State Policy Disclosures, Exclusions and Limitations

Plans insured by Cigna Health and Life Insurance Company or its affiliates

State Policy Disclosures, Exclusions and Limitations 2018

Health Insurance Plans

Rates will vary by plan design and the plan deductible, copay, coinsurance, and out-of-pocket maximums selected. Rates vary based on age, family size, geographic location (residential zip code) and tobacco use.

Rates for new medical policies with an effective date on or after 01/01/2018 are guaranteed through 12/31/2018. Thereafter, medical rates are subject to change upon 30 days' notice in IL, MO and TN; 45 days' notice in FL and NC; 60 days' notice in AZ and CO; and, 75 days' notice in VA.

Provider networks can vary by state and market. For the plan(s) you are interested in, view the Summary of Benefits for important market-specific provider network information.

To see if your provider is in-network or to find a new in-network provider, visit www.cigna.com/ifp-providers.

Major medical insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Medical applications are accepted during the annual Open Enrollment Period, or within 60 calendar days of a qualifying life event. Benefits are provided only for those services that are medically necessary as defined in the policy/service agreement and for which the insured person has benefits.

Form Series for Cigna Health and Life Insurance Company:

Exclusive Provider: CO: COINDEPO042017, FL: FLCHINDEPO012018, FLCHINDHYBRIDEPO012018, MO: MOINDEPO042017, TN: TNINDEPO042017, VA: VAINDEPO042017, VAINDEPO042017-HIX

Form Series for Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc.:

HMO: AZ: INDHMOAZ01-2018, IL: INDHMOIL01-2018, NC: INDHMONC042017

The policy/service agreement may be cancelled by Cigna due to failure to pay premium, fraud (in VA, any act, practice or omission that constitutes fraud), ineligibility, when the insured no longer lives in the service area, or when Cigna ceases to offer policies of this type or cease to offer any plans in the individual market in the state, in accordance with applicable law. You may cancel the policy/service agreement on the first of the month following our receipt of your written notice. In VA, you may cancel the policy/service agreement on the date of our receipt of your written cancellation notice, unless otherwise stated.

Cigna reserves the right to modify the policy, including policy provisions, benefits and coverages, consistent with state or federal law. Policies renew on a calendar year basis.

Cigna does not intentionally discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at 866.494.2111.

Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le envíen algunos en español. Para obtener ayuda, llámenos al 866.494.2111.

For costs, and additional details about coverage, contact Cigna at 900 Cottage Grove Rd, Hartford, CT 06152 or call 1-866-GET-Cigna. (1-866-438-2446).

Health Plan Exclusions and Limitations & State Specific Information

Access Plan

If you would like more information on: (1) who participates in the provider network; (2) how Cigna’s ensures that the network meets the health care needs of its members; (3) how the provider referral process works; (4) how care is continued if providers leave the network; (5) what steps are taken to ensure medical quality and customer satisfaction; (6) where you can go for information on other policy services and features. You may request a copy of Cigna’s Access Plan. The Access Plan is designed to disclose all the policy information required under Colorado law, and is available for review upon request.

Rates

These rates are for illustrative purposes only. A person should not send money to the issuer of the health benefit plan in response to the advertisement. A person cannot obtain coverage under the health benefit plan until the person completes an application for coverage. Benefit exclusions and limitations may apply to the health benefit plan.

Dental Insurance Plans

Individual and Family Dental Insurance Plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates may vary based on age, family size, geographic location (residential zip code), and plan design.

Dental rates are subject to change upon 30 days’ prior notice in AK, AL, AR, AZ, CO, CT, DC, DE, HI, IA, ID, IL, IN, KS, KY, MA, ME, MI, MN, MO, MT, ND, NE, NH, NJ, NM, NY, OH, OK, OR, PA, RI, SD, TN, UT, VT, WA, WI and WY, 31 days’ prior notice in SC, 40 days’ prior notice in MD, 45 days’ prior notice in FL, and 60 days’ prior notice in CA, GA, MS, NV, TX, VA, and WV. In LA, dental rates are guaranteed for the initial 12 months of coverage, except if due to addition of a newly covered person, a change in age or geographic location, or a change in policy coverage. Thereafter, rates are subject to change upon 45 days’ notice. In NC, dental rates are guaranteed for a 12 month period.

Cigna Dental insurance coverage shall be only for the classes of services referred to in The Schedule of a purchased plan. Discounts are not available in MD and VA. Some dental plans apply waiting periods to covered basic (6 months), major (12 months) and orthodontic (12 months) dental care services. In IL, NJ and VT, a 6 month waiting period applies to covered basic, major and orthodontic dental care services. In PA, waiting period does not apply to covered basic dental care services. In WV, a 3 month waiting period applies to covered basic, major and orthodontic dental care services. Waiting periods do not apply in RI. Dental plans do not apply waiting periods to covered preventive/diagnostic services and temporomandibular joint services in AR, NV, NM, MN and VT.

Some covered services are determined by age, including topical application of fluoride or sealant, space maintainers, and materials for crowns and bridges. If the plan covers replacement of teeth, there is no payment for replacement of teeth that are missing prior to coverage. In MD, NY and OH, a 12 month limitation applies. FL applies a 24 month limitation.

The policy may be cancelled by Cigna due to failure to pay premium, fraud (in VA, any act, practice or omission that constitutes fraud), ineligibility, when the insured no longer lives in the service area, or if we cease to offer policies of this type or any individual dental plans in the state, in accordance with applicable law. You may cancel the policy, on the first of the month following our receipt of your written notice. In VA, you may cancel the policy on the date of our receipt of your written cancellation notice, unless otherwise stated.

Cigna reserves the right to modify the policy, including policy provisions, benefits and coverages, consistent with state or federal law. The policy renews on a calendar year basis. Dental preferred provider insurance policies have exclusions, limitations, reduction of benefits and terms under which a policy may be continued in force or discontinued.

Form Series: AL, CO, DE, CT, GA, IL, MA, MI, PA, UT, VA, WV, and WY: HC-NOT11 et al., AR: HC-NOT36 et al., CA: INDENTPOLCA0713 et al., FL: HC-NOT15 et al., ID: HC-NOT51 et al, KS: HC-NOT49 et al., LA: INDDENTPOLLA0713, MS: HC-NOT48 et al., MO: INDDENTPOLMO0713, NC: HC-NOT18, et al., NE: HC-NOT47 et al., NH: INDDENPOLNH0713, NM: INDDENPOLNM0713, NV: HC-NOT39 et al., NY: INDENTPOLNY, OH: INDDENTPOLOH et al., OK: HC-NOT26 et al., OR: INDDENTPOLOR0713, RI: HC-NOT35 et al., SC: HC-NOT19 et al., SD: HC-NOT59 et al., TN: HC-NOT20 et al., TX: HC-NOT21 et al., VT: HC-NOT56 et al., WA: INDENTPOLWA, WI: HC-NOT54 et al.

10-DAY RIGHT TO RETURN POLICY

If you are not satisfied with your policy, for any reason, you may return it to us within 10 days of receipt. Cigna will then cancel your coverage as of the original effective date and promptly refund any premium you have paid.

Notice to Buyer: This policy provides dental coverage only. Review your policy carefully.

These rates are for illustrative purposes only. A person should not send money to the issuer of the dental benefit plan in response to the advertisement. A person cannot obtain coverage under the dental benefit plan until the person completes an application for coverage. Benefit exclusions and limitations may apply to the dental benefit plan.

For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 1-866-GET-Cigna. (1-866-438-2446). In Texas, the dental plan is known as Cigna Dental Choice and the plan utilizes the national Cigna Dental PPO network.

Dental Plan Exclusions & Limitations

All States Except New York

Dental insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Covered Dental Expenses do not include expenses incurred for:

  • procedures which are not included in the policy.
  • procedures which are not necessary and which do not have uniform professional endorsement.
  • procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
  • any procedure, service, supply or appliance, the sole or primary purpose of which relates to the change or maintenance of vertical dimension.
  • procedures, appliances or restorations whose main purpose is to diagnose or treat dysfunction of the temporomandibular joint (Services are covered in AR*, MN, NM, NV and VT*).
  • the alteration or restoration of occlusion.
  • the restoration of teeth which have been damaged by erosion, attrition or abrasion.
  • bite registration or bite analysis.
  • any procedure, service, or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.
  • the surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant.
  • crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite resin filling due to major decay or fracture.
  • core build-ups.
  • replacement of a partial denture, full denture, or fixed bridge or the addition of teeth to a partial denture unless: (a)replacement occurs at least 84 consecutive months after the initial date of insertion of the current full or partial denture; or (b)the partial denture is less than 84 consecutive months old, and the replacement is needed due to a necessary extraction of an additional functioning natural tooth while the person is covered under this plan (alternate benefits of adding a tooth to an existing appliance may be applied); or (c)replacement occurs at least 84 consecutive months after the initial date of insertion of an existing fixed bridge (if the prior bridge is less than 84 consecutive months old, and replacement is needed due to an additional necessary extraction of a functioning natural tooth while the person is covered under this plan. Benefits will be considered only for the pontic replacing the additionally extracted tooth).
  • the removal of only a permanent third molar will not qualify an initial or replacement partial denture, full denture or fixed bridge for benefits.
  • the replacement of crowns, cast restoration, inlay, onlay or other laboratory prepared restorations within 84 consecutive months of the date of insertion.
  • the replacement of a bridge, crown, cast restoration, inlay, onlay or other laboratory prepared restoration regardless of age unless necessitated by major decay or fracture of the underlying natural tooth.
  • any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards;
  • replacement of a partial denture or full denture which can be made serviceable or is replaceable.
  • replacement of lost or stolen appliances.
  • replacement of teeth beyond the normal complement of 32.
  • prescription drugs.
  • any procedure, service, supply or appliance used primarily for the purpose of splinting.
  • athletic mouth guards.
  • myofunctional therapy.
  • precision or semiprecision attachments.
  • denture duplication.
  • separate charges for acid etch.
  • labial veneers (laminate).
  • porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars;
  • Precious or semi-precious metals for crowns, bridges, pontics and abutments; crowns and bridges other than stainless steel or resin for participants under 16 years old;
  • treatment of jaw fractures and orthognathic surgery.
  • orthodontic treatment. Exclusion does not apply if the plan otherwise covers services for orthodontic treatment.
  • charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
  • charges for travel time; transportation costs; or professional advice given on the phone.
  • temporary, transitional or interim dental services.
  • any procedure, service or supply not reasonably expected to correct the patient’s dental condition for a period of at least 3 years, as determined by Cigna.
  • diagnostic casts, diagnostic models, or study models.
  • any charge for any treatment performed outside of the United States other than for emergency treatment (any benefits for emergency treatment which is performed outside of the United States will be limited to a maximum of $100 per consecutive 12-month period);
  • oral hygiene and diet instruction; broken appointments; completion of claim forms; personal supplies (e.g., water pick, toothbrush, floss holder, etc.); duplication of x-rays and exams required by a third party;
  • any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility;
  • services that are deemed to be medical services;
  • services for which benefits are not payable according to the "General Limitations" section.

* Depending on plan

General Limitations

No payment will be made for dental expenses incurred for you or any one of your dependents:

  • For services not specifically listed as covered services in the policy.
  • For services or supplies that are not dentally necessary.
  • For services received before the effective date of coverage.
  • For services received after coverage under this policy ends.
  • For services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
  • For professional services or supplies received or purchased directly or on your behalf by anyone, including a dentist,from any of the following:
    • yourself or your employer;
    • a person who lives in the insured person's home, or that person’s employer;
    • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
  • for or in connection with an injury arising out of, or in the course of, any employment for wage or profit;
  • for or in connection with a sickness which is covered under any workers' compensation or similar law;
  • for charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition;
  • services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;
  • to the extent that payment is unlawful where the person resides when the expenses are incurred;
  • for charges which the person is not legally required to pay;
  • for charges which would not have been made if the person had no insurance;
  • to the extent that billed charges exceed the rate of reimbursement as described in the schedule;
  • for charges for unnecessary care, treatment or surgery;
  • to the extent that you or any of your dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid. Exclusion does not apply in WA;
  • for or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society;
  • Procedures that are a covered expense under any other dental plan which provides dental benefits;
  • To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you or any one of your dependents.

New York Dental Plan Exclusions and Limitations

Dental insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. No coverage is available under this Policy for the following:

A. Cosmetic Services.

We do not cover cosmetic services or surgery unless otherwise specified, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered child which has resulted in a functional defect. Cosmetic surgery does not include surgery determined to be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in the Utilization Review and External Appeals sections of this Policy unless medical information is submitted.

B. Coverage in Canada or Mexico or Outside of the United States.

We do not cover care or treatment provided in Canada or Mexico, or outside of the United States and its possessions, except for Emergency Dental Care as described in the Policy.

C. Experimental or Investigational Treatment.

We do not cover any health care service, procedure, treatment, or device that is experimental or investigational. However, we will cover experimental or investigational treatments, including treatment for your rare disease or patient costs for your participation in a clinical trial, when our denial of services is overturned by an External Appeal Agent certified by the state. However, for clinical trials, we will not cover the costs of any investigational drugs or devices, non-health services required for you to receive the treatment, the costs of managing the research, or costs that would not be covered under the Policy for noninvestigational treatments. See the Utilization Review and External Appeal sections of this Policy for a further explanation of your Appeal rights.

D. Felony Participation.

We do not cover any illness, treatment or medical condition due to your participation in a felony, riot or insurrection.

E. Government Facility.

We do not cover care or treatment provided in a hospital that is owned or operated by any federal, state or other governmental entity, except as otherwise required by law.

F. Medical Services.

We do not cover medical services or dental services that are medical in nature, including any hospital charges or prescription drug charges.

G. Medically Necessary.

In general, we will not cover any dental service, procedure, treatment, test or device that we determine is not Medically Necessary. If an External Appeal Agent certified by the state overturns our denial, however, we will cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise covered under the terms of this Policy.

H. Medicare or Other Governmental Program.

We do not cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid).

I. Military Service.

We do not cover an illness, treatment or medical condition due to service in the armed forces or auxiliary units.

J. No-Fault Automobile Insurance.

We do not cover any benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable. This exclusion applies even if you do not make a proper or timely claim for the benefits available to you under a mandatory no-fault policy.

K. Services not Listed.

We do not cover services that are not listed in this Policy as being covered.

L. Services Provided by a Family Member.

We do not cover services performed by a member of the covered person’s immediate family. “Immediate family” shall mean a child, spouse, mother, father, sister, or brother of you or your spouse.

M. Services Separately Billed by Hospital Employees.

We do not cover services rendered and separately billed by employees of hospitals, laboratories or other institutions.

N. Services with No Charge.

We do not cover services for which no charge is normally made.

O. War.

We will not cover an illness, treatment or medical condition due to war, declared or undeclared.

P. Workers’ Compensation.

We do not cover services if benefits for such services are provided under any state or federal Workers’ Compensation, employers’ liability or occupational disease law.

Dental Pediatric Insurance Plans

Dental Pediatric Insurance Plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates may vary based on age, number of enrolled dependents, geographic location (residential zip code), and plan design.

Dental rates are subject to change upon 30 days’ prior notice in AZ, CO, CT, IL, MO, TN, 31 days’ prior notice in SC, 40 days’ prior notice in MD, 45 days’ prior notice in FL, and 60 days’ prior notice GA, TX, and VA. In NC, dental rates are guaranteed for a 12-month period.

Cigna Dental Preventive and Cigna Dental 1000 plans include a combination of insurance coverage and discounted services. The insurance coverage shall be only for the classes of services referred to in The Schedule of a purchased plan. Discounts are not available in MD and VA.

Waiting periods do not apply.

Dental preferred provider insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued.

Form Series:

CO: 49375CO0030001_20170101, CT: CTINDCH062016, FL:INDDENPEDI.FL.1, IL: INDDENPEDI.IL.1, MO: INDDENPEDI.MO.1, NC: INDDENPEDI.NC.1, SC:INDDENPEDI.SC.2, TN: INDDENPEDI.TN.1, TX: INDDENPEDI.TX.1, VA: INDDENPEDI.VA.4.2016

10-DAY RIGHT TO RETURN POLICY

If you are not satisfied with your policy, for any reason, you may return it to us within 10 days of receipt. Cigna will then cancel your coverage as of the original effective date and promptly refund any premium you have paid. Some covered services are determined by age, including topical application of fluoride or sealant, space maintainers, and materials for crowns and bridges.

The policy may be cancelled by Cigna due to failure to pay premium, fraud (in VA, any act, practice or omission that constitutes fraud), ineligibility, when the insured no longer lives in the service area, or if we cease to offer policies of this type or any individual dental plans in the state, in accordance with applicable law. You may cancel the policy, on the first of the month following our receipt of your written notice. In VA, you may cancel the policy on the date of our receipt of your written cancellation notice, unless otherwise stated.

Cigna reserves the right to modify the policy, including policy provisions, benefits and coverages, consistent with state or federal law. The policy renews on a calendar year basis.

Notice to Buyer: This policy provides dental coverage only. Review your policy carefully.

These rates are for illustrative purposes only. A person should not send money to the issuer of the dental benefit plan in response to the advertisement. A person cannot obtain coverage under the dental benefit plan until the person completes an application for coverage. Benefit exclusions and limitations may apply to the dental benefit plan.

For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 1-866-GET-Cigna. (1-866-438-2446). In Texas, the dental plan is known as Cigna Dental Choice and the plan utilizes the national Cigna Dental PPO network.

These dental plans offer the full range of Essential Health Benefit Pediatric Oral Care and satisfy the requirements under the Affordable Care Act.

Dental Pediatric Plan Exclusions and Limitations & State Specific Information

Dental Family + Pediatric Insurance Plans

Dental Family + Pediatric Insurance Plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates may vary based on age, family size, geographic location (residential zip code), and plan design. Dental rates are subject to change upon 30 days’ prior notice in AZ, CO & TN, 45 days’ prior notice in FL, and 60 days’ prior notice in TX.

Cigna Dental Preventive and Cigna Dental 1000 plans include a combination of insurance coverage and discounted services. The insurance coverage shall be only for the classes of services referred to in The Schedule of a purchased plan.

Waiting periods do not apply to eligible children. Waiting periods may apply to adult family members for covered basic (6 months), major (12 months) and orthodontic (12 months) dental care services. Waiting periods do not apply to covered preventive/diagnostic dental care services.

Dental preferred provider insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued.

Form Series:

CO: 49375CO0030002_20170101, FL: INDDENCOMB.FL.1, TN: INDDENCOMB.TN.1, TX: INDDENCOMB.TX.1

10-DAY RIGHT TO RETURN POLICY

If you are not satisfied with your policy, for any reason, you may return it to us within 10 days of receipt. Cigna will then cancel your coverage as of the original effective date and promptly refund any premium you have paid. Some covered services are determined by age, including topical application of fluoride or sealant, space maintainers, and materials for crowns and bridges.

The policy may be cancelled by Cigna due to failure to pay premium, fraud, ineligibility, when the insured no longer lives in the service area, or if we cease to offer policies of this type or any individual dental plans in the state, in accordance with applicable law. You may cancel the policy, on the first of the month following our receipt of your written notice.

Cigna reserves the right to modify the policy, including policy provisions, benefits and coverages, consistent with state or federal law. The policy renews on a calendar year basis.

Notice to Buyer: This policy provides dental coverage only. Review your policy carefully.

These rates are for illustrative purposes only. A person should not send money to the issuer of the dental benefit plan in response to the advertisement. A person cannot obtain coverage under the dental benefit plan until the person completes an application for coverage. Benefit exclusions and limitations may apply to the dental benefit plan.

For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 1-866-GET-Cigna. (1-866-438-2446). In Texas, the dental plan is known as Cigna Dental Choice and the plan utilizes the national Cigna Dental PPO network.

These dental plans offer the full range of Essential Health Benefit Pediatric Oral Care and satisfy the requirements under the Affordable Care Act.

Dental Family + Pediatric Plan Exclusions and Limitations & State Specific Information