Member Services for precertification.
Contacting CIGNA Member Services
For CIGNA Open Access and CIGNA Point-of-Service Plans
Refer to your ID card for the Mental
Health/Substance Abuse phone number.