Health Questions 2012

   
 
What are my co-pays for a physician office visit?
 
In-network primary care physicians are paid 100% after your $20 co-pay.
In-network Cigna Care Network (CCN) specialists are paid 100% after your $50 co-pay. In-network Non CCN specialists are paid 100% after your $70 co-pay.

What is a Cigna Care Network (CCN) specialist?
 
These are specialists of a designated network that have been identified by Cigna to have demonstrated the best outcome in management of patient treatment.

What specialites are included in this network?
 
There are 19 different specialties, and 1,725 CCN providers are located in South Florida. 

How do I determine if my specialist is on the CCN network?
 
You may access the CCN provider network at www.Cigna.com.  Click on the find Welcome link, then on the Find a doctor link, then click on Physicians, data enter your zip code and click on next.  Then select “Open Access Plus, OA Plus with CareLink (second bullet), then click on Specialist and a list of participating CCN provider, with a tree of life symbol next to their name will appear. On the website, the symbol of a “leaf” will be next to the physician’s name.

How does the annual deductible work?
 
The annual deductible is the amount you are responsible for and is separate from any co-payments.  Deductibles are expenses to be paid by you or your dependent(s) for medical services provided in a hospital or hospital affiliated facility.

How much is the deductible?
 
OAP 20 the in-network annual maximum deductible is $500/individual and $1,000/family.  Out-of-network is $1,250/individual and $2,500/family.

OAP 10 The in-network annual maximum deductible is $250/individual and $500/family.  Out-of-network is $750/individual and $1,500/family.

Note: Current OAP 20 participants that have met their 2012 deductibles ($250/$500) prior to 04/01/2012 will have to satisfy the additional deductible amount of $250/individual and $500/family, so that the total annual deductible is satisfied.

Current OAP10 participants continuing their enrollment in OAP 10 will have to satisfy the deductible amount of $250/individual and $500/family.  If changing to OAP 20, the in-network deductible is $500/individual and $1,000/family.

What does the annual maximum out-of-pocket (MOOP) mean?
 
The annual out-of-pocket maximum is the amount you are responsible for before the plan pays 100%.  Deductibles and set dollar amount co-pays do not apply to the out-of-pocket maximum. 

OAP 20 in-network out-of-pocket maximum is $2,000 per individual or $4,000 per family.  Out-of-network pocket maximum is $6,500 for individual and $13,000 for family.

OAP 10 in-network out-of-pocket maximum is $2,000 per individual or $4,000 per family. Out-of-network pocket maximum is $3,500 for individual and $7,000 for family.

What does the plan co-insurance mean?
 
The plan co-insurance is the percentage that the insurance will pay on covered services after you have satisfied the annual deductible.

OAP 20 Plan will pay 80% in network and 60% out-of-network.

OAP 10 Plan will pay 90% in network and 70% out-of-network.

What services do the co-insurance percentages apply to?
 
Co-insurance percentages apply to all services provided in a hospital or hospital affiliated facility, and that do not have a fixed co-pay (dollar) amount.

What happens if I am hospitalized?
 
OAP 20- Hospital admissions are subject to 20% of allowable charges after the $500 deductible for employee only & $1,000 for family.
Out-of-network hospital admissions are subject to 40% of allowable charges after $1,250 deductible for employee only & $2,500 for family.

OAP 10- Hospital admissions are subject to 10% of allowable charges after the $250 deductible for employee only & $500 deductible for family.
Out-of-network hospital admissions are subject to 30% of allowable charges after $750 deductible for employee only & $1,500 for family.

For example: if you are hospitalized in an in-network hospital:
  OAP 20 OAP 10
Deductible:  $500 Individual  $250 Individual
Co-Insurance: 20% 10%
Out-of-pocket:  $2,000 Individual $2,000 Individual
Maximum Cost: $2,500 Individual $2,250 Individual

What are the co-pays for emergency room visit?
 
In-network emergency room charges are paid 100% after your $300 co-pay.  Jackson Hospital System emergency room charges are paid 100% after your $150. The emergency room co-pay is waived if you are admitted.

What are the co-pays for urgent care centers?
 
Urgent care charges are paid 100% after your $70 co-pay.
What are the co-pays for convenience care centers?
 
Convenience care charges are paid 100% after your $20 office visit co-pay.
Prescription Drugs Retail (up to 31 day supply)
 
Tier 1 - $15 Generic Medications
Tier 2 - $40 Preferred Brand Medications (when generic is not available)
Tier 3 - 50% coinsurance (minimum $100 & maximum $150) Non-Preferred Brand Medications (These medications have a generic or a Tier 2 alternative within the same drug class.)

OAP 20 - Out-of-network pharmacies prescriptions are covered at 50%.
OAP 10 - Out-of-network pharmacies prescriptions are covered at 50%.

What is a mandatory prescription mail order program?
 
This program is designed for prescription medications taken on a regular basis, including specialty drugs.  Employees must request a prescription from their doctor for a 90-day supply with refills. Cigna Home Delivery Pharmacy will deliver to your home a 90-day supply with a co-pay of two times the tier cost, saving you time and money.  The co-pays for this benefit are as follows:
Tier 1 - $30 Generic Medications (2X $15)
Tier 2 - $80 Preferred Brand Medications (when generic is not available) (2X$40)
Tier 3 - 2 times 50% coinsurance (minimum $200 & maximum $300)

What’s a Narrow Retail Pharmacy Network?
 
This is a network of participating pharmacies where prescriptions can be filled.  All other pharmacies are not participating in the plan.

Which are the pharmacies participating in the Narrow Retail Network?
 
Only Walgreens, Wal-Mart, Publix, Navarro and specific identified independent pharmacies are in the network.

What’s the coverage for Durable Medical Equipment (DME)?
 
After you have satisfied the annual deductible:

OAP 20 Plan will pay 80% in-network and 60% out-of-network.
OAP 10 Plan will pay 90% in-network and 70% out-of-network.
Once you have met your maximum out-of-pocket, the coverage will be 100%.
Examples of DME are wheelchair, crutches, walkers, CPAP, hospital bed, etc.

Can I decline healthcare coverage?
 
Yes, you can decline healthcare coverage and in lieu, you will receive a monthly contribution of $100 paid through the payroll system based on your deduction schedule (Subject to withholding and FICA).
Additionally, you must be enrolled in a group or state funded healthcare plan to decline healthcare coverage.  You will be required to submit proof of this other enrollment, if proof is not submitted your declination selection will be cancel and you will automatically be enrolled in Cigna OAP 20 employee only coverage.

Is there a cost when enrolling in Cigna OAP20?
 
No, OAP 20 remains free - no cost for employee only coverage.

Will M-DCPS continue to subsidize the cost of dependent premium?
 
Yes, M-DCPS will continue to subsidize dependent premium between 70-90%.

Will dependent premiums continue to be based on my annual base salary (by salary bands)?
 
Yes, salary bands were negotiated as of January 1, 2010. Dependent Healthcare subsidies are based upon higher subsidies being in place for the lower paid employees.

Must all eligible employees enroll during this enrollment period for benefits effective April 1, 2012?
 
Yes, this is a full enrollment and if you do not re-enroll during this Open Enrollment Period you will be automatically assigned to Cigna OAP 20 Employee Only coverage.  Your current dependent and employee-paid flexible benefits will terminate March 31, 2012, so you must enroll for all benefits.  Also, if you have selected to decline the School Board’s healthcare coverage, and do not re-elect the declination during this enrollment, you will be automatically assigned to Cigna OAP 20 Employee Only coverage.

What number do I call for additional information on the healthcare plan?
 
Call Cigna Healthcare at 1-800-806-3052, 24-hours/7 days a week.

What number do I call for additional information on my enrollment and all other benefits?
 
Call FBMC Customer Care Center at 1-800-342-8017, Mon-Fri, 7 a.m. – 10 p.m. ET

   

For individual claims questions, contact Cigna Customer Service at 1.800.806.3052
For additional information on enrollment and all other benefits, contact FBMC at 1.800.342.8017

Ask a Question at: healthquestions2012@dadeschools.net

 

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