YNHHS Medical Plan
What you need to know
The YNHHS Medical Plan connects you to the world-class care provided by our Signature networks of facilities and providers. Of course, you can also use Cigna Open Access Plus (OAP) or out-of-network providers, but you’ll usually pay more if you do. The medical plan is administered by Cigna.
Connect with the Signature Network
The YNHHS Medical Plan Tier 1 and Tier 2 Provider 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, SoNE Health (Trinity Health of New England – CT only). Specialists from NEMG, CMG, YM, SoNE Health and medical staff at a YNHHS hospital.
View the YNHHS Medical Plan Tier 1 and Tier 2 Provider Listing.
View the Trinity Health of New England facilities. Note: Only CT locations are included in the Tier 1/Signature Network.
Patient Resource Coordinators are available to assist you with your Tier 1/Signature Network needs, such as:
- Finding a physician,
- Making an appointment,
- Signing up for My Chart, and
- Claims issues.
Contact them by calling 844-543-2147, press option 3.
How the Plan Works
The YNHHS Medical Plan is designed to help keep you and your family healthy. Used in tandem with your other benefits—including care and condition management and coaching services—it’s here to support you when you need care.
- You’ll pay nothing for preventive care—including some preventive tests and prescription medications—when you use network providers.
- If you choose a provider in Tier 2, you will have to meet an annual deductible before receiving reimbursement for certain types of services.
- Behavioral health and substance abuse benefits are included in the medical plan.
- You only need to meet one combined annual out-of-pocket maximum for medical and prescription drugs. All your copays and coinsurance for covered services are applied toward this maximum. Once the out-of-pocket maximum is met, the plan pays 100% of eligible expenses for the remainder of the calendar year for each enrolled person.
- Special rules apply when you or your covered dependents are covered by more than one plan.
You may choose to waive medical coverage if you’re covered by another plan or your spouse is a YNHHS employee.
How much you pay for care depends on the provider or facility you choose:
Signature Network—YNHHS Facilities & Providers
When you use a Signature network provider and facility, you’ll pay less for covered services. You pay a flat copay for care and do not have to pay a deductible before the plan begins to pay benefits.
Note: Some Signature Network providers also provide care at facilities that are not in our health system. If you receive care at these other sites, you will pay higher costs for these facilities. For example, a surgeon who practices at Signature network facilities may also perform surgery at private surgical centers. If your surgery is done at a private center, you would pay the Cigna OAP provider or Out-Of-Network rate for the doctor and the facility.
- You’ll generally pay a flat copay for care when you use Signature network providers and facilities, including:
- Facilities owned by Yale New Haven Health and Trinity New England
- Our Signature clinician network of primary care providers and specialists who are credentialed at a facility owned by Yale New Haven Health
- Connect with the Tier 1/Signature Network
- Use the links below to search for a YNHHS facility that provides these services:
- Once you meet your annual out-of-pocket maximum, the plan will pay 100% of covered expenses through that calendar year.
Cigna Open Access Plus (OAP) Providers
When you choose to receive care from an Cigna Open Access Plus (OAP) provider:
- If you choose a provider in Tier 2, you will have to meet your annual deductible before receiving reimbursement for certain types of services.
- After you meet your deductible, you’ll generally pay 20% coinsurance or a copay until you reach your annual out-of-pocket maximum.
- Once you meet your annual out-of-pocket maximum, the plan will pay 100% of covered expenses through that calendar year.
To find a provider in the Cigna OAP Network, visit myCigna.com or call 833-739-6447 (833-73-YNHHS). Or download the myCigna app to find health care services, resources, and important contacts.
Out-of-Network Providers
- You’ll pay the most for care.
- Anthem will pay a maximum allowable amount (MAA) for covered services.
- You will be responsible for costs up to your annual deductible, coinsurance, and any difference between the MAA and the amount billed by the provider.
- You’ll need to file a claim for the care to be covered. Payments will be made directly to the provider unless you submit a bill showing you’ve paid it already. Get a claim form and instructions.
No-cost vaccines when you use the right ID card
What You Pay for Care
Below is a summary of how certain services are covered. For a more complete list and any limitations, visit HRConnect to view the summary plan description (SPD).
To see employee premium contributions for the medical plan, visit the enrollment site.
Your Annual Deductible and Out-of-Pocket Maximum
Family: $0
Family: $3,500
Family: $20,000
Family: $6,000
Family: $16,300
(combined with prescription drugs)
Family: $60,000
[1] Amounts paid toward care provided by all in-network providers accumulate toward both the YNHHS and Cigna Open Access Plus (OAP) out-of-pocket maximums. However, when the YNHHS in-network out-of-pocket maximum has been reached, amounts paid for YNHHS in-network care no longer accrue toward the Cigna OAP out-of-pocket maximum. Amounts paid for Cigna OAP in-network care continue to accrue until the Cigna OAP out-of-pocket maximum is met.
Office Visits and Physician Services
[1] Tests (e.g., some lab work) that are associated with office visits may be subject to a copay or deductible and coinsurance if they are not mandated by the ACA. Check with your provider or call Cigna to determine if a specific test is covered at 100%. In addition, some Tier 1 providers send lab work to a Tier 2 lab. In this case, the lab work is covered as a Tier 2 benefit.
[2]Find a list of Signature providers.
[3] One exam every calendar year starting at age 22 (includes immunizations).
[4] Other than office visit; includes maternity claims.
[5] Nutritional counseling is covered with no limit for mental health/substance abuse (anorexia or bulimia) and diabetes (that are medically necessary). For all other conditions, there is a 3 visit maximum. Note: The YNNHS LivingWell Cares program also provides nutritional counseling services at no cost to the member.
Women and Children
[1] One per calendar year. All other OB/GYN office visits are covered at the specialist office visit benefit level.
[2] Screening mammography only. Does not include breast ultrasounds.
[3] Prenatal care and delivery. Well visits to the obstetric provider are billed with one global fee that includes trimester visits, delivery, and postpartum care. Any maternity-related tests that are needed, such as blood work, glucose tolerance tests, stress tests, ultrasounds, or amniocentesis, are billed separately. Inpatient hospital and doctor or surgeon services also apply.
[4] Seven exams from birth to age 1 year; seven exams from ages 1 to 5; one exam from ages 6 to 21.
[5] Tests (e.g., some lab work) that are associated with office visits may be subject to a copay or deductible and coinsurance if they are not mandated by the ACA. Check with your provider or call Cigna to determine if a specific test is covered at 100%.
[6] The Signature Facility/Provider is Yale Reproductive Endocrinology and Infertility (REI) Center which has locations in Greenwich, Fairfield, New Haven and New London. Prescription medications are also included up to a lifetime maximum of $2,000 through your CVS Caremark pharmacy benefit. However, specialty medications need to be obtained through YNHHS Outpatient Pharmacy Services.
Ancillary Services
[1] Includes x-rays, echo stress tests, ultrasounds, diagnostic mammograms, sleep studies, and EKGs. Patients will receive a bill for the reading of the diagnostic testing and imaging (covered under “Doctor or Surgeon Services”).
[2] PET, SPECT, MRI, MRA, CTA, and CAT.
[3] Diagnostic colonoscopies covered under the outpatient surgery benefit level. Includes fecal occult blood test, barium enema, flexible sigmoidoscopy, and screening colonoscopy.
[4] Chiropractic, physical therapy, occupational therapy, and speech therapy combined maximum: 50 visits per calendar year.
[5] Cardiac rehabilitation: maximum 36 visits per calendar year.
Inpatient and Outpatient Care
[1] Room and board, lab work, medical supplies, and other hospital ancillary services.
[2] Hospital or surgical center facility charges only.
[3] Some Tier 1 providers send lab work to a Tier 2 lab. In this case, the lab work is covered as a Tier 2 benefit.
Behavioral Health and Substance Abuse
[1] The Employee and Family Resources (EFR) program provides up to six (6) confidential counseling sessions at no cost.
[2] Includes ABA therapy.
Urgent and Emergency Care and Telehealth
Non-Acute Care
[1] Up to 120 days per calendar year after a hospital stay.
[2] Up to 120 days per calendar year.
[3] No day limit.
Other
[1]Two hearing aids every 36 months.
Save With Signature Providers & Facilities
The following examples* show how using a Signature provider and facility can save you money. As a reminder, if you use a Signature provider but your care takes place in a facility that is not in our network, the facility expenses will be covered as Cigna or out-of-network care.
Example #1: Signature Savings
Tony saves $5,750 using a Signature provider and Signature facility for his knee surgery.
Example #2: Signature Provider + Cigna Facility Costs
If Tony had the same procedure but it takes place in an Cigna facility, he will spend $5,150 more than in the first example.
Example #3: Cigna Provider + Cigna Facility Costs
If Tony uses an Cigna provider and an Cigna facility, he will spend $600 more than in the second example.
* These examples are for illustrative purposes only. Your actual cost share may vary depending on the care you receive, the facility used, and specifics if you’re admitted as an inpatient. These examples are not provided as a guarantee of coverage or an actual estimate of specific benefits under the plan.
When to Connect with Cigna
For a medical, behavioral health, or substance abuse stays and/or service preauthorizations, call 833-739-6447 (833-73-YNHHS).
- Inpatient stays in a hospital, skilled nursing facility, hospice facility, subacute care or acute rehabilitation facility, or a behavioral health or substance abuse treatment center (CALL at least 24 hours before the start of your stay)
- High-cost diagnostic imaging services prescribed by an out-of-network provider
- Organ/tissue transplants, including evaluation, donor search, organ procurement/tissue harvest, or transplant
For admissions following emergency or urgent care, you, your representative, or your doctor must call Cigna within 48 hours of admission.
If you do not precertify for the services above:
- Benefits for inpatient stays will be reduced by $200.
- Benefits for doctor fees will be reduced by 25%.
You can also connect with Cigna to:
- Find a provider in the Cigna Open Access Plus (OAP) Network
- Resolve insurance claim and billing issues
- Ask questions about preventive and/or diagnostic care
- Get general health information
HRConnect
Monday–Friday,
7:30 a.m. to 5 p.m. ET
844-543-2147
203-200-3838 (fax)
Website
Choose the YNHH_PRD option
Cigna
833-739-6447 (833-73-YNHHS)
Website
Patient Resource Coordinators (PRC) for the YNHHS Medical Plan
844-543-2147, press option 3
COBRA
bswift
866-365-2413
Telehealth
MDLIVE
888-632-2738 (888-MDCARE-8)
Website
Telehealth
OnDemand
833-483-5363
Website