1 Table of contents 89

2025 SPD for CIGNA HSA Plan

Important Information		5
THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY MID-AMERICA APARTMENTS, L.P. WHICH IS RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY (CIGNA) PROVIDES ...		5
THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CIGNA," "INSURANCE COMPANY," ...		5
Explanation of Terms		6
The Schedule		6
The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description of each benefit, refer to the appropriate section listed in the Table of Contents.		6
Special Plan Provisions		7
Services Available in Conjunction With Your Medical Plan		7
Case Management		7
Additional Programs		7
Incentives to Participating Providers		8
Care Management and Care Coordination Services		8
Important Notices		8
Important Information Rebates and Other Payments		8
Coupons, Incentives and Other Communications		8
Discrimination is Against the Law		9
Proficiency of Language Assistance Services		9
Japanese –		10
Federal CAA - Consolidated Appropriations Act and TIC		10
- Transparency in Coverage Notice		10
Federal CAA - Consolidated Appropriations Act Continuity of Care		10
Appeals		11
Provider Directories and Provider Networks		11
Direct Access to Obstetricians and Gynecologists		11
Selection of a Primary Care Provider		11
Your Rights and Protections Against Surprise Medical Bills		11
What is “balance billing” (sometimes called “surprise billing”)?		11
You are protected from balance billing for:		11
You are never required to give up your protections from balance billing. You also are not required to get out-of- network care. You can choose a provider or facility in your plan’s network.		12
When balance billing is not allowed, you have these protections:		12
Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) - Non-Quantitative Treatment Limitations (NQTLs)		12
How To File Your Claim		12
CLAIM REMINDERS		13
Timely Filing of Out-of-Network Claims		13
Eligibility - Effective Date		13
Employee Insurance		13
Eligibility for Employee Insurance		13
Eligibility for Dependent Insurance		13
Waiting Period		13
Classes of Eligible Employees		13
Effective Date of Employee Insurance		13
Late Entrant - Employee		13
Dependent Insurance		13
Effective Date of Dependent Insurance		14
Late Entrant – Dependent		14
Exception for Newborns		14
Dual Eligibility		14
Important Information About Your Medical Plan		14
Opportunity to Select a Primary Care Physician		14
Changing Primary Care Physicians		14
Direct Access For Mental Health and Substance Use Disorder Services		14
Open Access Plus Medical Benefits		35
Certification Requirements - Out-of-Network		35
For You and Your Dependents		35
Pre-Admission Certification/Continued Stay Review for Hospital Confinement		35
Outpatient Certification Requirements – Out-of-Network		35
Outpatient Diagnostic Testing and Outpatient Procedures		35
Prior Authorization/Pre-Authorized		35
Covered Expenses		36
Covered Expenses		36
Virtual Care		37
Dedicated Virtual Providers		37
Virtual Physician Services		37
Convenience Care Clinic		37
Genetic Counseling		37
Nutritional Counseling		37
Enteral Nutrition		37
Internal Prosthetic/Medical Appliances		37
Obesity Treatment		37
Condition-Specific Care		38
Condition-Specific Care Travel Services		38
Home Health Care Services		38
Hospice Care Services		39
Mental Health and Substance Use Disorder Services		39
Inpatient Mental Health Services (including Mental Health Acute Inpatient Services and Mental Health Residential Treatment Services)		40
Outpatient Mental Health Services (including Mental Health Partial Hospitalization and Mental Health Intensive Outpatient Services)		40
Inpatient Substance Use Disorder Services (including Acute Inpatient Detoxification, Substance Use Disorder Inpatient Rehabilitation, Substance Use Disorder Residential Treatment Services)		40
Outpatient Substance Use Disorder Rehabilitation Services (including Outpatient Detoxification, Substance Use Disorder Partial Hospitalization, and Substance Use Disorder Intensive Outpatient Services)		41
Durable Medical Equipment		41
 Car/Van Modifications.		41
External Prosthetic Appliances and Devices		41
Prostheses/Prosthetic Appliances and Devices		42
Orthoses and Orthotic Devices		42
Braces		42
Splints		42
Fertility Services		42
Outpatient Therapy Services		43
Cognitive Therapy, Occupational Therapy, Osteopathic Manipulation, Physical Therapy, Pulmonary Rehabilitation, Speech Therapy		43
Cardiac Rehabilitation		43
Chiropractic Care Services		43
Breast Reconstruction and Breast Prostheses		44
Reconstructive Surgery		44
Transplant Services and Related Specialty Care		44
Transplant and Related Specialty Care Travel Services		45
Advanced Cellular Therapy		45
Advanced Cellular Therapy Travel Services		45
Medical Pharmaceuticals		46
Gene Therapy		47
Gene Therapy Travel Services		47
Clinical Trials		47
Prescription Drug Benefits		52
Covered Expenses		52
Prescription Drug List Management		52
Limitations		52
Prior Authorization Requirements		53
Step Therapy		53
Supply Limits		53
Specialty Prescription Drug Products		53
Designated Pharmacies		53
New Prescription Drug Products		54
Your Payments		54
Deductible		54
Coinsurance		54
Payments at Non-Network Pharmacies		54
Exclusions		54
Reimbursement/Filing a Claim		55
Retail Pharmacy		55
Exclusions, Expenses Not Covered and General Limitations		56
Additional coverage limitations determined by plan or provider type are shown in The Schedule. Payment for the following is specifically excluded from this plan:		56
Coordination of Benefits		59
Coverage under this Plan plus another Plan will not guarantee 100% reimbursement.		59
Definitions		59
Plan		59
Closed Panel Plan		59
Primary Plan		59
Secondary Plan		59
Reasonable Cash Value		59
Order of Benefit Determination Rules		59
Effect on the Benefits of This Plan		60
Recovery of Excess Benefits		60
Right to Receive and Release Information		60
Expenses For Which A Third Party May Be Responsible		61
Subrogation/Right of Reimbursement		61
Lien of the Plan		61
Additional Terms		61
Payment of Benefits		62
Assignment and Payment of Benefits		62
Recovery of Overpayment		62
Calculation of Covered Expenses		62
Termination of Insurance		63
Employees		63
Temporary Layoff or Leave of Absence		63
Injury or Sickness		63
Dependents		63
Rescissions		63
Federal Requirements		63
Notice of Provider Directory/Networks		63
Notice Regarding Provider Directories and Provider Networks		63
Notice Regarding Pharmacy Directories and Pharmacy Networks		63
Qualified Medical Child Support Order (QMCSO)		63
Eligibility for Coverage Under a QMCSO		63
Qualified Medical Child Support Order Defined		64
Payment of Benefits		64
Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA)		64
Except as stated above, special enrollment must be requested within 30 days after the occurrence of the special enrollment event. If the special enrollment event is the birth or adoption of a Dependent child, coverage will be effective immediately on...		65
A. Coverage elections		65
B. Change of status		65
C. Court order		66
D. Medicare or Medicaid eligibility/entitlement		66
E. Change in cost of coverage		66
F. Changes in coverage of spouse or Dependent under another employer’s plan		66
Eligibility for Coverage for Adopted Children		66
Coverage for Maternity Hospital Stay		66
Women’s Health and Cancer Rights Act (WHCRA)		66
Group Plan Coverage Instead of Medicaid		67
Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA)		67
Continuation of Health Insurance During Leave		67
Reinstatement of Canceled Insurance Following Leave		67
Uniformed Services Employment and Re- Employment Rights Act of 1994 (USERRA)		67
Continuation of Coverage		67
Reinstatement of Benefits (applicable to all coverages)		67
Appointment of Authorized Representative		67
Medical - When You Have a Complaint or an Appeal		68
Start With Customer Service		68
Internal Appeals Procedure		68
External Review Procedure		69
Notice of Benefit Determination on Appeal		69
Relevant Information		69
Legal Action		69
COBRA Continuation Rights Under Federal Law		70
For You and Your Dependents		70
What is COBRA Continuation Coverage?		70
When is COBRA Continuation Available?		70
Who is Entitled to COBRA Continuation?		70
Secondary Qualifying Events		70
Disability Extension		70
Medicare Extension for Your Dependents		71
Termination of COBRA Continuation		71
Moving Out of Employer’s Service Area or Elimination of a Service Area		71
Employer’s Notification Requirements		71
How to Elect COBRA Continuation Coverage		71
How Much Does COBRA Continuation Coverage Cost?		72
When and How to Pay COBRA Premiums		72
You Must Give Notice of Certain Qualifying Events		72
Newly Acquired Dependents		72
COBRA Continuation for Retirees Following Employer’s Bankruptcy		72
Interaction With Other Continuation Benefits		73
ERISA Required Information		73
Plan Trustees		73
Plan Type		73
Collective Bargaining Agreements		73
Discretionary Authority		73
Plan Modification, Amendment and Termination		73
Statement of Rights		74
Receive Information About Your Plan and Benefits		74
Continue Group Health Plan Coverage		74
Prudent Actions by Plan Fiduciaries		74
Enforce Your Rights		74
Assistance with Your Questions		75
Definitions		75
Active Service		75
Ambulance		75
Ancillary Charge		75
Biologic		75
Biosimilar		75
Brand Drug		76
Business Decision Team		76
Charges		76
Chiropractic Care		76
Convenience Care Clinics		76
Custodial Services		76
Dependent		76
Designated Pharmacy		77
Emergency Medical Condition		77
Emergency Services		77
Employee		77
Employer		78
Essential Health Benefits		78
Expense Incurred		78
Free-Standing Surgical Facility		78
Generic Drug		78
Hospice Care Program		78
Hospice Care Services		78
Hospice Facility		79
Hospital		79
Hospital Confinement or Confined in a Hospital		79
Injury		79
Maintenance Drug Product		79
Maintenance Treatment		79
Maximum Reimbursable Charge – Medical		79
Medicaid		80
Medical Pharmaceutical		80
Medically Necessary/Medical Necessity		80
Medicare		81
Necessary Services and Supplies		81
Network Pharmacy		81
New Prescription Drug Product		81
Nurse		81
Other Health Care Facility		81
Other Health Professional		81
Participating Provider		82
Patient Protection and Affordable Care Act of 2010 (“PPACA”)		82
Pharmacy		82
Pharmacy & Therapeutics (P&T) Committee		82
Physician		82
Prescription Drug Charge		82
Prescription Drug List		82
Prescription Drug Product		83
Prescription Order or Refill		83
PPACA Preventive Medication		83
Preventive Treatment		83
Primary Care Physician		83
Psychologist		83
Review Organization		84
Room and Board		84
Sickness – For Medical Insurance		84
Skilled Nursing Facility		84
Specialist		84
Specialty Prescription Drug Product		84
Stabilize		84
Terminal Illness		85
Usual and Customary (U&C) Charge		85
Therapeutic Alternative		85
Therapeutic Equivalent		85
Urgent Care		85
What You Should Know About Cigna Choice Fund® – Health Savings Account		87
Cigna Choice Fund is designed to give you:		87
The Basics Who is eligible?		87
How does it work?		87
2. You choose how to pay for qualified health care expenses:		87
Which services are covered by my Cigna Choice Fund Health Savings Account?		88
Which services are covered by my Cigna medical plan, and which will I have to pay out of my own pocket?		88
Tools and Resources at Your Fingertips		88
If you’re not sure where to begin, you have access to health advocates.		88
Wherever you go in the U.S., you take the Cigna 24-Hour Health Information Line with you.		88
www.myCigna.com		88
Compare costs		88
Find out more about your local hospitals		88
Get the facts about your medication, cost, treatment options and side effects		88
Take control of your health		89
Explore topics on medicine, health and wellness		89
Keep track of your personal health information		89
Chart progress of important health indicators		89
Getting the Most from Your HSA		89
If you need hospital care, there are several tools to help you make informed decisions about quality and cost.		89
A little knowledge goes a long way.		89

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