Cigna in California

Overview
General Information

We offer a number of products, services, tools and capabilities to a wide variety of clients and to individuals.

 

Our HMO and Network plans are offered by Cigna HealthCare of California, Inc. Our Point-of-Service plans are offered by Cigna HealthCare of California, Inc. (in-network), Connecticut General Life Insurance Company (out-of-network) or Cigna Health and Life Insurance Company. Our Cigna Health Access, OAP, PPO, Indemnity, HRA, HSA, and Voluntary plans are offered and/or administered by Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company.

 

  • Connecticut General Life Insurance Company and Cigna Health and Life Insurance Company offer insurance plans in all counties in the state.
  • Cigna HealthCare of California, Inc. offers plans  in the following counties:

     

    Alameda, Butte, Contra Costa, El Dorado*, Fresno, Glenn, Kern, Kings, Los Angeles, Marin, Merced*, Placer*, Riverside*, Sacramento, San Bernardino*, San Diego, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma*, Stanislaus, Tulare*, Ventura and Yolo.

     

    *Partial County Only

If you are offered a Cigna plan through your employer and would like a better understanding of the benefit plan(s) offered to you, look for general descriptions in our Products and Services section.

Accessing Medical Services

Cigna HealthCare® offers a broad network of health care professionals and facilities throughout California. Our interactive Provider Directory can show you the participating physicians, hospitals and pharmacies located in the area you specify.   If you are enrolled in a Cigna HealthCare of California, Inc. plan, and you select a Primary Care Physician that is affiliated with a medical group, please be aware that your provider will refer you within that medical group for specialty care and some services.  To find out which providers are in Cigna Healthcare's networks, please view our Provider Directory by clicking on the "Find a Doctor" button at the top of the page. Customer's can also login to myCigna.com to get personal results for their specific medical plan. GWH-Cigna customers can login to myCignaforhealth.com for results specific to their medical plan. For a listing of health care professionals that participate in the Cigna Behavioral Health network, please visit apps.CignaBehavioral.com.

 

Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call Cigna HealthCare at the health plan at the number on your ID card to ensure that you can obtain the health care services you need.

 

You may contact Cigna Healthcare by calling customer services if you wish to obtain a list of the facilities with which the health care service plan is contracting for sub-acute care and/or transitional inpatient care.

Accessing Vision, Pharmacy and Mental Health and Substance Abuse Services

Some plans include vision, pharmacy and mental health and substance abuse services.

 

If you are currently enrolled in a Cigna Healthcare plan, and would like to learn more about what mental health services are available under your plan, which doctors are in the network and how to obtain services, please call the number on your Cigna ID card.

 

For information about optometry services, please call the number on your ID card.

 

Drug List: For information about which drugs are considered "Formulary" or "Preferred" and generally cost you less out-of-pocket, click on the following link: https://secure.cigna.com/cgi-bin/customer_care/member/drug_list/DrugList.cgi

Language Assistance

For non-English-speaking customers, we provide a 140-language capability through the Language Line Service. And we also offer translation services for some documents, to members who qualify.

Language Assistance Disclosure.

Transition of Care and Continuity of Care

If you are a new Cigna HealthCare of California, Inc. (HMO or Network Plan) enrollee living in California and meet certain criteria, you may be able to continue to receive services from a health care professional who is not in the Cigna HealthCare network. Please see our Transition of Care Brochure / / for more information.

 

If you are currently a Cigna HealthCare of California, Inc. (HMO or Network Plan) enrollee living in California and your health care professional or facility has left our network, you may be able to continue to receive services from that health care professional or facility if you meet certain criteria. Please see our Continuity of Care Brochure /   /  for more information.

 

If you are a new Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company (Cigna PPO or OAP plan) enrollee covered under a policy issued in California, you may be able to continue to receive services from a health care professional or facility that is not in the Cigna network. Please see our Transition of Care Brochure / / for more information and contact a customer service associate to determine if your plan is eligible.

 

If you are currently a Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company (Cigna PPO or OAP plan) enrollee, covered under a policy issued in California, and your health care professional or facility has left our network, you may be able to continue to receive services from that health care professional or facility if you meet certain criteria. Please see our Continuity of Care Brochure /   /  for more information and contact a customer service associate to determine if your plan is eligible.

Coverage After Your Group Coverage Ends
Cal-COBRA Continuation

If you began federal COBRA on or after January 1, 2003, and have recently exhausted that continuation coverage, you may be eligible to continue your Cigna HealthCare of California coverage through Cal-COBRA continuation.Please refer to your plan booklet for more information.You should receive notice of the availability of Cal-COBRA when your COBRA coverage ends. If you qualify for Cal-COBRA or are unsure whether you qualify, please call us at call us at 1.800.315.6011.We will confirm you are eligible to apply and will send you an application if you weren’t provided with a copy.You have 60 days from the date of the notice to apply.

Conversion Plan Information

Conversion is an individual plan that may be available to you after you exhaust COBRA and if applicable Cal-COBRA.The benefits and premium are not the same as those offered under the group continuation plan.Your employer will notify you within 15 days after your group continuation coverage ends that you qualify for a conversion plan.You must send your completed application to Cigna HealthCare along with your first month’s premium within 63 days of your termination date.  For more information please call us at call us at 1.800.315.6011. You should compare the benefits and premiums of the conversion plan with the benefits and premiums in a HIPAA plan (offered through various insurance companies), which is another option you may qualify for.Once you enroll in a conversion plan, you will not have the choice of later moving to a HIPAA plan.

 

To view the Cigna HealthCare of California, Inc. Conversion Comparative Benefit Matrix and Rates, go to the California Department of Managed Health Care website: www.dmhc.ca.gov/coverage/conversion/hp_default.aspx

Medical Review of Requested Services or Supplies
Covered Expense

Covered Expenses are expenses for services or supplies which are not excluded from your benefit plan, are recommended by a Physician, and are Medically Necessary for the care and treatment of an Injury or a Sickness.

Prior Authorization

Prior Authorization means the approval that must be received prior to services being rendered, in order for certain services and benefits to be covered expenses under your policy.  The Prior Authorization review may include benefit verification and a clinical review to determine whether the service or supply is medically necessary.  When you are seeking services or supplies from a contracted Cigna Health Care Physician or other Provider, that provider will determine whether a prior authorization review is required and submit the service/supply request for a prior authorization decision.  Approval decisions will be communicated to the Physician/Provider, and denial decisions will be communicated to you and the Physician/Provider in writing.

Medically Necessary/Medical Necessity

Medically Necessary Covered Services and Supplies are those determined by the Medical Director to be:

 

  • required to diagnose or treat an illness, injury, disease or its symptoms;
  • in accordance with generally accepted standards of medical practice;
  • clinically appropriate in terms of type, frequency, extent, site and duration;
  • not primarily for the convenience of the patient, Physician or other health care provider; and rendered in the least intensive setting that is appropriate for the delivery of the services and supplies. Where applicable, the Medical Director may compare the cost-effectiveness of alternative services, settings or supplies when determining least intensive setting.
Behavioral Health Review of Requested Services or Supplies
Receiving Assistance

If Cigna handles your behavioral health benefits, our staff can answer your benefit questions and assist you in getting behavioral health care and can assist you or your provider with the claim submission process or help answer questions about how claims have been processed.  Just contact us by dialing the number on your ID card.

Open Access to Outpatient Benefits

For routine outpatient office visits for behavioral care with an in-network psychiatrist or therapist, you do not need to contact us before your treatment appointment. To find an in-network psychiatrist or therapist, use our online directory or call us at the number listed on your member benefit card.

 

Be sure you understand the difference between in-network and out-of-network coverage. Seeing an in-network psychiatrist or therapist means you'll pay less and have no paperwork. In addition, Cigna requires that psychiatrists or therapists are licensed and meet Cigna’s quality guidelines for behavioral health.

Prior Benefit Authorization Required for Other Care

For any other type of behavioral care, you must contact us to pre-authorize benefit coverage to receive the maximum amount payment for your claims. Call the toll-free phone number on your insurance identification card to reach our staff. An Advocate or Care Manager will be happy to help. Have your insurance ID number available when you call.

 

Our phones are staffed 24 hours a day, seven days a week. When you contact us, you'll be connected with the staff who can best meet your needs. Our Customer Service and Advocate staff can answer benefit or network questions and our licensed Care Managers can help to select the type and level of care you need.

 

If you don't understand what is and isn't covered under your plan, please contact us. We can help explain your coverage, deductibles and copays, and tell you how to access the kind of care you need. Also, carefully read your benefit plan materials from your employer or health plan for details on your coverage.

Cigna HealthCare, Grievances & Appeals
Cigna HealthCare Grievance Procedure

We want you to be satisfied with the care that you receive. That's why we've established an internal grievance process for addressing your concerns and resolving your problems. Grievances include both complaints and appeals. Complaints can include concerns about people, quality of service, quality of care, benefit exclusions or eligibility. Appeals are requests to reverse a prior denial or a modified decision about your care.

How to File a Grievance

You can notify us of complaints or appeals in one of the following ways:

  1. Call us at 1.800.244.6224 or at the toll-free telephone number for mental health/substance abuse services on your Cigna HealthCare ID card. The hearing impaired may call the California Relay Service dialing 711.
  2. Write to us at:

    Cigna HealthCare Appeals Unit
    P.O. Box 188011
    Chattanooga, TN 37422
  3. If you prefer, you can print and complete our Medical Grievance Form / / . Simply mail the form to the address above or fax it to 1.877.815.4827.
  4. Submit an online grievance form.

If you are enrolled in a Cigna HealthCare of California, Inc. plan and the member  is a minor or is incompetent or unable to exercise rational judgment or give consent, the parent, guardian, conservator, relative or other legal representative acting on behalf of the customer, as appropriate, may submit a grievance to Cigna HealthCare or to the California Department of Managed Health Care as the agent of the customer.

 

A participating health care professional or any other person you identify may join with or assist you or act as your agent in submitting a grievance to Cigna HealthCare or the DMHC.

A. Complaints

If you are concerned about the quality of service or care you have received a benefit exclusion or an eligibility issue you should contact us to file a verbal or written complaint. If you contact us by telephone to file a complaint, we will attempt to document and/or resolve your complaint over the telephone. If we are unable to resolve your complaint on the day your call was received, or if we receive your complaint in the mail, we will investigate your complaint and will notify you of the outcome within 30 calendar days, unless your complaint is regarding the treatment you received. These complaints will be investigated by a clinician. If appropriate the complaint may go before a committee of physician reviewers. The outcome of these types of investigations must be kept confidential according to California law.

B. Appeals

If you are not satisfied with the outcome of a decision that was made about your care and are requesting that Cigna HealthCare reverse a previous decision, you should contact us to file a verbal or written appeal within one year of receiving the denial notice. Be sure to share any new information that may help justify a reversal of the original decision. We will tell you who to contact at Cigna HealthCare should you have questions or if you would like to submit additional information about your appeal. We will make sure that your appeal is handled by someone who has authority to take action. We will investigate your appeal and notify you of our decision within 30 calendar days. You may request that the appeal process be expedited if the timeframes under this process would seriously jeopardize your life or health or your ability to regain maximum functionality, or if you are experiencing severe pain. A competent Cigna HealthCare medical professional, in consultation with your treating physician, will decide if an expedited appeal is necessary. When an appeal is expedited, Cigna HealthCare will respond orally and in writing with a decision within 72 hours.

Language Assistance

For all customers who request language services through the grievance process, Cigna provides interpretation (oral) or translation services (written) in the customer’s preferred language to both notify Cigna of a complaint or appeal and to receive information from Cigna about their complaint or appeal.  If you have request for language assistance please call member services using the number on your ID card.

You Have Additional Rights Under State Law

If you are a Cigna HealthCare of California customer:

 

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1.800.244.6224 or the toll-free telephone number on your Cigna identification card [The hearing impaired may call the California Relay Service at 711]and use your health plan's grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.

If you need help with a grievance involving an emergency, or one that has not been satisfactorily resolved by your health plan, or one that has not been resolved after 30 days, call the Department for assistance.

You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of: medical decisions made by a health plan related to the medical necessity of a proposed service or treatment; coverage decisions for treatments that are experimental or investigational in nature; and payment disputes for emergency or urgent medical services. Call us at 1.800.753.0540 or at the toll-free telephone number for mental health/substance abuse services on your Cigna HealthCare ID card. The hearing impaired may call the California Relay Service at 711. The Department's Internet Web site www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

 

If you are a Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company customer:

 

You have the right to contact the California Department of Insurance for assistance at any time. The Commissioner may be contacted at the following address and fax number:

California Department of Insurance
Claims Service Bureau
300 South Spring Street
Los Angeles, CA 90013
Or fax to 213-897-5891

Voluntary Mediation

If you have received an appeal decision from Cigna HealthCare that you are not satisfied with, you may also request voluntary mediation with us before exercising the right to submit a grievance to the DMHC (if you are enrolled in a Cigna HealthCare of California plan) or to the California Department of Insurance (if you are enrolled in a Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company plan).  or participate in the IMR process. In order for mediation to take place, you and Cigna HealthCare each have to voluntarily agree to the mediation. Cigna HealthCare will consider each request for mediation on a case-by-case basis. Each side will equally share the expenses of the mediation. To initiate mediation, please submit a written request for mediation to:

Cigna HealthCare of California, Inc.
PO Box 188011
Chattanooga, TN 37422

Mandatory Binding Arbitration

To the extent permitted by law, Cigna HealthCare contractually requires the use of binding arbitration when disputes are left unsettled by other means. Arbitration may be initiated by a Demand to Arbitrate served on Cigna HealthCare of California, Inc. Binding arbitration is not mandatory for disputes pertaining to coverage plans governed by the Employee Retirement Income Security Act of 1974 (ERISA). If your plan is governed by ERISA, you have the right to bring civil action under Section 502(a) if you are not satisfied with the outcome of the appeal procedure. In most instances, you may not initiate a legal action until you have completed the Cigna HealthCare internal appeal process.

Cigna Dental Health of California, Inc., Grievances and Appeals
How to File a Grievance

You can notify us of complaints or appeals concerning the Cigna Dental Care (DHMO) Plan in one of the following ways:

  1. Call Customer Service at 1.800.244.6224.
  2. Write to us at:

    Cigna Dental Health of California, Inc.
    P.O. Box 188047
    Chattanooga, TN 37422-8047
  3. If you prefer, you can print and complete our Dental Grievance Form / / . Simply mail the form to the address above or fax it to 1.559.735.8257.
  4. Submit a dental online grievance form.

    For specific information regarding the Cigna Dental Health of California, Inc., grievance process, please
    • refer to your Combined Evidence of Coverage and Disclosure Form in your plan booklet; or
    • contact our Customer Service Department.
Cigna Behavioral Health of California, Inc., Grievances and Appeals
How to File a Grievance

You can notify us of complaints or appeals concerning Cigna Behavioral Health in one of the following ways:

  1. Call us at 1.800.753.0540 or at the toll-free telephone number for mental health/substance abuse services on your Cigna HealthCare ID card. The hearing impaired may call the California Relay Service at 1.800.735.2929 or 1.888.877.5378.
  2. Write to us at:

    Cigna Behavioral Health of California, Inc.
    450 N. Brand Boulevard, Suite 500
    Glendale, CA 91203
  3. If you prefer, you can print and complete a behavioral health grievance form / Formulario de queja de los miembros / 會員抱怨書表格. Simply mail the form to the address above or fax it to the Complaint/Appeal Department at 1.818.551.2787.
  4. Submit a Cigna Behavioral Health online grievance form.

For more specific information about these grievance procedures, please refer to your Group Service Agreement or contact our Customer Services Department.



If the Cigna Behavioral Health customer is a minor or is incompetent or unable to exercise rational judgment or give consent, the parent, guardian, conservator, relative or other legal representative acting on behalf of the member, as appropriate, may submit a grievance to Cigna Behavioral Health or the California Department of Managed Health Care (DMHC or "the Department") as the agent of the member.

 

In addition, a participating provider or any other person you identify may assist you or act as your agent in submitting a grievance to Cigna Behavioral Health or the DMHC.

 

The California Department of Managed Health Care is responsible for regulating health care service plans.

 

If you have a grievance against your health plan, you should first telephone your health plan at 1.800.244.6224 or 1.800.321.9545 (TTY) for the hearing and speech impaired) or the toll-free telephone number on your Cigna HealthCare identification card and use your health plan's grievance process before contacting the Department.

 

Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.

 

The Department also has a toll-free telephone number: 1.888.HMO.2219 and a TDD line 1.877.688.9891 for the hearing and speech impaired. The Department's Internet website http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

 

Product Disclosures
General Information

IMPORTANT NOTICE:

 

Please note that the products and services described on Cigna's websites may not be applicable to you or available to you under your employer’s plan. Please refer to your plan documents for information that is applicable to your specific plan.

 

If you are offered a Cigna plan through your employer and are a plan member or customer, or planning to become a plan member or customer, we recommend reading any disclosure that’s applicable to you so that you can become more familiar with your plan and any state-specific mandates. If you are considering becoming a plan member or customer and have questions about your plan coverage, please contact your employer.

 

While reviewing the information on this page, it’s important to note:

  • The disclosures provided here are general and your plan documents may contain additional disclosures which are required by your state and/or specific to your plan. The disclosures in your plan documents take precedence.
  • Certain mandates may only apply to certain plan types.
  • State mandates may not apply to employer-funded (or self-funded) plans. Please contact your employer if you need to know whether your plan is self-funded and whether any state mandates apply to your plan.
Exclusions and Limitations

All plans have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Rates may vary based upon the plan design selected and employee demographics. Cigna reserves the right to change the premium rates. For a complete list of both covered and not covered services under your plan or policy, including benefits required by your state, see your evidence of coverage, insurance certificate or summary plan description.

Discount Programs

CignaPlus Savings

  • CignaPlus Savings is a dental discount program that provides customers access to discounted fees, pursuant to schedules negotiated by Cigna Dental with participating providers, which customers are responsible for paying in full, directly to participating providers. Although all participating providers go through a credentialing process to assure that they are appropriately licensed and qualified, Cigna Dental does not otherwise guarantee nor is it responsible for the quality of any services or products purchased by customers. Customers have the right to cancel within thirty (30) calendar days of enrolling in the program. For more information, please call or write the company:

    Cigna Dental
    Attn: Operations
    1571 Sawgrass Corporate Parkway, Suite 140
    Sunrise, FL 33323
    Telephone: 1.877.521.0244

    CignaPlus Savings is not available for plans sitused in California and may not be offered by your employer. Please review your benefits materials and contact your plan administrator for availability of this program.

Healthy Rewards

  • This program offers discounts on health and wellness programs and services. If your Cigna plan includes coverage for any of these services, this program is in addition to, not instead of, your plan benefits. Healthy Rewards programs are separate from your medical benefits. A discount program is NOT insurance, and the customer must pay the entire discounted charge.
Health Reimbursement Account (HRA) Plan Option

HRA's can only be chosen together with certain plan types. Your HRA is self-funded by your employer, who is solely responsible for contributing the funds used to pay benefits under your plan using the funds in your HRA. You are not required to make any contribution to the HRA account, either pursuant to a salary deduction election or otherwise under a Section 125 cafeteria plan (except that contributions are required from those under COBRA continuation coverage). You may not enroll under this option if you are considered self-employed (including partners and more-than-2% shareholders in a subchapter S corporation).

Health Savings Account (HSA) Pre-enrollment Statements

WARNING: You cannot open an HSA if, in addition to coverage under an HSA-qualified High Deductible Health Plan ("HDHP"), you are also covered under a Health Flexible Spending Account (FSA) or an HRA or any other health coverage that is not a HDHP.

 

If you have elected to enroll in a HSA plan, you expressed your interest in opening a Health Savings Account with JPMorgan Chase Bank (Mellon Trust of New England, N.A. for GWH-Cigna Customers), an HSA service provider, or any other successor HSA service provider (hereafter "the HSA Service Provider"). The HSA Service Provider will contact you and provide you with an HSA enrollment form, a signature card, a request for information for any Customer Identification Program compliance and other related materials necessary to open an HSA account with the HSA Service Provider. In order to open an HSA with the HSA Service Provider, you must:

  1. In a timely manner, complete, sign and submit all the forms required by the HSA Service Provider; and
  2. Be found to meet all of the requirements prescribed by the HSA Service Provider.

However, if your employer has not selected JPMorgan Chase Bank (Mellon Trust of New England, N.A. for GWH-Cigna Customers) as the HSA service provider, you may open the HSA with an HSA custodian/trustee that is either arranged by your employer or that you personally select. You must agree to complete necessary forms and meet the requirements set forth by the HSA custodian/trustee pertaining to the establishment and operation of your HSA.

 

With respect to an HSA opened pursuant to this arrangement, the HSA trustee/custodian will be solely responsible for all HSA services, transactions and activities related thereto. Neither your employer nor Cigna is responsible for any aspects of the HSA services, administration and operation.

Prior to enrollment, you must certify that you have enrolled or plan to enroll under a HDHP and are not covered under any other health coverage that is not a HDHP.

Cigna Mobile

While accessing Cigna.com or myCigna.com remotely through Cigna Mobile, standard mobile phone carrier and data usage charges will apply. Cigna's mobile web solution is available to any current Cigna customer who has been provided user access to myCigna.com, which includes the personalized Health Care Provider (HCP) directory, contact info, and prescription drug price quote tool (if your plan includes prescription drug coverage through Cigna). Cigna’s mobile HCP directory is also available at www.Cigna.com. The listing of a HCP in the mobile directories available at myCigna.com and Cigna.com does not guarantee that the services rendered by that professional are covered under your specific medical plan. Check your official plan documents, or call the number listed on your ID card, for information about the services covered under your plan benefits. Cigna Mobile currently is not available to GWH-Cigna Customers.

Reimbursement for Out-of-Network Services

Many of the group health insurance policies and employee health benefit plans that Cigna administers cover expenses incurred for services from health care professionals or facilities who do not participate in the Cigna health care professional network. Those policies and plans include Maximum Reimbursable Charge ("MRC") provisions that may limit the amount of an out-of-network charge that will be considered by Cigna in calculating reimbursement. The plan sponsor (your employer or other organization) may choose one of the following MRC provisions:

 

MRC I
Under this option, a data base compiled by Ingenix, Inc., a subsidiary of United Healthcare, is used to determine the billed charges made by health care professionals or facilities in the same geographic area for the same procedure codes using data. The maximum reimbursable amount is then determined by applying a percentile (typically the 70th or 80th percentile) of billed charges, based upon the Ingenix data.  For example, if the plan sponsor has selected the 80th percentile, then any portion of a charge that is in excess of the 80th percentile of charges billed for the particular service in the same relative geographic area (as determined using the Ingenix data) will not be considered in determining reimbursement and the patient will be fully responsible for such excess.

 

As a result of a recent settlement agreement between United Healthcare and the New York Attorney General, the database used by Ingenix to compile the billed-charge data for the health insurance industry will be turned over to an independent non-profit company, FAIR Health, Inc.

 

Cigna will begin using data compiled by FAIR Health, Inc. to calculate MRC amounts as applicable to any Cigna administered plans (a) commencing April 1, 2011 for dental procedures and services and (b) commencing July 1, 2011 for medical, surgical and anesthesia procedures and services.

 

MRC II
This option uses a schedule of charges established using a methodology similar to that used by Medicare to determine allowable fees for services within a geographic market or at a particular facility.The schedule amount is then multiplied by a percentage (110%, 150% or 200%) selected by the plan sponsor to produce the MRC.

 

In the limited situations where a Medicare-based amount is not available (e.g., a certain type of health care professional or procedure is not covered by Medicare or charges relate to covered services for which Medicare has not established a reimbursement  rate), the MRC is determined based on the lesser of:

  • the health care professional or facilities' normal charge for a similar service or supply; or
  • the MRC I methodology based on the 80th percentile of billed charges.

 

There is no MRC with respect to services for which there is not enough charge data in a geographic area to determine a MRC charge.

 

Average Contracted Rate ("ACR")

Under this option, the MRC is determined based on the lesser of:

  • the health care professional or facilities’ normal charge for a similar service or supply; or
  • the Average Contracted Rate - i.e.,  the average percentage discount applied to all claims in a geographic area paid by Cigna during a recent 6 month period for the same or similar service/supply provided by health care professionals or facilities participating in the Cigna network.  The ACR is updated by Cigna on a semiannual basis.  The geographic area used by Cigna is either a Metropolitan Statistical Areas (MSA) or an area within governmental boundaries (e.g. state, county, zip code).

 

In some cases, the ACR amount will not be used and the MRC is determined based on the lesser of:

  • the health care professional or facilities’ normal charge for a similar service or supply; or
  • the MRC I methodology based on the 80th percentile of billed charges.

 

Whether the MRCI, MRC II or ACR methodology is used, the patient is responsible for all charges over the MRC amount, as well as any applicable deductible and coinsurance amounts for charges that do not exceed the MRC. The claim is also subject to all other exclusions and limitations in the applicable benefit plan.

 

If you are enrolled in a Cigna-administered plan, you and your authorized representatives can find the MRC for a particular procedure and geographic location by calling the 800 number on your ID card.

 

If you use a health care professional who is not in the Cigna network, be sure to check your plan documents to make sure that your plan covers out-of-network services. If you have a Flexible Spending Account, you may be able to use that money for out-of-network services.

Disclosure of Financial Arrangements

Compensation to Third Parties


Compensation is paid to third party brokers and insurance sales people for placing a Client’s (“Client” refers to employers or other groups sponsoring a health benefit plan) insurance coverage and/or plan administration contract with Cigna. This compensation is typically in the form of a percentage of premiums collected in the case of insurance policies, or a fixed, per-employee per-month rate (in the case of self-funded plans).

 

Additional compensation may be paid to brokers and insurance sales people based on persistency or other non-case-specific factors, sometimes referred to as "contingent commissions." This additional compensation is not part of the regular commissions.

 

Reports are sent to its employer policyholders and contract-holders regarding the commission and contingent commissions paid to brokers or insurance sales people for their use in preparing their Annual Return and report (Form 5500) where required under federal law (ERISA). Upon request, we will also disclose how the Client may receive more information directly from the broker or sales person regarding compensation arrangements.

Primary Source of Revenue

The primary compensation received with respect to insurance policies is the policyholder paid insurance premium. The primary source of revenue in connection with administrative services contracts is the service fees paid by the self-insured plan sponsor and/or the plan.

Other Revenue Sources

We negotiate for additional revenue from some third party vendors. We negotiate the additional revenue as part of the overall structure of each vendor agreement. The nature of negotiated contracts with vendors is that they are generally based on the aggregation of all business related to the contract and are not Client-specific.

 

Cigna retains this additional revenue for its sole and exclusive use, applying it in part to the overall cost of maintaining Client programs and other business expenses. The aggregate revenue generated from the third party vendors, including programs designed to generate cost savings for the Client, allows Cigna to cover the cost of client programs and other business expenses and to offer lower premiums and administrative fees to its Clients.

 

Cigna may offer programs and services where a third party vendor supplies all or part of the program or services. The claim amount charged to the Client for the program or services includes both an amount to cover the vendor fees and an amount for Cigna's related and other expenses. The disease management program is an example of a vendor program where the Client may be charged more than the amount charged by the vendor for the program.

 

Another example can be found in the rates for pharmacy benefits negotiated with a pharmacy benefit manager (PBM). The rates charged to a Client are typically expressed as a percentage discount from average wholesale price. Cigna may offer lower discounts to the Client than the discounts that Cigna is offered by the PBM. Cigna may obtain or retain all or a portion of drug manufacturer revenue that it receives from the PBM or directly from the drug manufacturer. This revenue may be based on factors including membership volume, volume of drug usage or placement of a drug on the formulary. Cigna’s drug formulary changes occasionally based on clinical efficacy, net drug cost and market share considerations. Customer reimbursements will differ depending on where the drug falls in the formulary. Changes to the formulary can impact the revenue paid by drug manufacturers to Cigna or the PBM.

 

Cigna may also receive transition fees when it changes third party vendors. These fees are paid to Cigna by the vendor to cover implementation and related expenses such as staffing or administrative changes that Cigna incurs during the transition. Cigna may receive marketing fees or commissions from vendors for placing the business with the vendor. These may be calculated on a per-member per-month (PMPM) basis, flat rate, or on a percentage basis. Cigna may receive other compensation from its third party vendors. For example, Cigna may receive payment for the development and installation of special computer systems or programs necessary for Cigna to deliver a particular service to its Clients.


Cigna may receive performance guarantee payments if a vendor does not meet performance targets.


Cigna uses a specialized vendor to negotiate discounts for large out-of-network (OON) claims. When a large out of network claim is received, the vendor will negotiate with the provider to obtain a lower rate, or discount, to the charges. The amount for the claim charged to our Client will reflect the discounted charges and an administrative fee will be charged for providing the savings program. Similar savings programs are in place for secondary networks and to audit large, complex hospital claims.


When a third party should have been responsible for the claims incurred by a customer (as a result of an automobile accident, for example), after paying the claim, Cigna may try to obtain reimbursement from the third party source. Cigna currently pursues reimbursement using a specialized subrogation vendor. For successful efforts, a percentage of the recovery is retained by Cigna. Additionally, Cigna has priority right to reimbursement of any stop loss payments. Any excess is credited to the Client.


In most situations, Cigna processes claims directly and the claim amount collected by Cigna from the Client equals the amount paid to the provider. Where a third party manages a particular type of medical service, a portion of the claim amount paid to the third party may in turn be paid to Cigna by the third party to cover Cigna’s costs of administration and other business costs. A Customer’s coinsurance, deductible and lifetime maximum are calculated based on the entire claim amount including the portion retained by Cigna to cover costs.


Certain Cigna companies directly provide or arrange for the provision of covered heath care services including, but not limited to Cigna Behavioral Health, Inc. Their charges for providing or arranging for these services are reimbursed as claims.

Clinical Claims Review Program

In an effort to assure that high dollar claims are correctly billed and paid in accordance with industry and other applicable standards, we have extended our claims review program to include a review of select facility claims for billing and coding errors. This program is now available for all self-funded customers. Effective December 1, 2009, the Clinical Claims Review (CCR) program will be treated as a savings initiative pursuant to the Savings Initiative provision of your administrative services agreement and we will be retaining the specified fee for the savings realized.