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What is an HMO?
- In the HMO, or Health
Maintenance Organization, each enrollee must select a Primary
Care Physician (PCP) from within the CIGNA network. Doctors in the
CIGNA network are called participating providers and the PCP coordinates
the delivery of care for their patients.
- All covered services must be authorized by the PCP, with the following
exceptions: enrollees may self-refer for routine OB/GYN care, pregnancy
related services, chiropractic care, routine vision appointments,
outpatient services for mental health/substance abuse and, of course,
emergency services.
- Except in cases of emergency, enrollees must use participating
providers to be eligible for benefits. An enrollee can verify whether
a doctor or health care facility is in the CIGNA network by either
calling Member Services (the phone number is on the back of their
SchoolCare ID card), or using the Web
site, www.cigna.com
and click on “Provider Directory.”
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What is a POS (Open Access)?
- The POS or Point
of Service is an Open Access plan that does not require members
to select a PCP or obtain referrals to see other providers or specialists
in the CIGNA network. *
- Enrollees receive the highest level of benefits if services are
obtained using participating providers.
- If an enrollee chooses to use a doctor or facility that is not
part of the CIGNA network, coverage will be provided at a lower level,
requiring the enrollee to pay a larger portion of the cost out-of-pocket.
- POS enrollees can choose to use in or out-of-network providers each
time they receive medical care.
*While not required to select a primacy care physician (PCP), members
are encouraged to establish and maintain a relationship with a PCP to
meet preventive and basic health care needs. Also, a PCP may be helpful
in coordinating your care and initially arranging referrals to specialists.
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What is an Open Access +?
- The Open
Access + Plan is similar to the HMO. However, as an Open Access
plan, enrollees are not required to select a PCP or obtain referrals
to see other providers or specialists in the CIGNA network. *
- The plan emphasizes wellness and prevention through $0 copays for
preventive care (including mental health benefits) and generic maintenance
medications.
- Other benefits are subject to a deductible and coinsurance.
- Except in cases of emergency, enrollees must use participating providers
to be eligible for benefits.
*While not required to select a primacy care physician (PCP), members
are encouraged to establish and maintain a relationship with a PCP to
meet preventive and basic health care needs. Also, a PCP may be helpful
in coordinating your care and initially arranging referrals to specialists.
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What is the SCHOOLCARE 65+ Plan?
- SchoolCare
65+ is a plan for retirees enrolled in Medicare Parts A and B.
Medicare is the primary plan and SchoolCare
65+ is secondary, filling in some of the gaps not covered by Medicare
and providing additional benefits, such as prescription drug coverage.
- You can reside anywhere in the United States and use any provider.
To receive the highest level of benefits, you should use a provider
that accepts Medicare assignment; otherwise you will be responsible
for charges above the Medicare approved amount. For questions about
Medicare, contact your nearest Social Security office or call 1-800-633-4227,
or visit www.medicare.gov.
- United American and Express Scripts (Rx) administer the benefits
for SchoolCare 65+.
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