Cigna HealthCare Policies
- Alternative Medicine
- Breast Cancer Screening and Treatment
- Clinical Trials
- Commitment to Quality
- Continuity of Care
- Direct Access to Specialists
- Emergency Room
- Emerging Treatment (Experimental)
- Financial Incentives / Provider Reimbursement
- Health Plan Liability / Medical Director Liability
- Mandated Benefits
- Mandatory Point-of-Service
- Maternity Care
- Mental Health Parity
- Minority Providers / Essential Community Provider
- Off-Label Drug Use
- Physician-Hospital Organizations
- Physician-Patient Communication
- Specialists as PCPs
- Utilization Management
Recently special interest groups and the media have focused on the issue of access to alternative medicine in the managed care setting. Some of the alternative therapies of interest include acupuncture, naturopathy, biofeedback, and massage therapy. A few employers provide coverage for alternative medicine for their employees, and some health plans provide coverage for alternative medicine. Organized medicine has just begun to look at the benefits of certain alternative treatments.
The Cigna HealthCare Medical Technology Assessment Council regularly reviews new treatments and technologies to help ensure that our members have access to effective treatments. Requests for coverage of an alternative therapy are reviewed on a case-by-case basis by the local Cigna HealthCare physician-medical director to determine if the treatment has been proven scientifically to be effective (i.e. supported by peer review literature) and whether it is covered under the member's benefit plan. If there is proven effectiveness, and if the local medical director has additional questions, he/she may consult with an independent medical expert, who provides a complete objective assessment based on medical evidence.
Breast Cancer Screening and Treatment
We care about the health and well-being of our members and provide access to preventive care and patient education. Cigna HealthCare provides Women's Health preventive care benefits for female participants in our managed care (Network, POS EPO and PPO) plans. Necessary mammograms, when ordered by a woman's physician or OB/GYN, are covered. It is at the discretion of each woman's doctor to decide, based upon her health history, when or how often she needs a mammogram.
There are two types of surgical treatment for breast cancer: lumpectomy, which is the removal of a lump from the breast; and mastectomy, the removal of the entire breast and sometimes the lymph nodes.
A biopsy is a procedure used to detect cancer that involves the removal of a small amount of breast tissue for evaluation.
We recognize that each woman enters surgery with a different health history and condition, and each woman recuperates at a different pace. A hospital stay is always a covered benefit for any Cigna HealthCare member who requires a mastectomy.
In Cigna HealthCare plans where prior authorization of medical procedures is required, biopsies and lumpectomies are typically authorized as outpatient procedures because it is safe for most patients to return home to recover from these procedures. Medically necessary inpatient care is also covered. Medically necessary home health care services are available following breast surgery procedures.
Following a mastectomy Cigna HealthCare medical plans provide coverage for breast reconstruction when appropriate.
As new drugs are developed for the treatment of a specific illness or condition, they are tested for safety and effectiveness. Health plan members sometimes request coverage for medical treatment associated with a clinical trial. Clinical trials are not without risks, and each trial needs to be evaluated for potential benefits and risks.
Cigna HealthCare reviews requests for coverage of treatment associated with Phase 3 and 4 clinical trials on a case-by-case basis.
- Health education to our customers through friendly reminders on our secure enrollee websites, myCigna.com and through customer mailings and other health and wellness programs; and
- Customers and healthcare professionals with preventive-health guidelines for women, men and children.
We promote safety and equity by:
- Verifying the credentials of healthcare professionals joining the Cigna HealthCare network of physicians to assure they meet the requirements for providing quality care;
- Assuring that the number and operating hours of physicians in any given service area are adequate to meet the needs of Cigna customers;
- Promoting the safe use of medications;
- Adhering to the Institute of Medicine principles in guiding our safety and equity-related activities;
- Honoring confidentiality of information and adhering to all federal and state regulations regarding confidentiality and the release of protected health information;
- Abiding by a nationally recognized set of Customer Rights including the right to be treated with respect, to participate in decision-making and to voice complaints and appeals;
- Providing hospital safety information through the hospital compare tool on myCigna.com that gives information on hospital mortality and complication rates. We also provide the Leapfrog Groups' survey results for standards to help reduce hospital errors and improve patient safety; and
- Training our Customer Service staff to assist in getting or giving written or spoken information in your preferred language. Additionally, Cigna utilizes the 711 relay center that is available to any hearing impaired person in the US and interfaces with the existing phone equipment used by the hearing impaired.
We measure the effectiveness of our program activities by seeking external validation of our programs.
- Cigna has a strong history with the NCQA process and all Cigna health plan locations have been accredited. Our Disease Management, Behavioral Health, and Wellness & Health Promotion Programs for our customers have also received NCQA Accreditation.
- Our Utilization and Case Management services, have been awarded accreditation from URAC, an independent, not-for-profit organization whose mission is to ensure consistent quality of care for clients and customers.
- We compare our clinical outcomes (HEDIS®) to the industry standards established by NCQA to evaluate areas of opportunity for quality improvement. Visit NCQA to see how we're rated.
- We measure the satisfaction of our customers annually and take appropriate action to improve our enrollees' experiences.
To learn more about our quality management program or to request a report on our progress in meeting our goals, call Customer Service at the number on your Cigna ID card.
Continuity of Care
Continuity of care concerns for participants in our managed care plans (Network, POS, EPO or PPO plans) can be triggered by several different events – i.e., a contract with a provider participating in a network is terminated (either by the provider or by the health plan) while a member is undergoing a course of treatment from the provider, or a member's employer selects a different health plan to provide coverage to its employees and a provider that an employee is actively receiving treatment from is not in the new network. This does not apply to Indemnity plans because they are not network-based plans. In a Indemnity plan, members are free to see any provider, so changes in managed care provider networks would not apply.
If a contract with a provider participating in a Cigna HealthCare network is terminated or an employer selects a Cigna HealthCare medical plan while an employee is receiving care from a provider who does not participate in a Cigna HealthCare network, we will work with the member to assure that there is continuity of care. Continuity of care can be accomplished by allowing the member to continue to receive treatment from the current non-participating provider or working to effect the smooth transition of care to a Cigna HealthCare participating provider.
Credentialing of providers who participate in our managed care plans (Network, POS, EPO, PPO) is one of the cornerstones of Cigna HealthCare quality assurance activities. We have developed national policies to credential practitioners and facilities that are adopted and managed at the local level by our local medical management staff. Because Indemnity plans are not network-based (participants can see any providers they choose), there are no "participating providers", so credentialing does not apply to Indemnity plans.
Before a physician is accepted into the Cigna HealthCare network, we perform a review of his/her credentials, which includes:
- residency or board certification (passing exams given by a board of specialists);
- state licensing and any actions against that license or certification;
- Drug Enforcement Agency (DEA) license status (the doctor's license to write prescriptions);
- admitting privileges at a Cigna HealthCare participating hospital;
- good standing with the medical staff at the Cigna HealthCare participating hospital;
- malpractice insurance coverage and malpractice history;
- sanctions (disciplinary actions) by Medicare or Medicaid;
- sanctions reported to the National Practitioner Data Bank;
- review of previous work history;
- office site assessment and file audit for primary care providers.
Cigna HealthCare accessibility and availability standards also apply to our participating providers. Our medical management staff checks:
- convenience of the location and its accessibility;
- office hours and 24-hour availability;
- office facilities and medical equipment;
- patient record-keeping procedures;
- patient satisfaction.
After a physician is admitted into a Cigna HealthCare network, we conduct a review every two years to make sure he/she continues to meet our standards. Also, we regularly survey our managed care plan participants on the delivery and quality of services they receive from the doctors participating in the Cigna HealthCare network.
Direct Access to Specialists
Managed care has reemphasized the importance of the primary care physician (PCP). Each Cigna HealthCare Network Plan and POS Plan member selects a primary care physician – usually a family practitioner, internist, or pediatrician, who becomes the cornerstone for that member's health care needs.
The primary care physician is familiar with the patient and his/her health history and helps coordinate care for the member, including the provision of primary and preventive care and referral to specialists when needed (except in Cigna HealthCare Network Open Access and POS Access plans – referrals are not required in these plans). The relationship Cigna HealthCare members establish with their PCP facilitates better use of specialty services. The PCP helps make sure that the member is seeing the appropriate specialist for his/her condition and confers with the specialist to give details on the member's condition and health history.
For members with complex health conditions, the role of the PCP is essential. The PCP leads the team helping the member to manage his/her multiple health conditions and treatment – often this includes assuring proper access to specialty care and making sure that all of the specialists are keeping one another informed.
Under certain circumstances when it is determined that the ongoing needs of a member with chronic or multiple illnesses would be most effectively met by a specialist, that specialist becomes the primary care provider for that member (i.e., an AIDS patient may use an infectious disease specialist as his/her PCP). This decision would be made as part of our case management process, which is an integral part of Cigna health plans.
Another example of the Cigna HealthCare commitment to providing proper access to specialty care is our policy on access to OB/GYNs. The health care needs of most healthy women at certain stages in their lives are more centered around their reproductive health. We provide women in our Network (HMO) and POS plans with direct access to Cigna HealthCare participating OB/GYNs without the need for a referral. This is often referred to as open access OB/GYN care. Easier access to OB/GYNs encourages women to take advantage of preventive care, to access maternity services earlier, and to seek help for covered OB/GYN services. Open access OB/GYN care does not apply to participants in our Network Open Access, POS Open Access, EPO and PPO plans; those plans do not require referrals to specialists of any kind and participants are free to see any participating specialists they choose.
Additionally, if a member would like to see out-of-network specialists for increased out-of-pocket costs, Cigna HealthCare Point-of-Service (POS) plans and Preferred Provider (PPO) plans offer this flexibility.
Disclosure of information to the consumer has surfaced as a key issue in the public debate over managed care. There is a misperception that health plans do not give their members basic information about the plan such as: what is contained in the benefit plan they have selected, how to access services, which providers are in the network, what is the appeal and grievance procedure, etc. Consumer advocates and others are interested in requiring health plans to disclose financial information such as: what percentage of each premium dollar goes to the delivery of medical care versus administration of the plan, the specific amount providers are compensated, etc.
We believe that full information disclosure is essential to member satisfaction and in providing access to quality care. Cigna HealthCare members receive a description of their benefit packages that includes information on: exclusions and limitations, the definition of emergency care, claims and reimbursement procedures. In addition, participants in our managed care (Network, POS, EPO, PPO) plans receive instructions on accessing primary and specialty care, away-from-home care, out-of-network benefits (POS and PPO plans only), member rights and responsibilities, the Cigna HealthCare appeal and grievance procedure, a directory of participating providers, and other important information.
Widespread reports of emergency room claim denials by managed care plans have led to calls for legislative solutions. The federal Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted to prevent hospitals from determining whether a patient should pay for care before it was rendered. EMTALA requires hospitals and emergency room physicians to screen and stabilize emergency room patients regardless of whether the patient is in an emergency situation. When a managed care plan participant seeks treatment for a non-emergency condition in the emergency room, he/she is responsible for the cost of screening and any treatment rendered. As a result, hospitals and emergency room physicians are often not being paid for these services. They have seized this issue and are seeking legislation that would guarantee payment for all treatment provided in emergency rooms, regardless of the medical necessity of the services. This proposal would remove the financial disincentive for inappropriate use of the emergency room. In effect, it would encourage people to use the most expensive health care setting, the emergency room, rather than their primary care physician or specialists.
Another issue is that emergency room claims are initially being denied because hospitals and emergency room physicians disclose only the final patient diagnosis on claim forms. When the presenting symptoms are disclosed, the claims are often paid.
Cigna HealthCare goal is to provide quality, coordinated care in the most appropriate setting. Emergencies should be treated in the emergency room, and patients should get emergency care when they need it at the sudden – and unexpected – onset of a serious injury or life-threatening illness. No Cigna HealthCare participant regardless of plan type (Network, POS, EOP, PPO or Indemnity) is required to get prior authorization before seeking treatment in an emergency room in a situation in which a "prudent layperson" would believe such emergency care is required. In addition, if a managed care plan participant's primary care provider refers him/her to the emergency room, regardless of the nature or severity of the illness or injury, the claim will be covered.
Non-emergency conditions should be treated by a physician in the physician's office. We encourage all Cigna HealthCare plan participants to seek treatment for non-emergency conditions as soon as possible. Cigna HealthCare, by contract, requires participating primary care physicians to maintain 24-hour, seven-day-a-week telephone coverage and to provide an appointment within 24 to 48 hours of a request for urgent medical conditions.
When members are unsure whether or not they have a condition that requires immediate medical attention, they should consult with their primary care physicians. If their symptoms warrant prompt medical attention, the PCP will refer them to the emergency room. This relationship facilitates better treatment in the emergency room because the primary care physician can alert the emergency room that the patient is coming and provide important details on the patient's condition and health history.
As a Cigna HealthCare plan participant, you have access to the Cigna HealthCare 24-Hour Health Information LineSM. Any hour of the day or night, from any phone in the U.S., you can call toll-free to speak with a registered nurse about your symptoms and situation. The toll-free number is on your Cigna HealthCare ID card. A Health Information nurse will help you determine if emergency room care is advisable, if you require urgent care, or if self-care followed by a physician office visit is best. Remember that this is not a call for authorization to seek emergency care. No authorization or referral is required by any Cigna HealthCare medical plan for emergency care. If you believe life or limb are at risk, don't delay. Go directly to the nearest emergency facility or notify your local emergency services immediately.
Emerging Treatment (Experimental)
Managed care plan (Network, POS, EPO, and PPO) standards for coverage for new and emerging treatments have become subject to increased scrutiny. The general public is under the false impression that managed care companies do not provide coverage for new treatments, drugs, or devices – often called experimental treatment – because they are expensive and unproven. This issue has received a great deal of media attention in relation to coverage for autologous bone marrow transplants (ABMT) for the treatment of breast cancer as well as coverage for clinical trials.
We evaluate requests for coverage for new treatments on a case-by-case basis. The Cigna HealthCare coverage review process uses internal and external sources including its Medical Technology Assessment Council, peer-reviewed medical literature, and independent medical experts to assist its medical directors in reaching coverage determinations. Key components of Cigna HealthCare's coverage review process are a(n):
Ethics Program. A consulting ethicist to advise Cigna HealthCare medical management on the ethics of health care decision making. With the ethicist's help, we have developed a decision making tool that makes explicit the ethical dimensions of issues that frequently arise in managed care. The Cigna HealthCare Medical Ethics Council is a standing committee established to ensure that ethical decision making is an integral part of each health plan's operations. Our Medical Ethics Council includes representation from various departments within the company.
Independent Review. The Cigna HealthCare Expert Review Program assists our medical directors in determining coverage for medically complex cases. The program provides extensive and objective assessments through a network of credentialed, independent medical experts in all domains of medical care. The medical experts may be local medical experts or from nationally recognized academic medical centers. They render opinions that address the issue of whether the requested technology will specifically benefit the member in question and whether this technology offers advantages over currently proven treatment modalities.
Medical Technology Assessment. The Cigna HealthCare Medical Technology Assessment process evaluates emerging and evolving technologies to help ensure that our members have access to effective treatments. The Medical Technology Assessment Council, composed of national and field medical directors, an ethicist, an attorney and nursing professionals, meets monthly to evaluate independent reports on medical technologies. The council also reviews reports produced by the Technology Assessment Unit research staff at the request of field medical directors. The actions of the council produce coverage statements that are communicated to all Cigna HealthCare medical directors. The Medical Technology Assessment process is a central source of scientific, objective, and consistent support for the administration of benefits.
We oppose legislative mandates that would require coverage for particular treatments or drugs. Medical science is not static, new treatments are constantly being discovered, and changes are being made to existing treatments on a regular basis. Government should not be involved in deciding what is the best medical treatment for a particular health condition.
Financial Incentives/Provider Reimbursement
The manner in which health plans reimburse providers is another issue that is coming under increased public scrutiny. Providers unhappy with the changes managed care has made in the way they are paid have raised the issue. They assert that managed care payment arrangements, particularly capitation, reward physicians for providing less care.
Managed care is changing the way that physicians are paid. In many cases they no longer receive a fee for every individual service, procedure or treatment they perform. This type of reimbursement encourages overtreatment which, in addition to being expensive, can be dangerous. There is a misperception that managed care offers physicians financial incentives to cut costs and corners when treating patients. We believe that physicians should direct their efforts toward providing quality health care to Cigna HealthCare participants and that cost reductions can be achieved without affecting quality, simply by eliminating care that is unnecessary or of no proven value. We oppose the use of financial incentives that encourage physicians to withhold necessary care. We do not offer physicians incentives to deny care. Compensation for Cigna HealthCare participating and out-of-network providers is determined using one of the following reimbursement methods:
Discounted fee for service. Payment for services is based on an agreed upon discounted amount for services provided. This compensation method applies to Cigna HealthCare EPO, PPO and Indemnity plans and also applies to compensation for out-of-network providers in our POS plans.
Capitation. Network physicians, physician groups, or physician/hospital organizations (PHOs) are paid a fixed amount (e.g. "capitation") at regular intervals for each participant assigned to the physician, group or PHO, whether or not services are provided. This payment covers physician and, where applicable, hospital or other services covered under the benefit plan. Medical groups and PHOs may in turn compensate providers using a variety of methods. This compensation method applies to Cigna HealthCare Network plans and the in-network providers in our POS plans.
Capitation provides physicians with a predictable income, encourages physicians to keep people well through preventive care, eliminates the financial incentive to provide services which will not benefit the patient, and reduces paperwork for physicians.
Salary. Physicians who are employed to work in a Cigna HealthCare medical facility are paid a salary. The physician's compensation is based on a dollar amount, decided in advance each year, that is guaranteed regardless of the services provided. Physicians are eligible for a bonus at the end of the year based on quality of care, quality of service and appropriate use of medical services. This compensation method applies to Cigna HealthCare plans in which participants see doctors and receive care in Cigna HealthCare-owned and-operated facilities, sometimes referred to as "staff model" plans.
Bonuses and Incentives. Eligible physicians may receive additional payments based on their performance. To determine who qualifies, Cigna HealthCare evaluates physician performance using criteria that may include quality of care, quality of service, and appropriate use of medical services.
Some patient advocates and independent pharmacists contend that drug formularies limit patient treatment options and can inhibit therapy. In particular, media attention has focused on certain drugs not being included on formularies. Patient advocacy groups are seeking coverage for all FDA-approved drugs, regardless of whether they are approved for the treatment for which they are being prescribed. Legislative attacks are under way.
A study published in The American Journal of Managed Care, a non-peer-reviewed journal (a.k.a. the Susan Horn study), concluded that use of formularies increased use of health care services, which resulted in lower quality and increased costs. The study is flawed in several ways, the most important of which is that it does not establish any baseline for results (i.e., it does not look at drug costs and drug/medical utilization patterns at the HMOs studied prior to the effective date of the formularies).
The Cigna HealthCare formulary – a list of drugs covered by a member's benefit plan – was developed to assure quality and cost effective drug therapy. Drugs included in our formulary are carefully selected by physicians and pharmacists for their efficacy, and the formulary is reviewed and updated regularly. This process allows our members to benefit on an ongoing basis from advances in pharmaceutical science that can dramatically improve the quality of people's lives. Hospitals have used drug formularies in the same way for many years.
The Cigna HealthCare national drug formulary contains 1,000 FDA-approved brand name and generic drugs. These drugs are placed on the formulary by the Cigna HealthCare Pharmacy and Therapeutic Committee, which meets quarterly and is composed of physicians and pharmacists.
The Cigna HealthCare Pharmacy and Therapeutic Committee reviews all FDA-approved drugs, groups them by therapeutic function and then, within each group, compares their relative therapeutic effectiveness and potential side effects. Only when two or more drugs are determined to be therapeutically equivalent does cost become a consideration. Cost is an appropriate and necessary consideration, since drug prices have risen three times faster than the rate of inflation over the last decade.
We offer a variety of formulary structures, depending on the level of prescription drug coverage your employer chooses to offer. Our Two-Tier Formulary covers generic drugs and preferred brand-name drugs that do not have generic equivalents (slightly higher copayment required). Our Three-Tier Formulary covers generics, preferred-brand and non-preferred brand drugs (medications that have generic equivalents or one or more preferred-brand options available at a higher copayment level). Your employer can tell you which formulary program you participate in or you can call Member Services. You can also review your specific formulary for covered medications online.
Local Cigna HealthCare plans may modify the national formulary to take into consideration local prescribing practices. If a physician wishes to prescribe a drug that is not on the formulary, the physician or a member may seek an exception to the formulary for coverage of a non-formulary drug.
Health Plan Liability/Medical Director Liability
The issue of health plan liability for medical decisions first surfaced in the debate over the health care reform legislation during the Clinton presidency. It has resurfaced again in several state legislatures and at the federal level. Critics of managed care are making the argument that when a health plan denies coverage for a treatment or procedure, it is a medical decision – because the health plan is deciding what treatment it will cover – and should be subject to medical malpractice liability. (The underlying assumption is that treatment will not be given unless the health plan will pay for it.)
Health plan medical professionals make coverage determinations based on the terms of a member's particular benefit plan. Health plan medical directors use utilization management guidelines to assist in making such coverage determinations, but they are used as just that – guidelines ndash; and are not a substitute for a clinician's judgment. The utilization management guidelines are a set of optimal clinical practice benchmarks for a given treatment with no complications and are based solely on sound clinical practices.
The Cigna HealthCare utilization management guidelines are reviewed by each local health plan's quality committee, composed of Cigna HealthCare participating physicians practicing in the area, and are modified to reflect local practice. The guidelines are applied on a case-by-case basis.
Mandated benefits require managed care companies and insurers by law to provide coverage for specific treatments and procedures and may set durational limits on coverage (e.g., 10 visits, 48 hours of hospitalization, etc.). These laws, typically enacted by state legislatures, apply only to HMOs and insured plans, and do not apply to self-insured plans. Federal mandates, however, apply to all employer-provided plans, whether insured or self-insured. One of the biggest concerns with mandated benefits is that they increase the cost of health care coverage. Some recent examples of mandated benefits include coverage for diabetic supplies, equipment and education, prostate screening antigen (PSA) testing for prostate cancer, bone densitometry for osteoporosis, breast reconstructive surgery following a mastectomy, and mastectomy length-of-stay requirements.
We are opposed to the government determining specific benefits to be included in managed care and insurance contracts. We believe that the marketplace should determine the benefits available to health plan participants.
Legislative mandates that would require all HMOs to offer a point-of-service plan – a plan that offers participants the option to choose out-of-network providers for covered services – have been introduced in several states and have been enacted in several others. Legislators are attempting to guarantee that consumers are offered a health care coverage option other than a traditional HMO.
We oppose legislative mandates that would require all HMOs to offer an out-of-network benefit. This mandate would increase costs for employers and members and would eliminate traditional HMOs as a product offering in the marketplace. Point-of-service plans are already an option widely available in the marketplace.
We care about the health and well-being of our members. Cigna HealthCare Network and Point-of-Service plan participants have open access to participating OB/GYNs without the need for PCP referrals. Participants in our Network Open Access, POS Open Access, EPO and PPO plans are not required to get referrals for any type of specialized care. Open access encourages women to take advantage of preventive care including pre-pregnancy planning, to access maternity services earlier, and to seek covered OB/GYN services. The Cigna HealthCare Healthy BabiesSM program, available to expectant participants in our Network, POS, EPO and PPO plans, provides educational support to help participants have a healthy pregnancy and baby.
To encourage women to see their OB/GYN for regular checkups during pregnancy, there are no co-payments for prenatal visits. We also provide expectant mothers with educational materials, including a handbook on pregnancy and infancy.
In order to identify high-risk pregnancies early, an expectant mother, in conjunction with her obstetrician or primary care physician, completes a risk assessment/screening questionnaire. If a high-risk pregnancy is identified, the woman will be followed throughout the pregnancy by a case manager who is a registered nurse. The case manager, trained in obstetrics, works with the doctor and member to develop and carry out an appropriate treatment plan that fosters a successful pregnancy and childbirth.
The time a mother and baby spend in the hospital after delivery is a medical decision. Consistent with federal law effective 1/1/98, the Cigna HealthCare national maternity policy includes coverage for 48 hours of hospitalization following a normal vaginal delivery and 96 hours following an uncomplicated Caesarean section. Shorter or longer lengths of stay may be approved at the request of the attending physician.
Medically necessary home care services are available following discharge from the hospital. Home care nurses are trained to give a full assessment of the mother's and baby's health as well as answer any questions. Many physicians find that home care is the most effective way to follow up with a new mother since it enables a complete assessment of both health and home environmental issues.
Mental Health Parity
In 1996, mental health advocates were successful in the passage of federal legislation that requires employers who provide mental health coverage to apply the same annual and lifetime dollar limits to the mental health benefits as are applied to benefits for physical illness. (This requirement became effective 1/1/98.) Mental health advocates are now seeking state legislative mandates that would require mental health coverage be provided in all health plans at the same level of benefits as physical illness. Some of the state proposals specify certain conditions, such as biologically based mental illnesses, while others would require all mental health conditions be treated the same as physical illnesses.
We do not support government-mandated benefits; however, we do support appropriate care and treatment for mental illness.
Minority Providers/Essential Community Provider
Minority providers, concerned about being excluded from health plan provider panels (also known as managed care physician networks), are seeking legislative mandates that would require health plans to contract with them. These proposals are often called "essential community provider." The stated goal of the proposals is to protect the existing health care infrastructure in the inner city, rural areas and other medically underserved communities. They touted as preventing racially discriminatory practices in the selection of providers.
The concerns of minority providers have grown as more health plans have entered the Medicare market – and as states have turned to managed care systems for their Medicaid programs – because health plans, responding to pressures from employers and consumers, contract with board-certified providers only. Historically, minority providers have not applied for board certification.
Cigna HealthCare provider networks reflect the demographics of the provider community and the member population.
Off-Label Drug Use
Physicians often prescribe drugs for "off-label" use – the use of an FDA-approved drug for treatment of a condition for which it has not received FDA approval. In certain instances this practice is considered to be experimental.
We do not prohibit off-label use of approved medications, but use of certain drugs does require preauthorization. Requests for coverage for off-label drug use are reviewed on a case-by-case basis.
Physician-Hospital Organizations (PHOs), also called Provider-Sponsored Organizations (PSOs), are managed care delivery systems formed by physicians and hospitals or health systems to compete with HMOs and other managed care plans. PHOs seek exemptions from federal antitrust standards, as well as state and federal solvency requirements and other consumer protection standards imposed on HMOs and insurers. As part of the Balanced Budget Act, PHOs were successful in their attempt to get special status to participate in the Medicare Risk program allowing them, for example, to meet less rigorous financial standards.
We believe that there should be a level playing field for all managed care players. All competitors should have to meet the same regulatory requirements.
Health plan restrictions on physician-patient communication, so-called "gag clauses", have been prohibited in most states. Several anti-gag clause provisions are currently pending before Congress. Gag clauses usually apply only to managed care plans – HMO, POS and PPO plans.
Cigna HealthCare managed care plans (Network, POS, EPO and PPO plans) make quality health care more accessible and less expensive for millions of Americans. Consumer education and preventive care are the most significant tools a managed care company has to keep health care affordable and provide access to quality care.
Quality health care is possible only when there is an open, unencumbered dialogue between physicians and their patients. We believe that our members should be fully informed. Our members cannot make sound, sensible decisions if they have been given inadequate or incomplete information. We encourage Cigna HealthCare participating physicians to freely and openly discuss the treatments and procedures best suited to treat an illness or condition, including those that are not covered in a member's benefit plan. In addition, physicians are free to discuss Cigna HealthCare physician reimbursement with their patients (e.g. capitation and fee-for-service).
Consequently, we have never imposed restrictions on health care-related communication between physician and patient.
Specialists as PCPs
Specialists, concerned about managed care's emphasis on primary and preventive care and having been unsuccessful at seeking direct access legislation, are seeking legislation that would allow them to be primary care providers in plans that require PCPs, such as HMOs and POS plans.
Managed care emphasizes the importance of the primary care physician who is specially trained for this role. Most specialists do not meet the training requirements to be primary care providers.
For HMO and POS plan members with complex health conditions, the role of the primary care physician is essential. The primary care physician leads the team helping the member to manage his/her multiple health conditions and treatment – often this includes assuring proper access to specialty care and making sure that all of the specialists are keeping one another informed.
Under certain circumstances when it is determined that the ongoing needs of a member with chronic or multiple illnesses would be most effectively met by a specialist, that specialist becomes the primary care provider for that member (i.e., an AIDS patient may use an infectious disease specialist as his/her primary care physician). This decision would be made as a part of our case management process, which is an integral part of all Cigna HealthCare health plans
Utilization management is one of the tools that HMO, POS, EPO and PPO plans use to help ensure that members have access to quality care. Utilization management is the review of a test or procedure by medical professionals – doctors and nurses – to make sure it is a benefit covered under the member's benefit plan and also to determine if it is medically appropriate.
Utilization management includes precertification for elective surgeries, procedures and tests. Precertification not only helps protect members from undergoing unnecessary procedures, but also offers other protection such as care provided in a contracted facility that meets standards for quality and is delivered by a physician who is a credentialed member of the Cigna HealthCare provider network. Another component of utilization management is concurrent review. Concurrent review is the evaluation of a hospital admission by a doctor while the member is in the hospital to ensure that the member is in the appropriate care setting and discharge planning, including home health care services when medically necessary. Precertification and concurrent review also help assure that the authorized procedure or treatment will be covered by the member's benefit plan.
Health plan medical professionals make coverage determinations based upon a member's particular benefit plan. Health plan medical directors use guidelines to assist in making such determinations, but they are used as just that – guidelines – and are not a substitute for a clinician's judgment. These guidelines are a set of optimal clinical practice benchmarks for a given condition with no complications. They are based solely on sound clinical practices.
Cigna HealthCare bases Utilization Management decisions on appropriateness of care and service. Individuals involved in the Utilization Review process include employees of the Health Services Department, Quality Management Department and Medical Management of Cigna HealthCare.
Coverage decisions are based only on the terms of the applicable plan of coverage as applied to the specific facts of each coverage request. Individuals from the Health Services Department, Quality Management Department and Medical Management of Cigna HealthCare do not receive any financial or other reward or incentive from any Cigna HealthCare company or otherwise for approving or denying individual requests for coverage.
It is important to remember that the use of clinical guidelines is not new. The medical community has traditionally used these guidelines as one of the tools in the medical decision making process.
We draw from the clinical knowledge and experience embodied in many different guidelines, such as the United States Preventive Service Task Force Guidelines and Healthy People 2000.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).