Mid-America Apartments, L.P.
OPEN ACCESS PLUS MEDICAL BENEFITS Health Reimbursement Account
EFFECTIVE DATE: January 1, 2020
ASO21 3332254
This document printed in May, 2020 takes the place of any documents previously issued to you which described your benefits.
Printed in U.S.A.
Table of Contents
Important Information..................................................................................................................5
Special Plan Provisions..................................................................................................................7
Important Notices ..........................................................................................................................8
How To File Your Claim .............................................................................................................10
Eligibility - Effective Date ...........................................................................................................11 Employee Insurance .............................................................................................................................................11 Waiting Period......................................................................................................................................................11 Dependent Insurance ............................................................................................................................................11
Important Information About Your Medical Plan...................................................................12
Open Access Plus Medical Benefits ............................................................................................13 The Schedule ........................................................................................................................................................13 Certification Requirements - Out-of-Network......................................................................................................28 Prior Authorization/Pre-Authorized .....................................................................................................................28 Covered Expenses ................................................................................................................................................29 Prescription Drug Benefits..........................................................................................................40 The Schedule ........................................................................................................................................................40 Covered Expenses ................................................................................................................................................43 Limitations............................................................................................................................................................43 Your Payments .....................................................................................................................................................45 Exclusions ............................................................................................................................................................45 Reimbursement/Filing a Claim.............................................................................................................................46
Exclusions, Expenses Not Covered and General Limitations ..................................................47
Coordination of Benefits..............................................................................................................49
Expenses For Which A Third Party May Be Responsible .......................................................51
Payment of Benefits .....................................................................................................................52
Termination of Insurance............................................................................................................53 Employees ............................................................................................................................................................53 Dependents ...........................................................................................................................................................53 Rescissions ...........................................................................................................................................................53 Federal Requirements .................................................................................................................53 Notice of Provider Directory/Networks................................................................................................................54 Qualified Medical Child Support Order (QMCSO) .............................................................................................54 Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) ..................54 Effect of Section 125 Tax Regulations on This Plan ............................................................................................55 Eligibility for Coverage for Adopted Children.....................................................................................................56 Coverage for Maternity Hospital Stay ..................................................................................................................57 Women’s Health and Cancer Rights Act (WHCRA) ...........................................................................................57 Group Plan Coverage Instead of Medicaid...........................................................................................................57 Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) ...............................................57
Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) ....................................57 Claim Determination Procedures under ERISA ...................................................................................................58 Appointment of Authorized Representative .........................................................................................................59 Medical - When You Have a Complaint or an Appeal .........................................................................................59 COBRA Continuation Rights Under Federal Law ...............................................................................................61 ERISA Required Information ...............................................................................................................................64 Definitions.....................................................................................................................................66 What You Should Know About Cigna Choice Fund ® – Health Reimbursement Account .........................................................................................................................................78
Important Information 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 CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT INSURE THE BENEFITS DESCRIBED. 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," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR "EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND "INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE."
HC-NOT89
Explanation of Terms You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms are defined in the Definitions section of your certificate.
The Schedule 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.
You, your dependent or an attending Physician can request Case Management services by calling the toll-free number shown on your ID card during normal business hours, Monday through Friday. In addition, your employer, a claim office or a utilization review program (see the PAC/CSR section of your certificate) may refer an individual for Case Management. The Review Organization assesses each case to determine whether Case Management is appropriate. You or your Dependent is contacted by an assigned Case Manager who explains in detail how the program works. Participation in the program is voluntary - no penalty or benefit reduction is imposed if you do not wish to participate in Case Management. Following an initial assessment, the Case Manager works with you, your family and Physician to determine the needs of the patient and to identify what alternate treatment programs are available (for example, in-home medical care in lieu of an extended Hospital convalescence). You are not penalized if the alternate treatment program is not followed. The Case Manager arranges for alternate treatment services and supplies, as needed (for example, nursing services or a Hospital bed and other Durable Medical Equipment for the home). The Case Manager also acts as a liaison between the insurer, the patient, his or her family and Physician as needed (for example, by helping you to understand a complex medical diagnosis or treatment plan). Once the alternate treatment program is in place, the Case Manager continues to manage the case to ensure the treatment program remains appropriate to the patient's needs. While participation in Case Management is strictly voluntary, Case Management professionals can offer quality, cost- effective treatment alternatives, as well as provide assistance in obtaining needed medical resources and ongoing family support in a time of need.
Special Plan Provisions When you select a Participating Provider, this Plan pays a greater share of the costs than if you select a non-Participating Provider. Participating Providers include Physicians, Hospitals and Other Health Care Professionals and Other Health Care Facilities. Consult your Physician Guide for a list of Participating Providers in your area. Participating Providers are committed to providing you and your Dependents appropriate care while lowering medical costs. Services Available in Conjunction With Your Medical Plan The following pages describe helpful services available in conjunction with your medical plan. You can access these services by calling the toll-free number shown on the back of your ID card.
HC-SPP44
04-17
Case Management Case Management is a service provided through a Review Organization, which assists individuals with treatment needs that extend beyond the acute care setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a Hospital or specialized facility. Should the need for Case Management arise, a Case Management professional will work closely with the patient, his or her family and the attending Physician to determine appropriate treatment options which will best meet the patient's needs and keep costs manageable. The Case Manager will help coordinate the treatment program and arrange for necessary resources. Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis. Case Managers are Registered Nurses (RNs) and other credentialed health care professionals, each trained in a clinical specialty area such as trauma, high risk pregnancy and neonates, oncology, mental health, rehabilitation or general medicine and surgery. A Case Manager trained in the appropriate clinical specialty area will be assigned to you or your dependent. In addition, Case Managers are supported by a panel of Physician advisors who offer guidance on up-to- date treatment programs and medical technology. While the Case Manager recommends alternate treatment programs and helps coordinate needed resources, the patient's attending Physician remains responsible for the actual medical care.
HC-SPP2
04-10
V1
Additional Programs We may, from time to time, offer or arrange for various entities to offer discounts, benefits, or other consideration to our members for the purpose of promoting the general health and well being of our members. We may also arrange for the reimbursement of all or a portion of the cost of services
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provided by other parties to the Policyholder. Contact us for details regarding any such arrangements.
Important Information Rebates and Other Payments
Cigna or its affiliates may receive rebates or other remuneration from pharmaceutical manufacturers in
HC-SPP3
04-10
connection with certain Medical Pharmaceuticals covered under your plan and Prescription Drug Products included on the Prescription Drug List. These rebates or remuneration are not obtained on you or your Employer’s or plan’s behalf or for your benefit. Cigna, its affiliates and the plan are not obligated to pass these rebates on to you, or apply them to your plan’s Deductible if any or take them into account in determining your Copayments and/or Coinsurance. Cigna and its affiliates or designees, conduct business with various pharmaceutical manufacturers separate and apart from this plan’s Medical Pharmaceutical and Prescription Drug Product benefits. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this plan. Cigna and its affiliates are not required to pass on to you, and do not pass on to you, such amounts. Coupons, Incentives and Other Communications At various times, Cigna or its designee may send mailings to you or your Dependents or to your Physician that communicate a variety of messages, including information about Medical Pharmaceuticals and Prescription Drug Products. These mailings may contain coupons or offers from pharmaceutical manufacturers that enable you or your Dependents, at your discretion, to purchase the described Medical Pharmaceutical and Prescription Drug Product at a discount or to obtain it at no charge. Pharmaceutical manufacturers may pay for and/or provide the content for these mailings. Cigna, its affiliates and the plan are not responsible in any way for any decision you make in connection with any coupon, incentive, or other offer you may receive from a pharmaceutical manufacturer or Physician.
V1
Care Management and Care Coordination Services Your plan may enter into specific collaborative arrangements with health care professionals committed to improving quality care, patient satisfaction and affordability. Through these collaborative arrangements, health care professionals commit to proactively providing participants with certain care management and care coordination services to facilitate achievement of these goals. Reimbursement is provided at 100% for these services when rendered by designated health care professionals in these collaborative arrangements.
HC-SPP27
06-15
V1
Important Notices Direct Access to Obstetricians and Gynecologists
You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit www.mycigna.com or contact customer service at the phone
number listed on the back of your ID card. Selection of a Primary Care Provider
HC-IMP258
01-19
This plan generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. For children, you may designate a pediatrician as the primary care provider.
Discrimination is Against the Law Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Cigna: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters
HC-NOT5
01-11
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Chinese – 注意：我們可為您免費提供語言協助服務。 對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。 其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711 ）。 Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711). Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 ( TTY : 다이얼 711 )번으로 전화해주십시오. Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711). Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).
Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as Qualified interpreters Information written in other languages If you need these services, contact customer service at the toll- free phone number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by sending an email to ACAGrievance@cigna.com or by writing to the following address: Cigna Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711). French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre
HC-NOT96
07-17
Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).
carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).
Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711). Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).
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Japanese – 注意事項：日本語を話される場合、無料の言語支援サー ビスをご利用いただけます。現在の Cigna の お客様は、 ID カード裏面の電話番号まで、お電話にてご 連絡ください。その他の方は、 1.800.244.6224 （ TTY: 711 ）まで、お電話にてご連絡ください。 Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).
Exclusions and/or restrictions based on geographic location, facility type or provider specialty. A description of your plan’s NQTL methodologies and processes applied to medical/surgical benefits and MH/SUD benefits is available for review by Plan Administrators (e.g. employers) and covered persons by accessing the appropriate link below: Employers (Plan Administrators): https://cignaaccess.cigna.com/secure/app/ca/centralRepo - Log in, select Resources and Training, then select the NQTL document. Covered Persons: www.cigna.com\sp To determine which document applies to your plan, select the relevant health plan product; medical management model (inpatient only or inpatient and outpatient) which can be located in this booklet immediately following The Schedule; and pharmacy coverage (whether or not your plan includes pharmacy coverage).
HC-NOT113
01-20
How To File Your Claim There’s no paperwork for In-Network care. Just show your identification card and pay your share of the cost, if any; your provider will submit a claim to Cigna for reimbursement. Out- of-Network claims can be submitted by the provider if the provider is able and willing to file on your behalf. If the provider is not submitting on your behalf, you must send your completed claim form and itemized bills to the claims address listed on the claim form. You may get the required claim forms from the website listed on your identification card or by using the toll-free number on
HC-NOT97
07-17
Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) - Non-Quantitative Treatment Limitations (NQTLs) Federal MHPAEA regulations provide that a plan cannot impose a Non-Quantitative Treatment Limitation (NQTL) on mental health or substance use disorder (MH/SUD) benefits in any classification unless the processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits are comparable to, and are applied no more stringently than, those used in applying the NQTL to medical/surgical benefits in the same classification of benefits as written and in operation under the terms of the plan. Non-Quantitative Treatment Limitations (NQTLs) include: Medical management standards limiting or excluding benefits based on Medical Necessity or whether the treatment is experimental or investigative; Prescription drug formulary design; Network admission standards; Methods for determining in-network and out-of-network provider reimbursement rates; Step therapy a/k/a fail-first requirements; and
your identification card. CLAIM REMINDERS
BE SURE TO USE YOUR MEMBER ID AND ACCOUNT/GROUP NUMBER WHEN YOU FILE CIGNA’S CLAIM FORMS, OR WHEN YOU CALL YOUR CIGNA CLAIM OFFICE. YOUR MEMBER ID IS THE ID SHOWN ON YOUR BENEFIT IDENTIFICATION CARD. YOUR ACCOUNT/GROUP NUMBER IS SHOWN ON YOUR BENEFIT IDENTIFICATION CARD. BE SURE TO FOLLOW THE INSTRUCTIONS LISTED ON THE BACK OF THE CLAIM FORM CAREFULLY WHEN SUBMITTING A CLAIM TO CIGNA.
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Timely Filing of Out-of-Network Claims Cigna will consider claims for coverage under our plans when proof of loss (a claim) is submitted within 180 days for Out- of-Network benefits after services are rendered. If services are rendered on consecutive days, such as for a Hospital Confinement, the limit will be counted from the last date of service. If claims are not submitted within 180 days for Out- of-Network benefits, the claim will not be considered valid and will be denied. WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information; or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.
Waiting Period First of the Month on or after 30 days of active service. Classes of Eligible Employees Each Employee as reported to the insurance company by your Employer. Effective Date of Employee Insurance You will become insured on the date you elect the insurance by completing the Employer’s specified enrollment process, but no earlier than the date you become eligible. You will become insured on your first day of eligibility, following your election, if you are in Active Service on that date, or if you are not in Active Service on that date due to your health status. Late Entrant - Employee You are a Late Entrant if: you elect the insurance more than 31days after you become eligible; or you again elect it after you cancel your payroll deduction (if required). Dependent Insurance For your Dependents to be insured, you will have to pay the required contribution, if any, toward the cost of Dependent Insurance. Effective Date of Dependent Insurance Insurance for your Dependents will become effective on the date you elect it by completing the Employer’s specified enrollment process, but no earlier than the day you become eligible for Dependent Insurance. All of your Dependents as defined will be included. Your Dependents will be insured only if you are insured. Late Entrant – Dependent You are a Late Entrant for Dependent Insurance if: you elect that insurance more than 31 days after you become eligible for it; or you again elect it after you cancel your payroll deduction (if required). Exception for Newborns Any Dependent child born while you are insured will become insured on the date of his birth if you elect Dependent Insurance no later than 31 days after his birth. If you do not elect to insure your newborn child within such 31 days, coverage for that child will end on the 31st day. No benefits for expenses incurred beyond the 31st day will be payable.
HC-CLM25
01-11
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Eligibility - Effective Date
Employee Insurance This plan is offered to you as an Employee. Eligibility for Employee Insurance You will become eligible for insurance on the day you complete the waiting period if: you are in a Class of Eligible Employees; and you are an eligible, full-time Employee; and you normally work at least 30 hours a week; and you pay any required contribution. If you were previously insured and your insurance ceased, you must satisfy the New Employee Group Waiting Period to become insured again. Initial Employee Group: You are in the Initial Employee Group if you are employed in a class of employees on the date that class of employees becomes a Class of Eligible Employees as determined by your Employer. New Employee Group: You are in the New Employee Group if you are not in the Initial Employee Group Eligibility for Dependent Insurance Insurance for your Dependents will become effective on the date you elect it by completing the Employer’s specified enrollment process, but no earlier than the day you become eligible for Dependent Insurance.
the day you become eligible for yourself; or the day you acquire your first Dependent.
HC-ELG274 M
01-19
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Important Information About Your Medical Plan Details of your medical benefits are described on the following pages. Opportunity to Select a Primary Care Physician Choice of Primary Care Physician: This medical plan does not require that you select a Primary Care Physician or obtain a referral from a Primary Care Physician in order to receive all benefits available to you under this medical plan. Notwithstanding, a Primary Care Physician may serve an important role in meeting your health care needs by providing or arranging for medical care for you and your Dependents. For this reason, we encourage the use of Primary Care Physicians and provide you with the opportunity to select a Primary Care Physician from a list provided by Cigna for yourself and your Dependents. If you choose to select a Primary Care Physician, the Primary Care Physician you select for yourself may be different from the Primary Care Physician you select for each of your Dependents. Changing Primary Care Physicians: You may request a transfer from one Primary Care Physician to another by contacting us at the member services number on your ID card. Any such transfer will be effective on the first day of the month following the month in which the processing of the change request is completed. In addition, if at any time a Primary Care Physician ceases to be a Participating Provider, you or your Dependent will be notified for the purpose of selecting a new Primary Care Physician.
HC-IMP212
01-18
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Open Access Plus Medical Benefits The Schedule
For You and Your Dependents Open Access Plus Medical Benefits provide coverage for care In-Network and Out-of-Network. To receive Open Access Plus Medical Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for services and supplies. That portion is the Copayment, Deductible or Coinsurance. When you receive services from an In-Network Provider, remind your provider to utilize In-Network Providers for x-rays, lab tests and other services to ensure the cost may be considered at the In-Network level. If you are unable to locate an In-Network Provider in your area who can provide you with a service or supply that is covered under this plan, you must call the number on the back of your I.D. card to obtain authorization for Out-of- Network Provider coverage. If you obtain authorization for services provided by an Out-of-Network Provider, benefits for those services will be covered at the In-Network benefit level. . Coinsurance The term Coinsurance means the percentage of Covered Expenses that an insured person is required to pay under the plan in addition to the Deductible, if any. Copayments/Deductibles Copayments are amounts to be paid by you or your Dependent for covered services. Deductibles are Covered Expenses to be paid by you or your Dependent before benefits are payable under this plan. Deductible amounts are separate from and not reduced by Copayments. Copayments and Deductibles are in addition to any Coinsurance. Once the Deductible maximum in The Schedule has been reached, you and your family need not satisfy any further medical deductible for the rest of that year. Out-of-Pocket Expenses - For In-Network Charges Only Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan because of any Deductibles, Copayments or Coinsurance. Such Covered Expenses accumulate to the Out-of-Pocket Maximum shown in The Schedule. When the Out-of-Pocket Maximum is reached, all Covered Expenses, except charges for non-compliance penalties, are payable by the benefit plan at 100%. Out-of-Pocket Expenses - For Out-of-Network Charges Only Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan. The following Expenses contribute to the Out-of-Pocket Maximum, and when the Out-of-Pocket Maximum shown in The Schedule is reached, they are payable by the benefit plan at 100%: Coinsurance. Plan Deductible. Once the Out-of-Pocket Maximum is reached for covered services that apply to the Out-of-Pocket Maximum, any copayments and/or benefit deductibles are no longer required. The following Out-of-Pocket Expenses and charges do not contribute to the Out-of-Pocket Maximum, and they are not payable by the benefit plan at 100% when the Out-of-Pocket Maximum shown in The Schedule is reached: Non-compliance penalties. Any copayments and/or benefit deductibles not listed above as accumulating to the Out-of-Pocket maximum. Provider charges in excess of the Maximum Reimbursable Charge. .
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Open Access Plus Medical Benefits The Schedule
Accumulation of Plan Deductibles and Out-of-Pocket Maximums Deductibles and Out-of-Pocket Maximums will accumulate in one direction (that is, Out-of-Network will accumulate to In-Network). All other plan maximums and service-specific maximums (dollar and occurrence) cross-accumulate between In- and Out-of-Network unless otherwise noted. . Note: For information about your health fund benefit and how it can help you pay for expenses that may not be covered under this plan, refer to “What You Should Know about Cigna Choice Fund”. Multiple Surgical Reduction Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid as any other surgery.
Assistant Surgeon and Co-Surgeon Charges
Assistant Surgeon The maximum amount payable will be limited to charges made by an assistant surgeon that do not exceed a percentage of the surgeon's allowable charge as specified in Cigna Reimbursement Policies. (For purposes of this limitation, allowable charge means the amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts.) Co-Surgeon The maximum amount payable for charges made by co-surgeons will be limited to the amount specified in Cigna Reimbursement Policies. Out-of-Network Emergency Services Charges 1. Emergency Services are covered at the In-Network cost-sharing level if services are received from a non-participating (Out-of-Network) provider. 2. The allowable amount used to determine the Plan’s benefit payment for covered Emergency Services rendered in an Out-of-Network Hospital, or by an Out-of-Network provider in an In-Network Hospital, is the amount agreed to by the Out-of-Network provider and Cigna, or if no amount is agreed to, the greatest of the following, not to exceed the provider’s billed charges: (i) the median amount negotiated with In-Network providers for the Emergency Service, excluding any In-Network copay or coinsurance; (ii) the Maximum Reimbursable Charge; or (iii) the amount payable under the Medicare program. The member is responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance). The member is also responsible for all charges that may be made in excess of the allowable amount. If the Out-of-Network provider bills you for an amount higher than the amount you owe as indicated on the Explanation of Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card.
BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Unlimited
Lifetime Maximum
80%
50% of the Maximum Reimbursable Charge
The Percentage of Covered Expenses the Plan Pays
Note: "No charge" means an insured person is not required to pay Coinsurance.
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BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Maximum Reimbursable Charge
Maximum Reimbursable Charge is determined based on the lesser of the provider’s normal charge for a similar service or supply; or A policyholder-selected percentage of a fee schedule Cigna has developed that is based upon a methodology similar to a methodology utilized by Medicare to determine the allowable fee for the same or similar services within the geographic market. In some cases, a Medicare based schedule will not be used and the Maximum Reimbursable Charge for covered services is determined based on the lesser of: the provider’s normal charge for a similar service or supply; or the 80th percentile of charges made by providers of such service or supply in the geographic area where
Not Applicable
110%
it is received as compiled in a database selected by Cigna. If
sufficient charge data is unavailable in the database for that geographic area to determine the Maximum Reimbursable Charge, then data in the database for similar services may be used. Note: The provider may bill you for the difference between the provider’s normal charge and the Maximum Reimbursable Charge, in addition to applicable deductibles, copayments and coinsurance. Note: Some providers forgive or waive the
cost share obligation (e.g. your copayment, deductible and/or
coinsurance) that this plan requires you to pay. Waiver of your required cost share obligation can jeopardize your coverage under this plan. For more details, see the Exclusions Section. .
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BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Calendar Year Deductible
Individual
$1,500 per person
$3,000 per person
Family Maximum
$3,000 per family
$6,000 per family
Family Maximum Calculation Individual Calculation:
Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance. Combined Out-of-Pocket Maximum for Medical and Pharmacy expenses
Individual
$4,000 per person
$8,000 per person
Family Maximum
$8,000 per family
$16,000 per family
Family Maximum Calculation Individual Calculation:
Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of- Pocket being met, their claims will be paid at 100%.
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BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Combined Medical/Pharmacy Out- of-Pocket Maximum Combined Medical/Pharmacy Out- of-Pocket: includes retail and home delivery drugs Home Delivery Pharmacy Costs Contribute to the Combined Medical/Pharmacy Out-of-Pocket Maximum Physician’s Services Primary Care Physician’s Office Visit Specialty Care Physician’s Office Visits Consultant and Referral Physician’s Services Note: OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company. Surgery Performed in the Physician’s Office
Yes
Yes
Yes
Yes
No charge after $30 per office visit copay No charge after $40 Specialist per office visit copay
50% after plan deductible
50% after plan deductible
No charge after the $30 PCP or $40 Specialist per office visit copay No charge after the $30 PCP or $40 Specialist per office visit copay No charge after either the $30 PCP or $40 Specialist per office visit copay or the actual charge, whichever is less
50% after plan deductible
Second Opinion Consultations (provided on a voluntary basis)
50% after plan deductible
Allergy Treatment/Injections
50% after plan deductible
Allergy Serum (dispensed by the Physician in the office)
No charge
50% after plan deductible
Medical Telehealth
No charge
In-Network coverage only
Preventive Care Routine Preventive Care - all ages
No charge
In-Network coverage only
Immunizations - all ages
No charge
In-Network coverage only
Mammograms, PSA, PAP Smear Preventive Care Related Services (i.e. “routine” services)
No charge
50% after plan deductible
Diagnostic Related Services (i.e. “non-routine” services)
Subject to the plan’s x-ray & lab benefit; based on place of service
Subject to the plan’s x-ray & lab benefit; based on place of service
.
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BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
80% after plan deductible
50% after plan deductible
Inpatient Hospital - Facility Services
Semi-Private Room and Board
Limited to the semi-private room negotiated rate Limited to the semi-private room negotiated rate
Limited to the semi-private room rate
Private Room
Limited to the semi-private room rate
Special Care Units (ICU/CCU)
Limited to the ICU/CCU daily room rate
Limited to the negotiated rate
Outpatient Facility Services Operating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room
80% after plan deductible
50% after plan deductible
80% after plan deductible
50% after plan deductible
Inpatient Hospital Physician’s Visits/Consultations
80% after plan deductible
50% after plan deductible
Inpatient Hospital Professional Services
Surgeon Radiologist Pathologist Anesthesiologist
80% after plan deductible
50% after plan deductible
Outpatient Professional Services
Surgeon Radiologist Pathologist Anesthesiologist
Urgent Care Services
Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
No charge after the $30 PCP or $40 Specialist per office visit copay
Urgent Care Facility or Outpatient Facility
No charge after $50 per visit copay*
No charge after $50 per visit copay*
*waived if admitted
*waived if admitted
Outpatient Professional Services (radiology, pathology, physician) X-ray and/or Lab performed at the Urgent Care Facility (billed by the facility as part of the UC visit) Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans, PET Scans etc.)
No charge
No charge
No charge
No charge
No charge
No charge
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BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Emergency Services
Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
No charge after the $30 PCP or $40 Specialist per office visit copay
Hospital Emergency Room
80% after plan deductible
80% after plan deductible
Outpatient Professional Services (radiology, pathology, ER physician) X-ray and/or Lab performed at the Emergency Room Facility (billed by the facility as part of the ER visit) Independent X-ray and/or Lab Facility in conjunction with an ER visit Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans, PET Scans etc.)
80% after plan deductible
80% after plan deductible
No charge
No charge
No charge
No charge
No charge
No charge
No charge
No charge
Ambulance
80% after plan deductible
50% after plan deductible
Inpatient Services at Other Health Care Facilities Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub- Acute Facilities Calendar Year Maximum: 90 days combined . Laboratory and Radiology Services (includes pre-admission testing) Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Outpatient Hospital Facility
80% after plan deductible
50% after plan deductible
Independent X-ray and/or Lab Facility
80% after plan deductible
50% after plan deductible
Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans and PET Scans) Physician’s Office Visit
No charge
50% after plan deductible
Inpatient Facility
80% after plan deductible
50% after plan deductible
Outpatient Facility
80% after plan deductible
50% after plan deductible
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BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Outpatient Therapy Services Calendar Year Maximum:
90 days for all therapies combined (The limit is not applicable to mental health conditions.)
Note: Outpatient Short Term Rehab copay applies, regardless of place of service, including the home. Outpatient Therapy Services copay
Includes: Physical Therapy Speech Therapy Occupational Therapy Pulmonary Rehab Cognitive Therapy
applies, regardless of place of service, including the home.
. Outpatient Cardiac Rehabilitation Calendar Year Maximum: 36 days
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Chiropractic Care Calendar Year Maximum: 20 days Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Home Health Care
80% after plan deductible
50% after plan deductible
Calendar Year Maximum: 120 days (includes outpatient private nursing when approved as Medically Necessary) (The limit is not applicable to Mental Health and Substance Use Disorder conditions.) . Hospice Inpatient Services Outpatient Services (same coinsurance level as Home Health Care) Bereavement Counseling Services provided as part of Hospice Care Inpatient
80% after plan deductible
50% after plan deductible
80% after plan deductible
50% after plan deductible
80% after plan deductible
50% after plan deductible
Outpatient
80% after plan deductible
50% after plan deductible
Services provided by Mental Health Professional
Covered under Mental Health benefit
Covered under Mental Health benefit
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BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Gene Therapy Includes prior authorized gene therapy products and services directly related to their administration, when Medically Necessary. Gene therapy must be received at an In- Network facility specifically contracted with Cigna to provide the specific gene therapy. Gene therapy at other In- Network facilities is not covered.
Gene Therapy Product
Subject to In-Network facility cost share based on place of service; separate from facility charges
In-Network coverage only
Inpatient Facility
80% after plan deductible
In-Network coverage only
Outpatient Facility
80% after plan deductible
In-Network coverage only
Physician’s Services
80% after plan deductible
In-Network coverage only
Travel Maximum: $10,000 per episode of gene therapy
No charge (available only for travel when prior authorized to receive gene therapy at a participating In- Network facility specifically contracted with Cigna to provide the specific gene therapy)
In-Network coverage only
Maternity Care Services Initial Visit to Confirm Pregnancy
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Note: OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company. All subsequent Prenatal Visits, Postnatal Visits and Physician’s Delivery Charges (i.e. global maternity fee) Physician’s Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist Delivery - Facility (Inpatient Hospital, Birthing Center)
80% after plan deductible
50% after plan deductible
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
80% after plan deductible
50% after plan deductible
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BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Abortion Includes only non-elective procedures Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Inpatient Facility
80% after plan deductible
50% after plan deductible
Outpatient Facility
80% after plan deductible
50% after plan deductible
Physician’s Services
80% after plan deductible
50% after plan deductible
Women’s Family Planning Services Office Visits, Lab and Radiology Tests and Counseling Note: Includes coverage for contraceptive devices (e.g., Depo-Provera and Intrauterine Devices (IUDs)) as ordered or prescribed by a physician. Diaphragms also are covered when services are provided in the physician’s office. Surgical Sterilization Procedures for Tubal Ligation (excludes reversals)
No charge
50% after plan deductible
Physician’s Office Visit
No charge
50% after plan deductible
Inpatient Facility
No charge
50% after plan deductible
Outpatient Facility
No charge
50% after plan deductible
Physician’s Services
No charge
50% after plan deductible
Men’s Family Planning Services Office Visits, Lab and Radiology Tests and Counseling Surgical Sterilization Procedures for Vasectomy (excludes reversals) Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Inpatient Facility
80% after plan deductible
50% after plan deductible
Outpatient Facility
80% after plan deductible
50% after plan deductible
Physician’s Services
80% after plan deductible
50% after plan deductible
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