Cigna is a new entrant to the Colorado individual health insurance market and their product is a very good option in many demographics in Colorado. To see if they are affordable for you and your family please run your own individual Colorado health insurance quote.
This section on Cigna’s individual plans is meant to answer some of the more obscure questions on the Cigna individual plans in Colorado, such as questions about maternity and pre-existing conditions. If you have Cigna right now, you can also peruse the information below which should answer nearly every conceivable question about the coverage in Colorado. For any other questions please call East Coast Health Insurance at 888 803 5917.
COLORADO HEALTH PLAN DESCRIPTION FORM
Connecticut General Life Insurance Company
2008 OPEN ACCESS PLANS FOR INDIVIDUALS and FAMILIES
PART A: TYPE OF COVERAGE
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1. TYPE OF PLAN |
Preferred Provider Plans. |
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2. OUT-OF-NETWORK CARE COVERED? 1 |
Yes, but patient pays more for out-of-network care. |
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3. AREAS OF COLORADO WHERE PLAN IS AVAILABLE |
Plans are available throughout Colorado. |
PART B: SUMMARY OF BENEFITS
Important Note: This form is not a contract, it is only a summary. The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. Your plan may exclude coverage for certain treatments, diagnoses, or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed (e.g., plans may require prior authorization, a referral from your primary care physician, or use of specified providers or facilities). Consult the actual policy to determine the exact terms and conditions of coverage. Coinsurance and copayment options reflect the amount the covered person will pay.
Remember the box on the right is in network and the box on the right is out of network.
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IN-NETWORK |
OUT-OF-NETWORK |
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4. DEDUCTIBLE TYPE 2 |
Calendar year |
Calendar year |
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4a. ANNUAL DEDUCTIBLE 2a
Open Access 1000 Open Access 2000 Open Access 3000 Open Access 5000 |
Individual 2b
$1,000 $2,000 $3,000 $5,000 |
Family 2c
$2,000 $4,000 $6,000 $10,000 |
Individual 2b
$2,000 $4,000 $6,000 $10,000 |
Family 2c
$4,000 $8,000 $12,000 $20,000 |
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5. OUT-OF-POCKET ANNUAL MAXIMUM 3
Open Access 1000 Open Access 2000 Open Access 3000 Open Access 5000 |
Individual 2b $2,000 $3,000 $4,000 $5,000 |
Family 2c $4,000 $6,000 $8,000 $10,000 |
Individual 2b $4,000 $6,000 $8,000 $10,000 |
Family 2c $8,000 $12,000 $16,000 $20,000 |
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6. LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE |
$5 million |
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7a. COVERED PROVIDERS |
Connecticut General Life Insurance Company PPO Network. See provider directory for complete list of current providers. |
All providers licensed or certified to provide covered benefits. |
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7b. With respect to network plans, are all the providers listed in 7a. accessible to me through my primary care physician? |
Yes |
Not applicable |
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8. ROUTINE MEDICAL OFFICE VISITS 4 a) Primary Care Providers
Open Access 1000, Open Access 2000
Open Access 3000, Open Access 5000
b) Specialists Open Access 1000, Open Access 2000
Open Access 3000, Open Access 5000 |
$20 copay (does not apply to out-of-pocket maximum) $30 copay (does not apply to out-of-pocket maximum)
$40 copay (does not apply to out-of-pocket maximum) $50 copay (does not apply to out-of-pocket maximum) |
40% coinsurance
40% coinsurance
40% coinsurance
40% coinsurance |
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9. PREVENTIVE CARE a) Children’s services through age 12 (Includes routine physicals and other routine services.) Office Visit Open Access 1000, Open Access 2000
Open Access 3000, Open Access 5000
b) Adult services (age 13 and above) Office Visit Open Access 1000, Open Access 2000
Open Access 3000, Open Access 5000 |
$20/$40 copay (does not apply to out-of-pocket maximum)
$30/$50 copay (does not apply to out-of-pocket maximum)
$20/$40 copay (does not apply to out-of-pocket maximum) $30/$50 copay (does not apply to out-of-pocket maximum) |
40% coinsurance (deductible waived)
40% coinsurance (deductible waived)
40% coinsurance
40% coinsurance |
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10. MATERNITY a) Pre-natal care b) Delivery & inpatient well-baby
care 5 |
Not covered Not covered |
Not covered Not covered |
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11. PRESCRIPTION DRUGS 6
(Pharmacy charges do not apply to out-of-pocket maximum.)
Brand Name Drug Deductible (Combined in- and out-of-network, this is a separate deductible from the Annual Deductible amount and does not apply to out-of-pocket maximum.) Open Access 1000 Open Access 2000 Open Access 3000 Open Access 5000
Generic (30-day supply) Brand (30-day supply) Non-preferred (30-day supply) Self Injectable
Mail Order Drugs (90-day supply) Generic Brand Non-preferred Self Injectable |
Members must show CIGNA ID card when filling prescriptions at both in- and out-of-network pharmacies. For drugs on the CIGNA-approved list, contact Member Services at 1-800-244-6224.
$100 $200 $300 $500
$10 copay 50% coinsurance $35 copay (subject to brand name drug deductible) 50% coinsurance $60 copay (subject to brand name drug deductible) 50% coinsurance 30% coinsurance 50% coinsurance
$25 copay Not covered $85 copay (subject to brand name drug deductible) Not covered $150 copay (subject to brand name drug deductible) Not covered 30% coinsurance Not covered |
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12. INPATIENT HOSPITAL |
20% coinsurance |
40% coinsurance |
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13. OUTPATIENT/AMBULATORY SURGERY |
20% coinsurance |
40% coinsurance |
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14. DIAGNOSTICS
a) Laboratory & X-ray b) MRI, nuclear medicine, CT, CTA, MRA, and PET scans |
20% coinsurance (in any setting)
20% coinsurance (in any setting) |
40% coinsurance (in any setting)
40% coinsurance (in any setting) |
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15. EMERGENCY CARE 7 |
$100 additional deductible (does not apply to out-of-pocket maximum), 20% coinsurance (deductible waived if admitted to hospital) |
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16. AMBULANCE (Emergency transport only.) (Plans pays $20,000 maximum per year, in- and out-of-network combined) |
20% coinsurance |
40% coinsurance |
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17. URGENT, NON-ROUTINE, AFTER HOURS CARE |
20% coinsurance |
40% coinsurance |
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18. BIOLOGICALLY-BASED MENTAL ILLNESS CARE 8 |
Included in Other Mental Health Care below, #19a and #19b. |
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19. OTHER MENTAL HEALTH CARE a) Inpatient Care
(Plan pays $2,500 maximum per person, per year, in- and out-of-network combined.)
b) Outpatient Care (Maximum 20 visits per person, per year, in-and out-of-network combined.) |
20% coinsurance
20% coinsurance |
40% coinsurance
40% coinsurance |
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20. ALCOHOL & SUBSTANCE ABUSE |
Included in Other Mental Health Care above: #19a and #19b. |
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21. PHYSICAL, OCCUPATIONAL, & SPEECH THERAPY |
Plan pays 100% to a maximum of $30 per visit, 24 visits per person, per year, all services combined. |
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22. DURABLE MEDICAL EQUIPMENT |
20% coinsurance (in any setting) |
40% coinsurance (in any setting) |
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23. OXYGEN |
Included under Durable Medical Equipment. |
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24. ORGAN TRANSPLANTS (Prior authorization required. Covered transplants include: liver, heart, heart/lung, lung, kidney, kidney/pancreas other single and multi-organ transplants, and autologous and allogenic bone marrow, peripheral stem cell transplant and similar procedures.) |
CIGNA Lifesource® Transplant Network Facility Plan pays 100% plus $10,000 travel benefit per person, per lifetime
Non-Lifesource® in-network facility 20% coinsurance, travel benefit excluded |
Not covered |
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25. HOME HEALTH CARE (Maximum 60 visits per person, per year, in- and out-of-network combined.) |
20% coinsurance |
40% coinsurance |
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26. HOSPICE CARE a) Routine Home Care
($100 per day maximum payment, for up to 91 days for each Benefit Period.)
b) Bereavement Services (Maximum payment of $1,150 for the family, for a 12-month period.)
c) All other Hospice Services |
20% coinsurance
20% coinsurance
20% coinsurance |
40% coinsurance
40% coinsurance
40% coinsurance |
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27. SKILLED NURSING FACILITY CARE (Maximum 30-days per person, per year, in-and out-of-network combined.) |
20% coinsurance |
40% coinsurance |
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28. DENTAL CARE
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Not covered Hospitalization for dental procedures for minors ONLY covered at 20% coinsurance in-network and 40% coinsurance out-of-network. |
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29. VISION CARE |
Not covered |
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30. CHIROPRACTIC CARE |
Included in Physical, Occupational and Speech Therapy benefit listed above: #21. |
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31. SIGNIFICANT ADDITIONAL COVERED SERVICES
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20% coinsurance
Plan pays 100% (deductible waived)
20% coinsurance (deductible waived
Plan pays 100% (deductible waived)
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40% coinsurance
100% coinsurance (deductible waived)
40% coinsurance (deductible waived)
40% coinsurance (deductible waived) |
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PART C: LIMITATIONS AND EXCLUSIONS
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BENEFIT LEVELS |
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BENEFIT LEVELS |
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32. PERIOD DURING WHICH PRE- EXISTING CONDITIONS ARE NOT COVERED 9 |
12 months for all pre-existing conditions unless the covered person is a HIPAA-eligible individual as defined under federal and state law, in hich there are no pre-existing conditions exclusions. |
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33. EXCLUSIONARY RIDERS. Can an individual’s specific, pre-existing condition be entirely excluded from the policy? |
w No |
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34. HOW DOES THE POLICY DEFINE A “PRE-EXISTING CONDITION”? |
A pre-existing condition is an injury, sickness or pregnancy for which a person incurred charges, received medical treatment, consulted a healthcare professional or took prescription drugs within 12 months immediate preceding effective date of coverage. |
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35. WHAT TREATMENTS AND CONDITIONS ARE EXCLUDED UNDER THIS POLICY? |
Exclusions vary by policy. A list of exclusions is available immediately upon request from your carrier or agent. Review the list to see if a service or treatment you may need is excluded from the policy. Standard exclusions: Conditions which are pre-existing. Services or supplies that CIGNA considers to be for Experimental Procedures or Investigative Procedures.
Services for which the Insured Person has no legal obligation to pay or for which no charge would be made if the Insured Person did not have a health policy or insurance coverage. Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if the Insured Person does not claim those benefits. Conditions caused by: (a) an act of war; (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) an Insured Person participating in the military service of any country; (d) an Insured Person participating in an insurrection, rebellion, or riot.
Any services provided by a local, state or federal government agency, except when payment under this Policy is expressly required by federal or state law. If the Insured Person is eligible for Medicare, any services covered by Medicare under parts A or B are excluded regardless of actual enrollment in Medicare or payment by Medicare for those services. However, for any Covered Services, if there is a balance remaining after the Medicare Payment, or the amount that Medicare would have paid had the Insured Person enrolled in the program, CIGNA will pay the remaining balance up to the Medicare allowable amount. In no event, however, will the actual amount CIGNA pays exceed the amount that CIGNA would have paid if it were the sole insurance carrier. Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Professional services received or supplies purchased from the Insured Person, a person who lives in the Insured Person’s home or who is related to the Insured Person by blood, marriage or adoption. Custodial Care. Inpatient or outpatient services of a private duty nurse. Inpatient room and board charges in connection with a Hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service. Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. Treatment of Mental, Emotional or Functional Nervous Disorders except as specifically stated in the Policy. . Smoking cessation programs. Treatment of substance abuse, except as specifically stated in the Policy. Dental services, Orthodontic Services and dental implants. Hearing aids and routine hearing tests. Optometric services, eye surgery to correct refractive defects of the eye. Any off label cancer drug that has been prescribed for a specific type of cancer for which use of the drug has not been approved by the U.S. Food and Drug Administration (US FDA) except as specifically stated in the Policy. Cosmetic surgery. Sex change surgery. Treatment of sexual dysfunction, impotence, fertility and/or Infertility and Cryopreservation of sperm or eggs. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics. Services primarily for weight reduction or treatment of obesity. Routine physical exams except as specifically stated in the Policy.
Charges for telephone or email consultations. Items which are furnished primarily for personal comfort or convenience. Educational services except as specifically stated in the Policy Nutritional counseling or food supplements. Syringes. All Foreign Country Provider charges. Growth Hormone Treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the Insured Person’s condition.
Routine foot care. Charges for animal to human organ transplants. Charges for Normal Pregnancy or Maternity Care.
Claims received by CIGNA after 15 months from the date service was rendered. |
PART D: USING THE PLAN
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IN-NETWORK |
OUT-OF-NETWORK |
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36. Does the enrollee have to obtain a referral and/or prior authorization for specialty care in most or all cases? |
Yes, as stated specifically in the Policy.
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No
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37. Is prior authorization required for surgical procedures and hospital care (except in an emergency)? |
Yes, as stated specifically in the Policy. |
Yes, as stated specifically in the Policy. |
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38. If the provider charges more for a covered service than the plan normally pays, does the enrollee have to pay the difference? |
Yes, as defined in the Policy. |
Yes, as defined in the Policy. |
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39. What is the main customer service number? |
1-800-244-6224 |
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40. Whom do I write/call if I have a complaint or want to file a grievance? |
CIGNA Medical P.O. Box 5200 Scranton, PA 18505-5200 1-800-244-6224 |
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41. Whom do I contact if I am not satisfied with the resolution of my complaint or grievance? 10 |
Colorado Division of Insurance ICARE Section 1560 Broadway, Suite 850 Denver, CO 80202 |
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42. To assist in filing a grievance, indicate the form number of this policy. |
COIND0480 Open Access 1000 – Policy form # 820951, Individual Open Access 2000 – Policy form # 820952, Individual Open Access 3000 – Policy form # 820953, Individual Open Access 5000 – Policy form # 820954, Individual |
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43. Does the plan have a binding arbitration clause? |
Yes |
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Endnotes
1] “Network” refers to a specified group of physicians, hospitals, medical clinics and other health care providers that CIGNA may require in order for you to get any coverage at all under the plan, or that CIGNA may encourage you to use because it may pay more of your bill if you use CIGNA network providers (i.e., go in-network) than if you don’t (i.e., go out-of-network).
2] “Deductible type” indicates whether the deductible period is “Calendar Year” (January 1 through December 31) or “Benefit Year” (i.e., based on a benefit year beginning on the policy’s anniversary date) or if the deductible is based on other requirements such as “Per Accident or Injury” or “Per Confinement”.
2a] “Deductible” means the amount you will have to pay for allowable covered expenses under a health plan during a specified time period (e.g., calendar year or benefit year) before CIGNA will cover those expenses. The specific expenses that are subject to the deductible may vary by policy.
2b] “Individual” means the deductible amount you and each individual covered by the policy will pay for allowable covered expenses before CIGNA will begin covering those expenses.
2c] “Family” is the maximum deductible amount that is required to be met for all family members covered by a non-HSA qualified policy and it may be an aggregated amount (e.g., “$3,000 per family or specified as the number of individual deductibles that must be met (e.g. “3 deductibles per family”). “Non-single” is the deductible amount that must be met by one or more family members covered by an HSA qualified plan before any covered expenses are paid.
3] “Out-of-pocket maximum” means the maximum amount you will have to pay for allowable covered expenses under a health plan, which may or may not include deductibles and copayments, depending on the contract for that plan. The specific deductibles and copayments included in the out-of-pocket maximum may vary by policy.
4] Medical office visits include physician, mid-level practitioner, and specialist visits, including outpatient psychotherapy visits for biologically-based mental illness.
5] Well baby care includes in-hospital newborn pediatric visit and newborn hearing screening.
6] Prescription drugs otherwise excluded are not covered, regardless of whether brand name, generic or non-preferred.
7] “Emergency care” means all services delivered in an emergency care facility that are necessary to screen and stabilize a covered person. The policy must cover this care if a prudent lay person having average knowledge of health services and medicine, and acting reasonably, would have believed that an emergency medical condition, or life and limb threatening emergency, existed.
8] “Biologically based mental illnesses” means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder.
9] Waiver of pre-existing conditions exclusions. State law requires CIGNA to waive some, or all, of the pre-existing condition period based on other coverage you may have had recently. Ask your carrier or agent for details.
10] Grievances. Colorado law requires all carriers to use consistent grievance procedures. Write the Colorado Division of Insurance for a copy of those procedures.
ACCESS PLAN
If you would like more information on:
(1) who participates in our provider network; (2) how we ensure that the network meets the health care needs of our members; (3) how our provider referral process works; (4) how care is continued if providers leave our network; (5) what steps we take to ensure medical quality and customer satisfaction; (6) where you can go for information on other plan services and features; you may request a copy of our Access Plan.
The Access Plan is designed to disclose all the plan information required under Colorado law, and can be obtained by calling Member Services at 1-800-244-6224.
Connecticut General Life Insurance Company, Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc.
