Out of Network

VERY IMPORTANT:  this message will only impact you if you have already reached your basic deductible and have further out-of-network claims. Read it all carefully before assume the worst..it should not impact most WEA members.
Cigna Letter from April 2014

Dear WEA colleague..as many of you have noticed when you check “Claims & Balances” on the mycigna.com site, there are two sliders..one labeled “In-Network” and one labeled “Out-Of-Network”  It also states that our plan starts on July 1st. The WEA has been bringing this to the attention of Cigna since the plan inception last September. Many members have complained that when they ask a Cigna rep on the phone about our plan, they are told that there are two different deductibles and that the plan runs from July 1 to June 30. We have had our insurance consultants working on fixing these errors but to no avail. We have not been too worried because we were assured that the plan would be administered correctly and follow our contract language.

Our contract says that we have a
  • $2000 (single)/$4000 (family) deductible which includes all in and out of network doctor claims, all imaging, all prescriptions at full negotiated price (no co-pay plan) and any lab work.
  • Once we reach that basic deductible of $2000/$4000, all further in-network doctor, lab and imaging services will be paid by the Westport BOE at 100%.
  • After the basic is met…
  • Out-of Network: we are responsible for 20% of out-of-network doctor visits to a further $2000/$4000 limit (that means that if the doctor visit costs $200 you would owe $40 and you would have to go 100 times before you reach $4000).
  • Prescriptions:We are responsible for paying the $10/$20/$45 copay for medications with a cap or $1000/$2000 for that. (you would have to get 50 $45 scripts to reach this limit)
A few weeks ago it was brought to our attention that some teachers who had reached the basic deductible of $2000/$4000 were getting back out of network claims from Cigna saying that they had to reach another $2000/$4000 deductible before the BOE would pay 100%. This is not correct but when Cigna was called it was confirmed that there is a separate out of network deductible and that is why the claims were rejected.
We immediately contacted our business office and Cigna and have now confirmed that Cigna had incorrectly set up our Westport HSA account. They have acknowledged their mistake and have assured us it will be fixed. We asked them to write a letter of explanation and a copy is attached here.
Before you panic, please know that this will only impact teachers who have already reached their basic $2000/$4000 deductible. Cigna has pledged to give us a list of any member who has been or will be effected by this mistake. The WEA will follow up on this and make sure that all mistakes are corrected.
IF you have not reached your basic $2000/$4000 limits, then this mistake will not impact you at all
IF you have reached your basic deductible, please continue to pay your bills. Remember that out-of-network claims are handled by the doctor like you don’t even have insurance and many doctors require up front payment in full.
Continue to send in your out of network claims and Cigna will refund you the 80% that Westport owes. If you have a different arrangement with your out of network doctor, then continue following that. Keep careful records so we can make sure you are paid every cent you are owed.
If you have reached your basic deductible and made some out of network claims that were refused, please use this form to let us know and we will get back to you. You will have to sign in to your school gmail to view the form.

Maximum Reimbursable Charge.


When you go to an in-network doctor, Cigna has negotiated and settled on a price for the service that the doctor must follow to be in the network.

All bets are off with an out-of-network doctor. They can charge whatever they like. Insurers use tables to set MRC or maximum reimbursable charges for services. They use this amount to decide how much to pay an out-of-network doctor.


For instance, if your out-of-network doctor charges $250 for a visit but Cigna’s MCR chart says the service should only cost $200.
  • You will get credit for $200 against your basic deductible.
  • If you have already reached your basic deductible, you will still owe 20% of the MRC.
  • You would pay $40 and the Westport BOE would pay $160.
  • The $50 difference between the doctor fee and the MRC is also the patient’s responsibility.
  • In total for the $250 bill, you would owe $90 and the BOE would owe $160. This is the way that all out of network claims are processed in any plan.

Here is the info on our website:  check out the Cigna doc, How it works

http://westportea.org/cigna/high-deductible-hsa-plan/how-the-high-deductible-plan-works/

  1. Out of network doctor visits will be credited towards deductible threshold at the maximum reimbursable charge (MRC).
  2. Once the 2000/$4000 deductible threshold is met, all in-network medical services will be covered by BOE.
  3. After the deductible threshold is met, insured are still responsible for:
  4. 20% of out of network fees and BOE will pay 80% amaximum reimbursable charge (MRC) for that service. Providers may still balance bill for the difference between what they charged and the MRC.  How it works
  5. The limit for out of network medical is ,based on 20% of MRC for services, $2000 single and $4000 family above the basic $2000/$4000 deductible threshold.