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CIGNA Plans & Services — HMO and Network
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The Right Care at the Right Price
CIGNA Health Maintenance Organization (HMO) and Network plans offers access to quality health care from a broad network of participating physicians. During enrollment, members may choose a Primary Care Physician (PCP) who may provide routine care, coordinate care and provide referrals to in-network specialists and facilities.
During an emergency or urgent care situation, members may receive approval to use out-of-network services in an HMO/Network plan.
In addition to our HMO and Network plans, we offer HMO Open Access and Network Open Access plans, which allows members to visit in-network specialists without a referral from a PCP.
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Where to Find the Care You Need
Here is a summary of your plan's services and how to arrange for care.
Routine Medical Care (such as physical exams, mild fever and pains, chronic pain and headaches, colds and flu).
- Call your Primary Care Physician's (PCP) office during office hours and he or she will provide you with medical advice and/or schedule an office visit for you.
Specialty Care (such as orthopedic or heart disease)
- Make an appointment with your PCP for an initial assessment, and he or she will refer you to a participating specialist if needed.
Hospital Care (such as inpatient care and surgery, or outpatient surgery)
- For non-emergency care, call your PCP and he or she will coordinate all your hospital care.
Urgent Medical Care (such as fever, sprains or strains, eye or ear infections, or severe sore throat)
- Call your PCP. He or she will assess your situation and if necessary, give you advice on where to seek immediate care.
Emergency Care (such as poisoning, chest pains, broken bones, uncontrolled bleeding, loss of consciousness or sudden paralysis)
- Go to the nearest emergency facility or call 911. Call your PCP as soon as reasonably possible and he or she will coordinate all follow-up care.
If you have a question about your health, call your CIGNA PCP. And for questions about your health plan or coverage, call the toll-free number on your CIGNA HealthCare ID card.
Next (Cost Example) >
How does the HMO/Network Plan work for you
You selected a CIGNA HealthCare PCP to be your overall care coordinator, and make an appointment regarding pains you are feeling in your lower legs. Your PCP refers you to lab and X-ray facilities for additional tests before referring you to an orthopedic specialist.
| Cost Example |
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| PCP office visit/exam fee |
$85 |
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| Your Copayment |
$20 |
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| Lab fee |
No cost to you |
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| X-rays |
No cost to you |
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| No deductible applies |
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| You pay |
$20 |
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Next (Special Programs) >
Special Programs
Members of CIGNA HealthCare plans may also have access to valuable Health and Wellness Programs:
- Well Informed — a personalized health improvement program designed to let CIGNA HealthCare members and their doctors know about opportunities to maintain or improve the member's health.
- 24-hour health information — call the CIGNA HealthCare 24-Hour Health Information LineSM any time to speak with a registered nurse or listen to our audio library for health-related information.
- Support for chronic conditions — manage your asthma, diabetes, heart condition, low back pain, or chronic obstructive pulmonary disease with help from CIGNA Well Aware for Better Health®.
- Member discounts — save up to 60% on products and services-from acupuncture to weight management-with our Healthy Rewards® discount program. Note: not all programs are available in all states.
- Quality transplant care — access care from nationally recognized facilities in the CIGNA LIFESOURCE Transplant Network®.
- CIGNA HealthCare Healthy Babies® — give your child a healthy beginning with information and support from the CIGNA HealthCare Healthy Babies® program.
- CIGNA Healthy Pregnancies, Healthy BabiesSM — the CIGNA Healthy Pregnancies, Healthy Babies® program offers a full scope of educational and care management services to members who are pregnant or considering pregnancy.
- Cancer prevention and education — the Comprehensive Oncology Program® addresses cancer prevention and education, as well as active management of members diagnosed with cancer.
- High Touch Personal Assistance — with CIGNA Health AdvisorSM, CIGNA Health Advisors proactively identify and reach out to members who are at risk for significant health issues but are not appropriate candidates for chronic or acute disease or case management programs.
- Lose weight and improve your health — when you enroll in the CIGNA Healthy Steps to Weight LossSM, you won't be starting a diet. Instead, this program helps you change your behaviors permanently. You'll learn healthier eating habits and how to incorporate exercise into your schedule – helping you to feel better, look better and improve your overall health.
Next (Employer Advantages - Benefits) >
Employer Advantages
Flexible HMO/Network plan designs include benefits for employees and employers alike:
- No referrals required for OB/GYN care or maternity care;
- Lower copayments or out-of-pocket costs for urgent care;
- Pharmacy and behavioral-care benefits;
- Consolidated billing, accounting, reporting and banking; and
- Standard health and wellness features, with optional features available at an additional cost.
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We've designed a flexible communication program to help your employees understand their plan and make better health care purchase decisions.
Pre-enrollment
- optimum communications time line and approach
- implementation plan
- introductory letter from your CEO/President or benefits administrator
- customized Intranet articles
- newsletter articles
- e-mail notices
- presentation scripts
- posters
- payroll stuffers
- "train the trainers" presentation
Open enrollment
- enrollment kits
- toll-free help line
- benefit fair
- kiosk (at an additional cost)
- on-site enrollers, workshops and seminars
Post-enrollment
- handbook
- ID card
- monthly e-mail copy
- customized Intranet services with online forms and detailed information about your company's plan
- customized, secure employee portal, myCIGNA.com, with extensive, reliable health information from Web MD®, physician and hospital ratings, side-by-side drug comparisons and health records and trackers
Your implementation manager will help you every step of the way with communication strategies and materials that best suit you and your employees.
Next (Options) >
Funding Options
Choose from multiple funding options:
Fully Insured
- Full premium paid monthly
- Predetermined and guaranteed rates
- Predictable, easy-to-budget expenses
- Protection from high claim costs
Fully Insured - Participating
- Full premium paid monthly
- Predetermined and guaranteed rates
- Predictable, easy-to-budget expenses
- Protection from high claim costs
- Year-end settlement
- Can earn cash back at year end if claims are low
Minimum Premium
- Lower premium paid monthly
- Claims funded through bank account with a monthly claim cap
- Protection from high claim costs
- Year-end settlement
- Improved cash flow
- Lower expenses and premium taxes
Administrative Services Only
- No monthly premium or premium taxes paid, just an administrative fee
- Exempt from most state regulations and mandates on coverage levels
- Stop Loss coverage available
- Maximizes cash flow
- Freedom to design your health benefits
- Financial protection against unanticipated, catastrophic claims
Health and Wellness Programs
Members of CIGNA HealthCare plans may also have access to valuable Health and Wellness programs and support.
- 24-hour health information — call the CIGNA HealthCare 24-Hour Health Information LineSM any time to speak with a registered nurse or listen to our audio library for health-related information.
- Support for chronic conditions — manage your asthma, diabetes, heart condition, low back pain, or chronic obstructive pulmonary disease with help from CIGNA Well Aware for Better Health®.
- Member discounts — save up to 60% on products and services-from acupuncture to weight management-with our Healthy Rewards® discount program. Note: not all programs are available in all states.
- Quality transplant care — access care from nationally recognized facilities in the CIGNA LIFESOURCE Transplant Network®.
- CIGNA HealthCare Healthy Babies® — give your child a healthy beginning with information and support from our Healthy Babies program.
- CIGNA Healthy Pregnancies, Healthy BabiesSM — the CIGNA Healthy Pregnancies, Healthy BabiesSM program offers a full scope of educational and care management services to members who are pregnant or considering pregnancy.
- Cancer prevention and education — the Comprehensive Oncology Program addresses cancer prevention and education, as well as active management of members diagnosed with cancer.
- High Touch Personal Assistance — with CIGNA Health AdvisorSM, CIGNA Health Advisors proactively identify and reach out to members who are at risk for significant health issues but are not appropriate candidates for chronic or acute disease or case management programs.
- Award Prgrams To Fit Your Needs — through the Healthy Awards Account® you can offer your employees health and well-being programs that are specific to your culture and needs.
- Lose weight and improve your health — when you enroll in the CIGNA Healthy Steps to Weight LossSM, you won't be starting a diet. Instead, this program helps you change your behaviors permanently. You'll learn healthier eating habits and how to incorporate exercise into your schedule – helping you to feel better, look better and improve your overall health.
Next (FAQ) >
FAQ
Do I have to choose a PCP?
You are required to choose a Primary Care Physician PCP), unless you are enrolled in a HMO Open Access or Network Open Access plan.
What if my doctor isn't on your list?
That means your doctor does not participate in the network. To receive coverage for healthcare benefits, you should select a doctor from the list of participating HMO or Network providers. Participating providers must meet standards to become a part of the network.
Do I need a referral to see a specialist?
Yes, unless you are enrolled in a HMO Open Access or Network Open Access plan. If you choose to see an out-of-network specialist, the health care services you receive will not be covered.
What is the difference between in-network coverage and out-of-network coverage?
HMO and Network products are lock in products. This means that a member will only be reimbursed for care covered through a CIGNA network provider.
How do I find participating doctors?
Search for participating HMO/Network Provider in the Provider Directory or visit the online directory at www.cigna.com. and select HMO/Network plans.
What is utilization review?
Utilization review is a process that helps determine if the services you receive are a covered benefit. CIGNA HealthCare performs utilization review, including hospital pre-admission certification, continued stay review and case management. Requests for non-emergency hospital stays other than maternity stays must be approved in advance.
Precertification is not required for a maternity stay of 48 hours for vaginal deliveries, or 96 hours for caesarean sections. Depending on your benefits plan, you may be eligible for additional benefits. Any maternity hospital stay beyond the initial 48 or 96 hours must be approved. Please call the toll-free number on your CIGNA HealthCare ID card for details.
Who is responsible for obtaining precertification?
Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis.
If your doctor participates in the network, he or she will arrange for precertification.
What if my doctor keeps me in the hospital longer than my precertification allows?
CIGNA HealthCare will contact your hospital the day before you are scheduled to be discharged. If your physician has extended your stay, then the additional days will be reviewed for coverage. CIGNA HealthCare will continue to review your hospital stay for coverage until you are discharged.
If you remain in the hospital for services that are not covered, your out-of-pocket costs may be higher.
Can my current doctor be added to your network?
If your current doctor meets our credentialing standards and is interested in becoming a participating provider, he or she can call our Provider Relations Department to get more information on joining the Network.
What if my doctor is on the list, but his/her office is shown as "accepting current patients only"? Can I still choose my doctor?
If you are an existing patient of a participating doctor, you may select him or her to provide your care.
Am I covered for emergency care?
Whenever there is an emergency, seek medical help immediately. An emergency is an accident or sudden illness that a person with average knowledge of medical science believes needs to be treated right away or it could result in serious medical complications or permanent disability.
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