Frequently Asked Questions - CIGNA Health Plan

This is a list of general questions received and responses made to faculty and staff since the announcement of the CIGNA self-insured medical plan.  Please send more questions.  They will be added to the list.

Eligibility/Qualifications/Plan Options

1.  June 10, 2002 - My doctor's not in CIGNA's network. What should I do?
I've sent the following letter to each doctor identified to date as a network provider to a Wesleyan participant and who is not in CIGNA's network.

June 6, 2002

«FirstName» «LastName»
«Address1»
«City», «State» «PostalCode»

Dear Dr. «LastName»:

Effective August 1, 2002, CIGNA will become Wesleyan University's exclusive healthcare administrator. While most doctors are in CIGNA's network, your name did not appear in the CIGNA provider directory. Because you provide services to Wesleyan employees and/or dependents, we're asking CIGNA to contact you and arrange for you to join on an expedited basis.

I'm copying Ms. Twila Palmer, CIGNA's client service specialist, to ask her to contact you ASAP. Wesleyan's decision to transition to CIGNA was made after a thorough request for proposal process, including referencing and a mapping of the providers of Wesleyan health plan participants. We understand the importance of continuity of health care and our goal is to have 100% of Wesleyan's current providers in CIGNA's network. I hope that you will agree to become a CIGNA provider. Please feel free to call me with comments or questions.

Sincerely,

David M. Landsberg

If one of your doctors isn't in CIGNA's network, please send me his or her name and address. We will send the above letter and your doctor will be contacted by CIGNA.

If your doctor does not join CIGNA's network then you may either elect the POS alternative or change physicians. If you elect the POS alternative and incur additional expenses between August and the end of 2002 the university will reimburse you for those expenses. Expenses for POS deductibles and co-insurance may be paid on a pre-tax basis through the university's MERA program.

2.  June 10, 2002 - Please describe the difference between HMO and POS plans.
Health Maintenance Organizations (HMO's)

Normally pay only for care obtained from providers who are part of the HMO's network and normally charge minimal co-payments for most care obtained from these providers.

Point-of-Service (POS) Plans

Are similar to HMO's and participants in them may obtain care from network providers with minimal co-payments. POS plans, however, also permit participants to obtain care from providers who are not part of the HMO network but require them to pay a larger share of the cost when they do so. Because of this freedom to choose non-network providers, POS premiums are generally higher than HMO premiums and the POS plan also may charge slightly higher co-payments for care obtained from network providers. Participants enroll in a POS plan because they want the flexibility to see any provider.

3. June 10, 2002 - Is there any advantage to me if I live in Connecticut, am a POS plan member, and go to a hospital in CIGNA's Massachusetts network?
Massachusetts's providers, including hospitals, will remain out-of-network to Connecticut residents, so expenses will be subject to the POS deductible and co-insurance limits. However, if you go to a CIGNA provider the CIGNA discount arrangement will apply. As a result, your 20% share of the provider's bill will be reduced and there is no chance that the bill will exceed "reasonable and customary" limits. This applies to all states except Connecticut, New York, New Jersey and parts of Pennsylvania and Delaware. CIGNA network providers in these states are in-network for Connecticut residents.

4. June 2002 - I want to stay in the HMO, but my primary care physician isn't in CIGNA's network. Can't I just pay his or her bills?
You may pay for your office visits but you will have no insurance for prescriptions he or she may write or lab tests or X-rays he or she may order. You should either change doctors or join the POS plan.

5. June 2002 - Do I have recourse if I feel that CIGNA hasn't paid my claim in accordance with the Plan?
Yes. CIGNA has a formal appeal process as described below. (In addition, there are new federal ERISA claims and appeals regulations that go into effect January 1, 2003.)

If you have any questions regarding this decision, you may initiate a formal appeal by submitting your written concern to:

CIGNA HealthCare Inc.

Attention: NAU

P.O. Box 37963

Charlotte, NC 28237-7963

Any such request should identify the reasons why the request should be approved and be accompanied by documents or requests in support of the appeal. CIGNA HealthCare will respond within thirty days after receipt of the appeal with our decision on the request. If you have any questions concerning this process, they may contact our Member Services Department at the telephone number listed on their CIGNA ID card.

CIGNA HealthCare of Connecticut has a two-level appeal process. Upon receipt of the first level appeal request, a physician not involved in the initial review will review your appeal and any additional information provided. If you are not satisfied with the decision, you may request a second level review, which is conducted by the Appeals Committee. This committee will include a physician who was not involved in any previous review of your case.

Two-Business Day Expedited Appeal Process

Normally, CIGNA HealthCare has up to 30 calendar days to process your appeal. In some cases, however, you may have a faster two-business day expedited appeal. You can get an expedited appeal if your life, health, or ability to regain maximum function could be seriously harmed by waiting the 30 calendar days for a standard appeal. If you ask for an expedited appeal, CIGNA HealthCare will make a determination as to whether your specific situation qualifies under the expedited appeal guidelines. If your situation does not qualify, your appeal request will be automatically transferred to the standard 30-calendar-day appeal process.

The Commissioner of Insurance has established an external appeals process for our members to review any determination not to certify an admission, service, procedure or extension of inpatient stay that may be initiated AFTER completing the Healthplan's appeals process as outlined above. The appeal must be initiated within 30 days of the Healthplan's final determination. For medical necessity denials related to cancer clinical trial coverage, the external appeal process is available immediately, in lieu of the Healthplan's appeals process. The member can contact the Insurance Department at 860.297.3910. Please note that the State of Connecticut does not offer the appeals process to the member if their employer is self-insured. This appeal should be directed to:

State of Connecticut Insurance Department
P.O. Box 816
Hartford, CT 06142-0816

 

6. June 2002 - Which urgent care facilities are included in CIGNA's network?
CIGNA will provide a listing of urgent care facilities. It will include any facility associated with the 31 hospitals in Connecticut, for example, Middlesex Hospital Labs and Centers.

7. June 2002 - I will soon be 65 but intend to continue working at Wesleyan. Do I lose Wesleyan coverage and join Medicare at that time?
As long as you remain employed by Wesleyan in a position with sufficient FTE you will be eligible to participate in Wesleyan's health plans. Faculty and staff eligible for early retirement programs also continue eligibility per plan specifications.

8.  May 2002 - Can I still maintain my current doctors?
The Connecticut physicians participants have seen during the three-year period from 1998 - 2001 were mapped to CIGNA's network. 98% of the physicians are in CIGNA's network.

9.  May 2002 - What if my doctor(s) aren't in the CIGNA network?
CIGNA and Wesleyan are writing to doctors identified as not being in the CIGNA network and asking them to consider joining. You might mention this to your doctor as well.

10.  May 2002 - What if my doctor(s) declines? Will I have to find a new doctor?
You have coverage for providers outside of the CIGNA network, if you are in the CIGNA POS plan.

11.  May 2002 - What can I expect if I change my current HMO plan to the POS plan?
The POS plan provides coverage, although you will have to satisfy a $250 individual deductible and pay 20% of the cost of the next $5,000 in medical expenses, up to a combined $1,250 per individual. (If you are changing from an HMO to CIGNA's POS plan in August, the deductible and co-insurance limits for the balance of 2002 will be $100 and $500). CIGNA will reimburse up to the eightieth percentile for "reasonable and customary" costs, but costs above the eightieth will be fully borne by you and will not count towards the $1,250.

12.  May 2002 - I'm in a POS plan now. Do I have to meet another deductible?
Expenses incurred in 2002 towards deductibles and co-insurance limits will carry over to CIGNA.

13.  May 2002 - My dependent child is away at college. Will she be covered on this plan?
CIGNA has a nation wide network, so receiving in-network coverage while away for an extended period will be made much easier. If your child is away at college you should apply for "guest privileges." Your child will then be able to go to a CIGNA network provider and pay co-payments as if he or she was at home.

The "guest privilege" provision will also be beneficial for participants who are away for extended periods, for example faculty who are on sabbatical or leave.

14.  May 2002 - I'm teaching in Europe next year, how does CIGNA handle overseas coverage?
The change to CIGNA will not effect overseas coverage. You and your family are covered for sudden, unexpected medical problems. CIGNA will likely expect you to delay routine medical treatment, such as physicals, until you return. It is possible that the overseas provider will insist on your paying and applying for reimbursement.

Materials/Information/Enrollment

15. June 2002 - MERA enrollment is normally at year-end. Will I be allowed to change my MERA deduction now if I expect that my out-of-pocket expenses will increase due to this change to CIGNA?
MERA plan enrollment is strictly enforced by the IRS on a calendar year basis. However, regulations permit changes in medical reimbursement accounts in the event of cost or coverage changes in health plans. If you change your enrollment from HMO to POS as a result of your doctor not being in the CIGNA network or otherwise incur increased POS expenses you may increase your MERA deduction. Also, if as a result of new plan features you expect that your out-of-pocket expenses will decrease you may decrease your MERA contributions for the rest of 2002. We cannot however return any money already deducted.

16. June 2002 - How do I contact CIGNA if I have questions prior to enrollment?
CIGNA has established a special pre-enrollment phone link for Wesleyan, 1-800-564-7642. This line is available until July 31.

17.  May 2002 - Where can I pick up a CIGNA provider directory and other materials?
At the fora on May 22, 23, or 29. In addition, materials will be distributed during the week of May 20 in an on-campus mailing.

18.  May 2002 - Please tell me about enrollment details.
Enrollment will be done through the web from June 10 - June 19.

19.  May 2002 - One of my colleagues is away. Are you contacting him?
We have the list of faculty on leave and/or sabbatical in Spring 02 and are contacting departments to ascertain the address where they may be reached. The web will simplify enrollment for faculty and staff as long as they are able to get to a computer anywhere in the world.

20.  May 2002 - Why August 1 and not the normal end-of-year enrollment?
The benefits from self-funding are immediate, and we were actually hoping to begin on July 1 but pushed it back to August in order to provide more time for the transition. There will be a normal end-of-year enrollment in 2002.

21.  May 2002 - If I am currently in an HMO may I change to a POS plan in August (or vice versa)?
Yes.

22.  May 2002 - Changing to CIGNA's POS plan will likely increase my out-of-pocket expenses. May I increase (or begin) MERA deductions?
Yes, but Wesleyan has a plan that will help with out-of-pocket expenses that are a result of this change (see below under transition issues). There are very tight government restrictions on mid-year MERA changes, so an increase must be based on a substantial change.

Gatekeeper and Open Panel

23.  May 2002 - What do "gatekeeper" and "open panel" mean?
"Gatekeeper" means that a referral from one's primary care physician is required to have insurance coverage for treatment from a specialist. "Open panel" means that no referral is required. With the CIGNA administered plan, members can go to any in-network provider without the approval of a PCP.

24.  May 2002 - Why is the gatekeeper provision being removed?
This is a direct benefit of self-insuring. Let me explain. There is a lot of uncertainty about the actual savings resulting from the imposition of gatekeeper restrictions, but to-date, Wesleyan's carriers, especially ConnectiCare, would have imposed premium increases if the plan did not require a gatekeeper. Since the plans were insured both the university and its employees would have had to pay higher premiums, whether or not the gatekeeper provision actually produces any savings. Now that Wesleyan is responsible for its own claims, we can decide if we believe a gatekeeper program is in the financial interest of the university and its participants. Since the research regarding gatekeepers and cost saving is inconclusive, we have decided to remove the gatekeeper restriction.

Self-Insurance

25.  May 2002 - What does "self-insurance" mean?
Wesleyan pays for the claims expenses of its participants itself and pays CIGNA to administer the plan and to provide "stop-loss" insurance for very expensive claims and for total claims that in any one-year exceed 125% of forecast.

Coverage Highlights

26. June 10, 2002 - There is no co-payment required in my Health Net POS plan if I go to an in-network inpatient facility, but CIGNA's is $50 per day. Isn't this a reduction in benefit coverage?
CIGNA and Wesleyan have agreed to eliminate the in-network POS in-patient co-payment. The $50 outpatient surgical co-payment has also been eliminated.

27. June 2002 - Has the infertility benefit limit been increased?
Yes. Wesleyan and CIGNA have agreed to raise the lifetime limit from $8,000 to $15,000.

28.  May 2002 - Is vision care included?
Yes, vision care is included.

29.  May 2002 - Will CIGNA provide dental coverage?
No. Dental coverage is still provided by Delta Dental.

Transition Issues

30.  May 2002 - Will Wesleyan assist faculty, staff, or graduate students who incur unanticipated out-of-pocket medical expenses as a result of this change?
Very few participants might incur additional medical expenses as a result of the loss of in-network providers or due to unavoidable changes in coverage. Those participants might currently be in a POS plan, or might transfer from an HMO to CIGNA POS. If participants incur additional POS plan out-of-pocket expenses between August 1, 2002 and December 31, 2002, as a result of the change to CIGNA administered plans, the university will reimburse them for those expenses.

Prescription Coverage

31. June 2002- What are the prescription co-payments if my doctor is out of network and I am a POS participant?
The $10/$20/$35 co-payments applies to POS participants whether their doctors are in or out of CIGNA's network.

32. June 2002 - Do I need new prescriptions?
Yes. If you regularly use a maintenance medication you will need to get a new prescription from your doctor. I suggest that you get the prescription early enough to take advantage of the mail-in discount program.

33.  May 2002 - Explain prescription co-payments under the CIGNA plan.
CIGNA co-payments are the same as Health Net's and an improvement compared to ConnectiCare's. The CIGNA plan includes the following co-payment schedule:

Generic - $10
Brand, on CIGNA's formulary - $20
Brand, not on the formulary - $35

ConnectiCare's co-payment schedule was the same, except if there is a generic substitute for a brand medication. In that case, the co-payment is $10 plus the difference in the price. This provision has led to co-payments of $75 or even $100 for one prescription.

The mail order co-payment program for current carriers is two co-payments for a three month supply - $20/$40/$70. With the CIGNA plan, the mail-order 90 day generic co-payment will only be $10.

Privacy

34.  May 2002 - Because of self-insurance will Wesleyan administrators know about my medical treatment?
No. Wesleyan will have access to a list of participants for whom payments have been made. That is so we may be sure that we are only paying for our own claims. But we will have no information regarding the cost of individual claims, medical treatment, or providers.