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| MEDICAL |
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Cigna CT HMO Option (CT residents / associates
only)
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A health maintenance organization (HMO) is an organization of doctors,
hospitals and other health care providers that offer medical services
within a plan network. Under this type of plan, you choose a primary
care physician (PCP) from the plan network to coordinate your care.
When you need health care services:
- Most medical care is covered in full or for a copay,
- You pay no deductible,
- There are no claim forms to complete,
- HMO providers take care of pre-certification.
Enrolling in an HMO
If you choose to participate in the Cigna CT HMO (CT residents only),
you should select a PCP for yourself and each covered member of your
family.
An ID card will be sent to you after your enrollment is processed.
You will also receive materials explaining how to use the plan. Refer
to these materials when you have questions about your HMO benefits,
limitations, exclusions and other details. If you have a problem with
coverage or need information on how to use the grievance procedure,
you should call your HMO at the number on your ID card.
Primary Care Physicians
When you enroll in an HMO, you and each covered family member
must select a PCP from the group of physicians affiliated with the HMO.
A PCP is usually a doctor whose area of expertise is general practice,
family practice, internal medicine or pediatrics.
You may choose a PCP for yourself and one for each of your covered
family members (for example, an internist for you and a pediatrician
for your children).
Your PCP will coordinate your overall care and will:
- Treat basic ailments and perform routine tests and check-ups;
- Help you make informed decisions by explaining the risks, benefits
and costs of medical procedures;
- Refer you to specialists and hospitals when medically necessary
and coordinate the care you receive;
- Help you stay healthy by encouraging preventive care and informing
you about good health habits and nutrition;
- Keep a comprehensive record of your health history
You may change your PCP for yourself or your covered dependents for
any reason. To change your PCP, call Member Services at the number on
your HMO ID card.
Covered Expenses Under the HMO Plan
HMOs typically provide participants with a range of network benefits,
including routine and preventive services, hospital care and mental
health and substance abuse services. They require no claim forms and
no deductibles. Generally, network services are covered; co-pays apply
for doctor’s office visits, emergency room visits and other services,
as specified by the HMO. For a more detailed look at what's covered
under the HMO plans, see a comparison
of what's covered under all your medical plan options for 2009.
HMOs generally do not pay benefits for care received from a doctor
or facility outside of the network, except for emergency treatment when
you are outside the HMO service area.
Specific coverage and benefit features will vary among HMOs, and HMO
networks may change. If your doctor drops out of the HMO network during
the year, it is not considered a qualified change in status and you
cannot change plans. For a description of the pharmacy benefit, see
Prescription Drug Coverage.
Breast Reconstruction Following Mastectomy Surgery
The Omnibus Consolidated and Emergency Supplemental Appropriations
Act requires medical plans to cover expenses associated with reconstructive
surgery following a mastectomy, expenses for reconstruction on the other
breast to achieve symmetry, the cost of prostheses and the cost for
treatment of physical complications at any stage of the mastectomy,
including lymphedemas. Normal plan deductibles and coinsurance will
apply.
Newborns’ and Mothers’ Health Protection
Act
A medical plan may not, under the Newborns’ and Mothers’
Health Protection Act, restrict benefits for any hospital length of
stay in connection with childbirth for the mother or newborn child to
less than 48 hours following a normal vaginal delivery or less than
96 hours following a cesarean section. A medical plan may only require
that your physician obtain authorization for a length of stay beyond
the noted time periods.
The attending provider, after consulting with the mother, may discharge
the mother and newborn earlier than the otherwise required minimum stay.
Filing Claims
If you are a member of an HMO, you will need to file claims only
for services received outside of the network service area.
If payment for services is denied, you may pay for the services yourself
if you still want to have them. If coverage for a service is denied,
you will receive a written explanation that will include the reason
for the denial and the criteria and benefit information used to support
the denial of your claim. You will also receive information about how
to file a grievance with the HMO.
Cigna CT HMO Plan Summary
Link to the Plan Document page to
review the Cigna CT HMO Plan Summary. The certificate of coverage you
receive directly from the HMO acts as your Plan Document.
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