Certification that an organization meets the reviewing organization's standards. Examples: accreditation of HMOs by the National Committee on Quality Assurance (NCQA) or accreditation of hospitals by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO).
An employee must work for the employer on a regular basis in the usual course of the employer's business to be considered an active, full-time employee and eligible for coverage. Usually, a minimum number of hours of regular work is specified.
The administrative procedure used to process a claim for service according to the coverage.
An arrangement in which an employer contracts with a third party, typically a health care carrier, to administer the health care plan for the employer who assumes the benefit plan claim risk. In an ASO arrangement, the third party processes the claims on the employer's behalf and the funds to pay the claims come from the employer. This is also referred to as self funded.
Highly technological radiology procedures performed in an office or hospital-like setting.
The health care professional's billed charge or primary carrier's negotiated fee.
An organization offering a "non-traditional" ("not like a hospital") setting for giving birth. Alternative birthing centers can range from free-standing centers to special areas within hospitals. Birthing centers are generally known for a more comfortable, home-like atmosphere. They allow the father to participate more. They're also more flexible than hospitals in allowing changes to the standard procedures followed during a birth.
A dental filling material, composed of mercury and other minerals, used to fill decayed teeth.
A general term for care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care.
Surgical procedures that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called outpatient surgery.
A national trade group that represents 1,300 health insurance companies. (Note: Cigna is a member.)
A professional association of dentists dedicated to serving the public and the profession of dentistry.
A professional association of physicians dedicated to promoting the art and science of medicine and the improvement of public health.
Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.
The day after a plan year ends. Usually, the month and day that coverage first goes into effect becomes its anniversary date each year.
Under health care reform, annual limits on essential health benefits for plans that begin on or after September 23, 2010 must be at least $750,000. Beginning September 23, 2011, the limit is $1.25 million and for September 23, 2012, it is $2 million. Reform does not allow annual minimum dollar limits for most plans beginning starting in 2014.
Employers and insurance companies can request a waiver to continue offering health plans with annual dollar limits until 2014. Waivers are available if removing the limits would reduce access to benefits or increase premiums. Only plans in effect on September 23, 2010 are eligible. No annual limits are allowed in 2014.
The most a customer will pay per plan year for covered health expenses before the plan pays 100 percent of covered health expenses for the rest of that plan year.
A patient's request that the health plan review or change a claim decision or grievance again.
All health plans must have a standard internal appeal process and an external review process for denied claims.
When a covered person requests that their claim payments are made directly to a health care professional for covered services. Traditional health insurance coverage pays claims directly to the dependent.
Certification that an organization meets the reviewing organization's standards. Examples: accreditation of HMOs by the National Committee on Quality Assurance (NCQA) or accreditation of hospitals by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO).
See Precertification: Getting approval from the health plan before a routine hospital stay or outpatient procedure. In precertification, Cigna reviews medical criteria to determine coverage. Also referred to as prior authorization.
Employers with more than 200 full-time employees will be required to enroll new full-time employees in a health plan. Employees will be enrolled in the plan with the lowest employee premium unless they opt out or choose another plan. Plans can have a waiting period before benefits begin.
Assessment and therapeutic services used to treat mental health and substance abuse problems.
A person who is eligible to receive coverage. Sometimes "beneficiary" is used for eligible dependents enrolled under a coverage plan; "beneficiary" can also be used to mean any person eligible for coverage, including both employees and eligible dependents.
A process of removing tissue to determine if it is healthy or not.
X-rays taken of the crowns of teeth to check for decay.
Any physician who has completed medical school, internship and residency in his or her chosen specialty and has successfully completed an examination conducted by a group (or board) of peers.
A process to chemically etch the tooth's enamel to better attach (or bond) composite filling material, veneers or plastic/acrylic.
A drug manufactured by a pharmaceutical company that's chosen to patent the drug's formula and register its brand name.
A non-removable dental solution used to replace missing teeth.
Brush biopsy is a painless procedure used to gather cells in the mouth. The dentist uses a small brush to take a tissue specimen, which is then sent to a laboratory for analysis to determine the presence of pre-cancerous or early stage cancerous cells. Laboratory results are used to determine the need for further procedures.
Health plans cannot retroactively cancel coverage. The only exceptions are for fraud or false statements. Thirty days advance notice must be given before coverage ends.
The portion of a tooth covered by enamel. Also a dental solution that covers the entire tooth and restores it to its original shape. Cap usually refers to a crown for a front tooth.
A program that offers customers access to a national network of health care professionals, hospitals and clinics. Customers in these plans can access a broad network consisting of Tufts Health Plan-contracted services in Massachusetts and Rhode Island and Cigna-contracted services in all other states. Customers can also choose to see any health care professional (in- or out-of-network) when out-of-network coverage is part of the plan.
Used by Cigna, "care management" refers to a Cigna initiative that takes a holistic approach to medical care from prevention through treatment and recovery.
A term historically used for licensed insurance companies. Today sometimes it is used to include both licensed insurers and health maintenance organization (HMOs).
Coordination and ongoing review of services to help make sure care is appropriate and meets a customer's health care needs. Case management is usually done when the customer has a condition that involves multiple services from several health care professionals. This term is also used to refer to coordination of care during and after a hospital stay, including preparing a discharge plan and following up after higher risk procedures.
A health care model in which customers are made aware of the true costs and value of health care, so that they can make informed decisions that balance choice with cost. Health plans that fall in this category may include flexible spending accounts (FSA), health savings accounts (HSA) and health reimbursement accounts (HRA).
Cigna identifies hospitals as Centers of Excellence when they achieve the highest (three star) scores for cost efficiency and effectiveness in treating selected procedures/conditions, based on publicly-available patient data. Through our provider directory, you can compare hospitals in your area for cost and quality.
The amount a health care professional bills for services to a customer.
A cancer treatment that uses drugs (chemical or biological antineoplastic agents) to help control or stop the growth and spread of cancerous cells.
The name derived from Connecticut General Corporation and Insurance Company of North America when they combined their operations in 1982. This is a service mark used by one or more of the Cigna group of operating subsidiaries.
Part of the Cigna division which offers Employee Assistance Programs (EAP), as well as mental health and substance abuse coverage management. Cigna Behavioral Health, Inc. provides access to services through a national contracted network, as well as a dedicated team of internal health care professionals.
A network of specialists selected from Cigna’s broad network of participating health care professionals. In certain specialties, Cigna Care Network includes doctors who meet specific criteria in the areas of quality, number of Cigna customers treated, efficiency and customer access.
A product name used to describe Cigna’s Preferred Provider Organization (PPO), Open Access Plus (OAP), LocalPlus, Exclusive Provider Organization (EPO) or Indemnity health plans when they are combined with a compatible Health Reimbursement Account (HRA), Health Savings Account (HAS) or Flexible Spending Account (FSA).
A division of Cigna that offers dental plans including dental indemnity, preferred (PPO) and managed care (DHMO) dental coverage and services.
A type of health coverage plan underwritten by Cigna Health Maintenance Organizations (HMOs) and Connecticut General Life Insurance Company, which combines the coverage of an HMO with traditional health insurance coverage. This coverage plan design allows employees and their covered dependents to enjoy all the advantages of an HMO, while still providing limited coverage to participating individuals who go outside the HMO network to receive health care services.
Through Cigna Health Advisor®, nurses offer customers personal assistance, expertise and guidance related to wellness and prevention to help customers achieve their health-related goals and make the most of their health benefit plans.
The Cigna mail order prescription service that provides customers with up to a 90-day supply of their prescription drugs.
A national organ transplant network, developed by Cigna, designed to give participants access to quality care for heart, heart/lung, liver, kidney/pancreas and bone marrow transplants.
A payment request to the health plan for covered services provided to an individual enrolled in the health plan. A claim can be submitted by the patient, the patient's representative or by the health care professional who provided the service.
A term used to describe where the claim is during the claim payment process. The claim could be paid, not paid, in-progress or waiting for action (for example, the doctor must provide more information before the claim can be processed).
The forceful holding together of the upper and lower teeth, which places stress on the ligaments that hold the teeth to the jawbone and the lower jaw to the skull.
These are general guidelines that are made by a team of doctors in a medical field, such as radiology or cardiology. Clinical practice guidelines help other doctors determine acceptable treatments for certain diseases or conditions.
Diagnostic services a doctor provides during delivery of medical services, consultations or care.
The percentage a covered person must pay (for example, 20 percent) of the allowed amount for covered health services after the health plan begins to pay, usually once the plan deductible has been met. This may also refer to the percentage of covered expenses paid by a health benefit plan.
A tax on health plans to fund research. The tax is currently $1 per enrollee. For plan years that start after October 1, 2012, it will be $2. The fee increases each year. It will not be collected after 2019.
This is the extensive dental repair of six or more units of crown and/or bridge within the same treatment plan. Using full crowns and/or fixed bridges that are cemented in place, the dentist rebuilds natural teeth, fills in spaces where teeth are missing and helps each tooth function along with the occlusion (bite). This procedure involves a large amount of time, effort and skill.
A tooth-colored filling made of plastic resin or porcelain
A federal agency that gives Congress impartial data to help make decisions about the federal budget.
A federal law that allows people to continue benefits for a period of time after group health coverage ends. COBRA applies after a job loss, reduction in hours, death or divorce. The person usually pays the entire premium plus two percent.
A discussion with another health care professional when additional feedback is needed during diagnosis or treatment. Usually, a consultation is by referral from a primary care physician.
A health plan that educates people about costs so they can make informed decisions. CDHPs usually offer a compatible Health Reimbursement Account or a tax-advantaged Health Savings Account with a qualified high deductible health plan.
An agreement that sets out the rights and obligations, including the financial obligations, agreed to between the contracting parties.
The option to purchase individual coverage offered to a person who will no longer be eligible for coverage through an employer-sponsored group health plan.
When a person is covered under more than one insurance or health plan. It requires that carriers coordinate with one another to correctly consider benefits for all services payable.
The amount a customer pays towards a doctor's visit. The amount can vary based on the health plan coverage terms and the type of covered health service received.
Any dental treatment or repair that is done solely to improve the appearance of the teeth or mouth.
Cost-sharing reductions help lower your out-of-pocket costs for deductible and coinsurance for specific medical expenses like prescriptions and doctor’s visits.
When a person signs up for a health plan, the plan provides protection ("coverage") for medical expenses the person or any dependents may incur during the plan year.
The day a plan's features and provisions end.
A term informally used to refer to the employer's coverage plan or to the coverage plan options from which the employee can choose.
Typically used when referring to disability plans, this amount is usually determined as a percentage of the employee's pre-disability income up to an overall maximum amount.
See Plan Year: Generally, any 12-consecutive-month period determined by the plan under which coverage is provided per the plan documents.
The services the health plan will pay for according to the agreement between the health care carrier and either the employer group or the individual.
A process that reviews a health care professional's credentials against the credentials required to participate in a managed care network. To participate in a Cigna network, doctors and health care organizations are thoroughly credentialed before being admitted and are recredentialed. They must meet specific criteria for continued participation in a Cigna health care professional network.
Care provided primarily to meet the personal needs of a patient. The care is not meant to improve health or provide medical treatment.
A person who is covered by a health plan. This term may refer to the person who enrolled in the plan, his or her spouse/partner or any other dependents who are eligible to enroll in the plan.
The unique identifier associated with a customer.
The date the customer received the service.
An outpatient hospital or clinic licensed to provide care and treatment without the customer staying overnight. These centers usually treat people who suffer from mental or nervous disorders or substance abuse.
Doctor of Dental Surgery or DMD, Doctor of Dental Medicine. These are educational degrees given to dental school graduates. Some dental schools identify their graduates as DMDs, while other schools confer a DDS. The degrees are the same.
An individual deductible is the amount a covered person needs to pay each plan year before the plan starts paying for covered services. A family deductible is the total amount the enrollee and their covered dependents need to pay each plan year before the plan starts paying for covered services.
Delegation is a formal process by which Cigna gives another firm the authority to perform the claims payment administration on behalf of Cigna.
When services aren't covered under the customer’s plan, the claim is denied. Cigna doesn't pay the claim but explains why the claim wasn't paid on the Explanation of Benefits (EOB).
A thin, nylon string, waxed or unwaxed, that is inserted between teeth to remove food and plaque.
A dental professional specializing in cleaning teeth by removing plaque, calculus and diseased gum tissue. The dental hygienist acts as the patient's guide in establishing a proper oral hygiene program.
A removable appliance used to replace teeth. A complete denture replaces all of the upper teeth and/or all the lower teeth.
A person, usually a spouse, partner, children or adopted children, who depends on another person for health coverage and who may be eligible for coverage under a health plan because of his or her relationship to the person enrolled in a health plan.
Health plans that cover dependents must offer coverage up to age 26. Coverage is available regardless of marital or student status, residency or financial dependence on a parent.
Medical centers selected to provide an advanced level of care for a disease or delivery of a specific procedure. For example, Cigna LIFESOURCE Transplant Network® is made up of 13 nationally acclaimed hospitals, including Johns Hopkins University Medical Center and the UCLA Medical Center.
A Cigna point-of-service product. Each customer chooses a Cigna-affiliated primary care physician (PCP), but has the added convenience of going outside the network for care at any time. The coverage for out-of-network care is reduced, as an incentive to stay in the network, and is subject to deductibles and coinsurance.
Tests and procedures ordered by a doctor to help diagnose or monitor a patient's condition or disease. Diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services or tests.
The definition of this term varies greatly by coverage plan. It's one of the most important provisions in a disability contract because it determines an employee's eligibility for coverage. Here are a couple common types of disability:
Total disability: Any occupation (any occur). Under this definition, an employee is considered disabled only if unable to work in any occupation for which she or he is qualified by education, training or experience. This is closely related to the definition that the Social Security Administration uses in determining disability.
Partial/residual disability:This definition of disability applies when an employee is able to return to work part-time or even full-time, but with a loss of earnings. If the employee is working in this limited capacity and is earning less than a certain level of income, she or he will still be eligible for limited coverage under the plan. Not all disability carriers use this terminology to describe a "part-time" work situation, but most provide some type of coverage to encourage return to work.
Identifying a patient's health care needs after discharge from inpatient (hospital or other health care clinic) care.
Voluntarily ending one's participation in a health coverage plan.
Adults can name any network doctor as their primary care physician (PCP). Children can name a pediatrician as their PCP.
See Formulary: A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of the drugs' clinical superiority, safety, ease of use and cost. Also referred to as the Cigna Drug List and the Cigna Prescription Drug List.
When a person has coverage for the same health services under more than one coverage plan.
Equipment that can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home as prescribed by a doctor.
To encourage employers to offer health insurance to early retirees, companies can be paid for some of the cost. Early retirees are between the ages of 55 and 64. As of May 5, 2011, companies can no longer apply for the ERRP.
The date on which coverage under a plan begins (also called start date).
Details contained in each health coverage plan that specify who qualifies for coverage under that plan.
The Medicare Part D coverage gap is when people reach the limit of their prescription drug benefit and must pay 100 percent of drug costs. Once they reach Medicare's catastrophic coverage level, they would again have prescription drug benefits. Before 2010, retirees paid 100 percent of their drug costs in the gap. In 2011, retirees pay 50 percent of the cost of brand-name drugs and 93 percent of the cost of generic drugs. The gap closes each year. By 2020, the percent retirees pay for generic drugs will be 25 percent.
This is the period of time between the date the disability begins and the beginning of the coverage payment period. It's the period during which an employee must be disabled before payment begins. It is sometimes called the qualifying period.
This is the acute care of patients who have not had a prior appointment for their condition. Emergency care must be covered at the in-network level, even if care is received out-of-network.
An EAP is an assessment and referral program or a short-term counseling program that is pre-purchased by some employers and is typically available to their employees, their dependents and household members. EAPs are separate from behavioral health care coverage plans and are typically available to employees at no additional cost whether or not they are enrolled in their employer-sponsored health plan.
Federal legislation that applies to retirement programs and to employee welfare coverage programs established or maintained by employers and unions.
The hard, calcified (mineralized) portion of the tooth that covers the crown. Enamel is the hardest substance in the body.
An individual who is offered health coverage by his or her employer. At Cigna, this person is also called a primary customer or subscriber.
These are benefits that health care reform requires plans to cover:
Documentation that proves a person is physically eligible for coverage.
These are benefits offered separately or that are not part of a health plan. Excepted benefits might be dental, vision, long-term care or disability income.
Health care reform says that by 2014 states must either:
A tax on health plans that cost more than $10,200 per year for single coverage or $27,500 for family coverage. This 40 percent excise tax begins in 2018.
Specific conditions or services that are not covered under the coverage agreement.
A specific type of Cigna health plan with a national network of physicians. Customers can visit specialists without a referral. Customers don't need to choose a primary care physician (PCP). An annual deductible is required and an out-of-pocket maximum applies. Coverage is not available for out-of-network care.
A type of Cigna coverage plan in which covered persons select a primary care physician (PCP) and receive covered services exclusively from the EPP network.
Unproven or investigational treatments that are not in line with generally accepted standards of care
The date stated in an insurance contract on which coverage ends (also called end date).
Statement sent by the health plan explaining what medical treatments and/or services were paid.
A medical care institution for people who need long-term custodial or medical care, especially for chronic disease or a condition needing prolonged rehabilitation therapy.
When coverage is extended under certain conditions, such as disability, after an individuals group health coverage would otherwise have ended.
Refers to the severity of the condition. Some policies require that employees be totally disabled before payments begin. Other policies pay for partial disability for a limited time. Most often, policies only pay for partial disability if that condition follows a period of total disability for the same cause.
The Mental Health Parity and Addiction Equity Act of 2008 is a law that makes benefits under Mental Health and Substance Use Disorder coverage the same as benefit limitations under a person's medical/surgical coverage.
Beginning in 2014, a Federal Premium Assistance Tax Credit is available to eligible people to help pay their insurance premiums through a state exchange. To be eligible, the person's income must be between 100 and 400 percent of the Federal Poverty Level and meet certain criteria. About 19 million people who buy health insurance through a state exchange may be eligible for the tax credit.
Material used to fill a cavity or replace part of a tooth.
A type of program that offers employees a menu of coverage options, allowing them to create a coverage package that best suits their individual needs.
An account that allows employees to set aside pre-tax dollars to pay for certain health care or dependent care costs during a specific time period (usually one year). Employees deposit funds in the accounts each pay period. Funds that are not spent by the end of the plan year are lost. In 2013, the maximum health care FSA contribution will be $2,500. That amount will increase based on inflation.
A chemical compound used to prevent dental decay, used in fluoridated water systems and/or applied directly to the teeth.
A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of the drugs' clinical superiority, safety, ease of use and cost. Also referred to as the Cigna Drug List and the Cigna Prescription Drug List.
A health plan where an employer group contracts with a health care carrier to provide health insurance coverage to its employees and their dependents. The carrier underwrites and administers the health plan, and also pays the covered claims.
A primary care physician (PCP) who provides a broad range of routine medical services and refers patients to specialists, hospitals and other health care professionals, as necessary. Under some coverage plans, a referral is required from the primary care physician to obtain coverage for services from other health care professionals.
A prescription drug that has the same active-ingredient formula as a brand-name drug. A generic drug is known only by its formula name and its formula is available to any pharmaceutical company. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs. Usually, generics cost less.
An inflammation or infection of the gingiva (gum tissue); the initial stage of gum disease
Health plans that existed on March 23, 2010 may be "grandfathered". These plans do not have to comply with all Patient Protection and Affordable Care Act (PPACA) provisions. Plans can make routine changes without losing grandfathered status. Plans can lose their status if they reduce benefits or increase employee costs too much. Employers can switch insurance companies and change from administrative services only (ASO) to fully-insured without losing grandfathered status.
A health coverage plan that covers a group of people as permitted by state and federal law.
This is a Cigna coverage option. With this type of coverage, in some situations, people can pay for in-network services when they temporarily live outside of their home network area for 90 days or longer.
See Periodontal disease: The inflammation and infection of gums, ligaments, bone, and other tissues surrounding the teeth. Gingivitis and periodontitis are the two main forms of periodontal disease. Also called gum disease or pyorrhea.
A managed care health plan with a large service area in Michigan. Cigna and Health Alliance Plan (HAP) are working together to provide quality care to Cigna customers, whether at home or traveling in the United States. Cigna customers in southeast Michigan have access to the HAP Preferred/PHP network of hospitals, doctors and other health care professionals. In the rest of Michigan and all other states, customers have access to the Cigna national network of health care professionals.
The department of the federal government that issues regulations for most of the provisions under health care reform, or the Patient Protection and Affordable Care Act (PPACA).
A new $8 billion annual tax on health insurance companies starting in 2014. The tax will grow to $14.3 billion a year by 2018 and rise with inflation after that. The tax will be based on each company's market share.
A federal law that protects the privacy of health information. HIPAA applies to health plans, health care clearinghouses and health care professionals.
A type of medical plan that offers coverage for a wide variety of health care services usually through the use of a primary care physician (PCP). These services usually include hospital care, physicians' services and many other kinds of health care services. HMOs emphasize preventive care.
Any health care service or program that helps maintain a person's good health. Health maintenance services include all standard preventive medical practices, such as immunizations and periodic examinations, as well as health education and special self-help programs.
Health plan can be used to mean a health maintenance organization (HMO), a health coverage plan provided by an employer to its employees, or a health coverage plan offered to employers by an insurer or third party administrator.
An employer-funded account that employees use to pay health care costs. The HRA pays 100 percent of eligible expenses until it is used up. HRA dollars used to pay for eligible medical expenses can be applied to the employee’s annual deductible. Some employers allow HRA dollars to roll over from year to year. An HRA is often combined with a high deductible health plan.
A tax-advantaged savings account used to pay for qualified health care costs. The account may be funded by the employee, the employer or both. A person must be covered by a qualified High Deductible Health Plan (HDHP) to contribute to an HSA. Unused funds in the account roll over.
The tax penalty for using Health Savings Account funds for ineligible expenses is 20 percent. Before January 1, 2011, the penalty was 10 percent. But health care reform law increased the tax.
Health services given in the home to an individual who is confined to the home. Such services are provided to individuals who do not need institutional care, but who need nursing services or therapy, medical supplies and special outpatient services.
A service that provides supportive health care for the terminally ill.
An institution that provides diagnostic and therapeutic inpatient services for a variety of surgical and non-surgical medical conditions. In addition, most hospitals provide outpatient services, including emergency care.
All group and individual health plan customers receive an identity document or identification (ID) card to help health care professionals verify their patients' eligibility for coverage
An unerupted or partially erupted tooth that's positioned against another tooth, bone or soft tissue so that complete eruption (reaching its normal position) is unlikely.
A change in health status documented by objective medical findings.
An artificial device, usually made of a metal alloy or ceramic material, which is placed within the jawbone as a means to attach an artificial crown, denture or bridge.
An opportunity for a customer to earn points toward prizes or extra dollars in the Cigna Choice Fund HRA. Participating in a disease management program is one way to gain these awards. For other incentives, visit myCigna.com. Incentives apply only to Cigna's Health Reimbursement Account (HRA) plan option.
A type of health plan under which a covered person must pay 100 percent of all covered charges up to the plan's annual deductible. Once the deductible is met, a percentage of the covered charges must be paid by the covered person, up to the plan's out-of-pocket maximum. Indemnity plans don't usually offer in- or out-of-network benefit restrictions, but out-of-pocket costs are usually less when services are received by in-network health care professionals.
All U.S. citizens and legal residents must have "minimum essential" health coverage in 2014 according to health care reform law. If they do not, they will pay a tax penalty.
A health insurance policy sold to an individual directly, not health coverage offered through an employer-sponsored plan. An individual plan can cover the individual and/or any family members.
The condition or the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception.
Treatment accomplished by placing therapeutic agents into a vein. One example is intravenous feeding. Another is enteral nutrition (the delivery of nutrients into the gastrointestinal tract by tube).
Cigna contracts with doctors, hospitals, labs, etc. to provide health services to its customers. This group of health care professionals forms a Cigna network. Customers usually pay less when they use these in-network health care professionals.
Any physician, hospital, lab, etc. in a Cigna network. When customers receive care from an in-network health care professional, they usually pay less for services.
Care given to a patient admitted to a hospital, extended care facility, nursing home or other similar health care institution.
A nonprofit group that provides information to help the government make informed health decisions. The IOM is advising on essential health benefits.
Regulations that are not final, but that are treated as final. Public comments are accepted during the interim period to help shape the final regulations.
An independent, nonprofit group working to improve the quality of health care. The JCAHO reviews health care organizations to make sure they meet quality standards.
Health plans offered by employers with more than 100 employees. Until 2016, the Patient Protection and Affordable Care Act (PPACA), the health care reform law, allows states to define "large group" as more than 50 employees.
The maximum amount a plan will pay over the lifetime of an individual's coverage. Health care reform law does not allow lifetime limits for most plans.
Limitations are specific provisions sometimes included in group health and disability plans that restrict coverage in certain situations. Often only limited coverage is payable for specific conditions or under specific circumstances. For example, a plan may have limitations on mental illness or pre-existing conditions.
Plans that provide limited benefits to part-time and low-wage workers. In many cases, this is the only way they can afford health care. These plans are also called "mini med" plans.
An injection given in the mouth to numb the areas where a tooth or area needs a dental procedure. Often referred to as Novocain.
The range of services typically provided by skilled nursing, intermediate-care, personal care or elder-care organizations.
A medication prescribed for long-term treatment of a chronic condition, such as diabetes, high blood pressure or asthma. Maintenance medications are available through Cigna Home Delivery Pharmacy and at participating network retail pharmacies.
A system of health care delivery that manages the cost of health care and access to health care professionals.
The maximum length of time for which coverage is payable under the plan, as long as the covered individual remains continuously disabled.
The highest dollar amount a disabled employee can receive on a monthly basis under the Long Term Disability plan.
The maximum amount Cigna will pay an out-of-network health care professional for billed services. Customers may have to pay any amounts not covered under their plan, including any difference over the Maximum Reimbursable Charge, to the out-of-network doctor or hospital.
Health plan for low income and disabled people. More people will be eligible for Medicaid under the Patient Protection and Affordable Care Act (PPACA), also known as the health care reform law.
A 2.9 percent national sales tax will be charged on medical devices sold after December 31, 2012. This is the medical device fee.
The percent of premium an insurance company spends on claims. If the MLR is less than 80 to 85 percent of premiums, the company must provide rebates to customers.
Health care services or supplies needed to diagnose, prevent or treat your condition and that meet accepted standards of medical practice.
A health plan for people age 65 and older. Medicare also covers certain disabled people and people with end-stage renal disease (ESRD).
The period each year when a person may enroll in a Medicare plan. The period is October 15 to December 7.
The part of Medicare that helps pay for hospital care. It also covers nursing home, home health and hospice care.
The part of Medicare that helps pay for doctors and outpatient care.
The part of Medicare that helps pay for prescription drugs. Insurance companies must be approved sponsors before they can offer Medicare Part D Prescription Drug plans.
A term used to describe health coverage that supplements Medicare coverage.
All U.S. citizens and legal residents must follow health care reform's rule called the individual mandate. This rule requires people to maintain health coverage that offers essential health benefits. People that do not buy this coverage beginning in 2014 will pay a tax penalty.
In a disability coverage plan, there is usually a minimum amount paid as a monthly coverage after reductions for "Other Income Coverage".
Under health care reform, a health plan provides minimum value if it pays at least 60 percent of the allowed cost of services.
The broad, multicusped back teeth, used for grinding food. Molars are the largest teeth in the mouth. In adults there are 12 molars (including the four wisdom teeth, or third molars), three on each side of the upper and lower jaws.
The organization of state insurance regulators for all 50 states, Washington, D.C. and the U.S. territories.
An independent, nonprofit group that reviews the quality of managed care plans.
The hospitals, health care professionals and labs that have contracted with a health plan to provide health care services.
A health plan that began after March 23, 2010. It may also be a plan that has made major benefit cuts or cost increases since that date.
A medical professional who has not contracted with a health plan.
Treatment to restore a physically disabled person's ability to perform tasks of daily living, such as walking, eating, drinking, dressing, toileting and bathing.
A period when employees can enroll in a health plan or make changes. Most employers offer an open enrollment period each year.
A general term used when a plan offers some coverage for out-of-network covered services. Often this coverage is less than the coverage available for in-network services. Usually the customer has to pay for services up front and then file a claim for reimbursement. The details of such privileges vary from plan to plan.
The removal of teeth and the repair and treatment of other oral problems, such as tumors and fractures.
A specialized branch of dentistry that corrects the misalignment of teeth and restores the teeth to proper alignment and function. There are several different types of appliances used in orthodontics, one of which is commonly referred to as braces.
While disabled, a covered employee may qualify for funds from sources-like Social Security and workers' compensation-beyond the disability plan. The insurer may reduce the coverage payable under a Long Term Disability plan because of these additional income sources.
Payments the health plan provides for covered services received from health care professionals outside of the network service area. Coverage details vary from plan to plan.
Health care professionals, hospitals, clinics and labs that do not belong to the Cigna network. Some plans provide coverage for services received from out-of-network health care professionals, but customers will typically pay more and might have to file a separate claim for payment.
A health care professional who does not belong to a Cigna network. Customers can receive out-of-network services, but they typically pay more than when using in-network health care professionals.
Costs not covered by the health plan such as copays, coinsurance, deductibles and fees that the covered person pays personally for health services or prescriptions.
The most a customer will pay for covered services during a plan year before the health plan begins to pay at 100 percent of covered charges. This limit does not include premiums, balance-billed charges or health care services not covered under the health plan. Some health plans don't include all copays, deductibles, co-insurance payments, out-of-network payments or other expenses towards this limit.
Any health care service provided to a patient who is not admitted to a hospital. You may receive outpatient care in a doctor's office, clinic, your home or a hospital outpatient department.
A condition in which the upper teeth excessively overlap the lower teeth when the jaw is closed. Dentists can correct overbites with orthodontics.
Drugs that can be bought without a prescription. Examples are drugs for pain, heartburn and allergies. Starting January 1, 2011, over-the-counter drugs cannot be paid from health reimbursement accounts, health savings accounts or flexible spending accounts without a prescription. A prescription is not needed for insulin or diabetic supplies.
The exact amount issued on a bank draft for services provided by a health care professional.
An extraoral full-mouth X-ray that records the teeth and the upper and lower jaws on one film.
A program offered by appropriately-licensed hospitals and clinics that includes either a day or evening treatment program, usually for mental health or substance abuse.
Any doctor, hospital, clinic or lab in a Cigna network. When customers receive care from a participating health care professional, they usually pay less for services.
The name of the health care reform law President Barack Obama signed on March 23, 2010.
As of 2014, an employer must provide health benefits for employees or pay a penalty.
The specialized branch of dentistry that deals solely with treating children's dental disease. Also referred to as pedodontics.
A claim that requires more information before Cigna can process it. A pended claim always has a specific reason code to clearly show what's missing.
The inflammation and infection of gums, ligaments, bone and other tissues surrounding the teeth. Gingivitis and periodontitis are the two main forms of periodontal disease. Also called gum disease or pyorrhea.
A $2.5 billion tax on the drug industry starting in 2011.
Rehabilitation to restore function and prevention of physical disability following disease, injury or loss of a body part.
An overview that outlines the coverage and financial terms of a health plan.
Generally, any 12-consecutive-month period determined by the plan under which coverage is provided per the plan documents.
A film of sticky material containing saliva, food particles and bacteria that attaches to the tooth surface both above and below the gum line. When left on the tooth, plaque can promote gum disease and tooth decay.
A health plan allowing the customer to choose to receive services from a participating (in-network) or non-participating (out-of-network) health care professional. The customer may be required to select a primary care physician (PCP) and can usually save more by using a participating health care professional.
The process through which Cigna evaluates a doctor's request for a customer's admission to an acute care hospital and length of stay. To determine coverage, Cigna reviews the medical necessity for the admission and stay. If PAC/CSR is part of the health coverage plan, the admission or continued stay must be certified for full payment of a claim.
Getting approval from the health plan before a routine hospital stay or outpatient procedure. In precertification, Cigna reviews medical criteria to determine coverage.
The amount of an employee's wages or salary in effect and covered by the plan on the day before a disability began.
A health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy. Although employer-sponsored group health plans provide coverage for pregnancy, Cigna's individual and family plans do not provide coverage for pregnancy-related medical costs.
A limitation or exclusion of health benefits for a condition that existed prior to the date a person enrolled in a new health plan or insurance policy. As a result of health care reform law, or the Patient Protection and Affordable Care Act (PPACA), a person under age 19 cannot have benefits limited based on a pre-existing condition. Pre-existing means the condition (other than pregnancy) was diagnosed before enrollment in a health plan. The rule expands to all ages in 2014. Although employer-sponsored group health plans provide coverage for pregnancy, Cigna's individual and family plans do not provide coverage for pregnancy-related medical costs.
A specific type of Cigna health plan with a national network of physicians. Customers can visit physicians both in- and out-of-network, and can visit specialists without a referral. Customers don't need to choose a primary care physician (PCP) for coverage. An annual deductible is usually required and an out-of-pocket maximum applies.
A periodic payment by the customer or plan participant required to keep the insurance coverage in effect.
If you are eligible, your premiums will be reduced immediately when you begin coverage under a qualified plan.
A drug approved by the Federal Food and Drug Administration that you can only get with a prescription from your doctor.
An account in which contributions are taken from an employee's pay before withholding income tax and Social Security.
Medical and dental services aimed at keeping you healthy and detecting and treating any health problems early. Examples include immunizations, teeth cleaning and routine physical exams.
Health care reform law requires preventive care and immunizations to be covered without any cost sharing. Cost sharing is any cost when care is received. Dollar limits are not allowed. Does not apply to grandfathered plans under health care reform law.
Any action taken by the patient, assisted by the dentist, hygienist and the office staff that serves to prevent dental or other disease. Sealants, cleanings and space maintainers are examples of preventive treatment.
The basic, comprehensive, routine level of health care typically provided by a person's general or family practitioner, internist or pediatrician.
A physician-usually a family or general practitioner, internist or pediatrician-who provides a broad range of routine medical services and refers patients to specialists, hospitals and other health care professionals, as necessary. Under some coverage plans, a referral by the PCP is required to obtain services from other health care professionals. Each covered family member chooses his or her own PCP from the network's physicians.
See Precertification: Getting approval from the health plan before a routine hospital stay or outpatient procedure. In precertification, Cigna reviews medical criteria to determine coverage.
Insured plans cannot provide greater benefits to highly-compensated employees. Previously, this rule applied only to self-insured plans. Employers who break this rule will pay penalties under health care reform law. Does not apply to grandfathered plans under the law.
A device that replaces all or a part of the human body because a part of the body is permanently damaged, is absent or is malfunctioning. An artificial leg is a prosthetic device.
A person or hospital that provides health care services. Cigna prefers the term "health care professional."
A listing of health care professionals who have contracted with a health care carrier to provide care to its customers.
A group of health care professionals contracted by a health care carrier to deliver medical services to its customers.
The dental term for the division of the jaws into four parts, beginning at the midline of the arch and extending toward the last tooth in the back of the mouth. There are four quadrants in the mouth. Each quadrant generally contains five to eight teeth.
A health plan that is certified by an exchange. To be certified, a plan must provide essential health benefits and meet other health care reform rules.
A condition characterized by the abnormal loss of gum tissue due to infection or bone loss.
A plan's recurrent disability provision is designed to protect an employee who tries to return to work but becomes disabled again from the same or a related cause. If this happens within a certain period of time, the employee is considered disabled from the original disability. That means disability payments will continue without a break. This provision helps protect people. It encourages an employee to return to work without fear of losing coverage.
When a patient from one office is sent to another health care professional, usually a specialist, for treatment or consultation.
Restoration of or improvement in an employee's health and ability to perform the functions of his or her job. Rehabilitation usually involves a program of clinical and vocational services, with the goal of returning employees to a satisfying occupation whenever possible.
Disability coverage that pays for a portion of a covered person's salary when they are able to work, but limited in their abilities because of the covered disability. For example, residual coverage may pay if a covered person is diagnosed with multiple sclerosis and can only work part time because of their condition.
A removable dental appliance, usually used in orthodontics, that maintains space between teeth or holds teeth in a fixed position until the bone solidifies around them.
This plan provision helps encourage injured or disabled employees to return to work as soon as safely possible. Under the provision, the employee can receive up to 100 percent of pre-disability earnings based on a combination of disability coverage, other coverage, income and return-to-work earnings.
The hollow part of the tooth's root. It runs from the tip of the root into the pulp.
The process of scaling and planing exposed root surfaces to remove all calculus, plaque and infected tissue.
A composite material used to seal the decay-prone pits, fissures and grooves of children's teeth to prevent decay.
A Cigna program that encourages or requires individuals to obtain the opinion of a second doctor after the first doctor has recommended non-emergency or elective surgery be performed.
The geographical locations covered by a network of health care professionals.
May include physical, occupational, hearing, speech, pulmonary, cognitive therapies and chiropractic services following an injury or illness. Covered short-term rehabilitation services will vary by plan.
A licensed organization that provides nursing care and related services for patients who do not require hospitalization in an acute care setting.
A program to increase health insurance options for small businesses and individuals. SHOP offers money to states to improve their insurance markets.
Prior to plan years beginning on or after January 1, 2016, states may define small employers as having one to 50 full-time employees. For plan years beginning on or after January 1, 2016, health care reform defines small employers as having one to 100 employees. Only small businesses and individuals can buy health insurance through a state insurance exchange starting in 2014.
Health plans offered by employers with 100 or fewer employees. Until 2016, the Patient Protection and Affordable Care Act allowed states to define small group as one to 50 employees.
Health care professionals, whose practices focus on a single disease, part of the body, age group or procedure. For example, oncologists treat only cancer patients. Otolaryngologists or ENTs specialize in ear, nose and throat problems. Pediatricians are doctors who only serve children. And a cardiac surgeon only performs surgeries involving the heart and great blood vessels.
Treatment to correct a speech impairment that resulted from birth or from disease, injury or prior medical treatment.
An HMO where doctors are employed by the health plan and provide care at a health care center.
A lifestyle event that may cause or allow a person to modify their health coverage category. Birth of a child, divorce or marriage are examples of status changes.
The date a claim was submitted and/or received by Cigna.
The person who first signed up for the Cigna plan. Cigna prefers using the term "primary customer" or simply "customer" or "individual."
Relating to the whole body.
A health plan that covers people with pre-existing conditions. They must have been uninsured for six months. Pools will be available until state exchanges begin in 2014. Insurance companies and employers may not encourage people to leave their current plan to join a high-risk pool.
The connecting hinge mechanism between the upper jaw and the base of the skull.
The problems associated with TMJ, usually involving pain or discomfort in the joints and ligaments that attach the lower jaw to the skull or in the muscles used for chewing.
A core set of performance measures developed through the collaborative effort of the National Committee for Quality Assurance (NCQA), employer groups and health care purchasers. HEDIS is a registered trademark of the National Committee for Quality Assurance.
When an employer changes insurance carriers, transition plans allow participants already in treatment to transition to an in-network health care professional. It gives the patient and their current health care professional a specific number of days to contact Cigna to discuss the patient's treatment plan and obtain approval to continue treatment at the in-network coverage level for a specified period of time, or to transition to a Cigna contracted professional.
In dentistry, a list of the work the dentist proposes to perform on a patient based on the results of the dentist's X-rays, examination and diagnosis. Dentists often present more than one treatment plan to give the patient options.
A program that offers customers enrolled in an open access coverage plan with access to a broad health care professional network, including Tufts-contracted professionals in Massachusetts and Rhode Island, and Cigna-contracted health care professionals in all other states.
A panel of doctors who review scientific evidence and suggest what preventive care services health plans should cover.
Care for an illness, injury or condition that requires prompt care, but not serious enough to require emergency room care. Examples of urgent care needs include ear infections, sprains, high fevers, vomiting and urinary tract infections.
The amount paid to a health care professional for a service based on the typical charges for that service within a specific geographical area.
An artificial filling material, usually plastic, composite or porcelain, used to provide an aesthetic covering over the visible surface of a tooth. Most often used on front teeth.
Employers must report the value of employer health coverage on each employee's W-2. Employee contributions to flexible spending accounts and health savings accounts are excluded.
To be eligible for coverage under a group insurance policy, an employee must have worked a certain number of continuous days as an active, full-time employee. Employees without the required days of employment are in the waiting period. Another type of waiting period is the time between when a disability occurs and when payments from the disability insurance policy begin.
When a covered person becomes disabled and eligible for coverage, they no longer have to pay for the coverage. Paying the plan's cost (premium) is stopped (waived). And they pay no disability premium payments as long as they are receiving payments from the plan.
The last of the three molar teeth, also called third molars. There are four third molars, two in the lower jaw and two in the upper jaw, one on each side. Some people are born without third molars.