Terms to Know
The insurance company or third party that reviews, approves, and pays benefits claims.
Dependent Children Over Age 26
Example: You typically receive preventive care during an annual checkup. If a preventive screening yields an abnormal result, you may receive diagnostic care to determine why.
Health Reimbursement Account (HRA)
Health Savings Account (HSA)
A special account that’s typically paired with a high-deductible health plan (HDHP). You and/or your employer contribute to the account, and you can use these funds to cover qualified healthcare expenses, including your annual deductible, copays, and coinsurance. Annual contributions for individuals and families are set by the IRS. The money in your HSA is yours to use into retirement, even if you change plans or employers.
High-Deductible Health Plan (HDHP)
A health plan with a higher annual deductible than most PPO plans. It doesn’t begin to share the costs for covered services until you meet the annual deductible. The annual deductible is $2,000 for individual coverage and $4,000 for family coverage (2 or more people). To help you cover these costs, you can use funds in the Health Savings Account (HSA) or Health Reimbursement Account (HRA) that’s paired with your HDHP.
Example: The individual deductible for the High-Deductible Health Plan is $2,000. When two covered members of your family have each met their $2,000 deductible, the $4,000 family deductible for the year will have been met. After you meet the deductibles, the plan will pay its share of costs for all covered family members during that calendar year.
The facilities, providers, and suppliers that Cigna has contracted with to provide health care services. The High-Deductible Health Plan uses the Cigna Open Access Plus (OAP) Network; the YNHHS Medical Plan offers two different in-network provider networks:
- The Tier 1 Signature Network facilities include: all YNHHS hospitals/locations (including Physician One in CT) and Trinity Health of New England facilities (CT only). PCPs from Northeast Medical Group (NEMG), Community Medical Group (CMG), Yale Medicine (YM), WestMed (CT only), SoNE Health (Trinity Health of New England – CT only). Specialists from NEMG, CMG, YM, SoNE Health and medical staff at a YNHHS hospital.
- Cigna in-network providers are in the Cigna Open Access Plus (OAP) network.
Maximum Allowable Amount (MAA)
The maximum amount that Cigna will pay for a covered service or the billed charge—whichever is lower. Applies to out-of-network services only.
Any provider or facility that has not contracted with Cigna and is not part of Cigna’s network. Cigna will pay up to the maximum allowed amount (MAA) for these services, and all claims will be subject to applicable deductibles and coinsurance.
Any cost or fee that you pay for medical services, prescription drugs, or medical supplies. These include your annual deductible, and copays and coinsurance.
The most you will pay in a calendar year for medical or prescription drug expenses. Once the out-of-pocket maximum has been met, the plan pays 100% of covered expenses for the covered person or family for the remainder of the calendar year, including copays and expenses that are applied toward the annual deductible.
The out-of-pocket maximum does not include benefit reductions due to failure to receive prior authorization, covered expenses paid at 100%, expenses exceeding the maximum allowed amount (MAA), expenses not covered by the plan, or employee premium contributions.
Open Access Plus (OAP) Providers
Doctors, hospitals, and other providers who have agreed to negotiated fees with Cigna. Typically, you’ll pay less than you would for services from an out-of-network provider.
Primary Care Physician
Qualifying Life Event
Examples include allergist, cardiologist, dermatologist, orthopedist, podiatrist, ear/nose/throat, gastroenterologist, OB/GYN, ophthalmologist.