Terms to Know
The insurance company or third party that reviews, approves, and pays benefits claims.
The amount you must pay for covered health services each year before the plan begins to pay its share of costs. The deductible may not apply to some services, including preventive care, in-network doctor visits, and services billed by a YNHHS facility.
Each family member covered under the plan must meet the deductible each calendar year. The deductible does not include copays, amounts exceeding the maximum allowable amount (MAA), prescription drug expenses, or expenses not covered by the plan.
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.
- 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)
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.