The Facts - HMO
Highlights
of Medical Plans for
Stanford University Postdoctoral Scholars
These are only the highlights.
Stanford University Office of Postdoctoral Affairs offers you a choice of two medical plans: the HMO plan and the PPO plan. There are differences in the level of benefits offered by each plan, as well as the cost to you. Please read this information carefully before deciding on the plan that best suits you and your family's needs.
The Benefit Summary addresses only some of the benefits available under the medical plans. A complete description regarding the terms of coverage, including legislated benefits, exclusions and limitations are provided in your benefit summary plan description.
Your plan is insured by Connecticut General Life Insurance Company (CIGNA). If you have any questions about your plan’s benefit provisions, conditions, or claim procedures, please contact CIGNA at 800-832-3211 (Group # TBFN-01, Policy Number 2456130).
Eligibility and Enrollment
You are eligible to enroll in either the HMO plan or the PPO plan on your date of appointment. Eligible dependents are your spouse, children to age 19, or children 19 to 25 if full time students. Domestic partners are also eligible for coverage. A signed Affidavit of Domestic Partnership form is required.
You must enroll within 30 days to be covered under the plan. If you do not enroll during this time frame, you may not enroll until the next open enrollment period, unless you have a life status change. Similarly, if you acquire any new dependents, including newborns, you must enroll them through the Office of Postdoctoral Affairs within 30 days of their becoming your dependent, or you will have to wait until the next Open Enrollment period before you can add them to your coverage.
In order to enroll in the CIGNA HMO Plan, you must live or work within the HMO service area (defined by residential zip codes). If you do not, then this plan is not an option available to you and your dependents, and you will need to enroll in the PPO plan.
The CIGNA HMO Plan
The HMO Plan provides medical services through a contracted CIGNA network of independent physicians, participating medical groups, hospitals, laboratories, and pharmacies which have agreed to provide their services on behalf of plan participants at pre-negotiated rates.
The accompanying chart (PDF file) highlights many of the specific benefits available under the CIGNA HMO Plan, as well as their related co-payments.
Selecting Your Primary Care Physician ("PCP")
Once you elect the CIGNA HMO Plan, each covered member of your family must choose a Primary Care Physician (PCP) from the CIGNA HealthCare Directory. If a PCP is not selected at the time of enrollment, one will be assigned for you by CIGNA.
You can change your PCP at any time by calling the Member Services number shown on the ID card you will receive from CIGNA. Changes are effective the first of the month following notification to CIGNA. After enrolling in the CIGNA HMO Plan and choosing your PCP, you and your covered dependents will each be issued a permanent ID cards which are usually sent by CIGNA to plan participants within 30 days of their effective date. You must present your ID card each time you request medical services. ID cards are sent to addresses in BISNet.
The Role of Your Primary Care Physician
Your Primary Care Physician serves as your own personal "guide" and health care consultant. He or she also:
Provides preventive care, and treatment when you require medical attention;
Your PCP will refer you to other plan-participating specialists, lab facilities and pharmacies. If the PCP you select is a member of a Medical Group, you are required to see specialists within that Medical Group including, but not limited to, the Group’s OB/GYNs. If you elect to go to a non-participating physician, specialist or pharmacy, you are not covered for these services.
Plan Limits on Your Out-of-Pocket Costs
When your medical care is coordinated by your PCP, there are no deductibles and you pay only a co-payment when you see your PCP for your health care. This co-payment also applies for your visits to any specialists you are referred to by your PCP and, also, to any prescriptions you obtain through a CIGNA network participating pharmacy.
Coverage Away from Home
If you or your eligible dependent(s) relocate temporarily because of a job assignment, school, or personal circumstances, HMO medical coverage may still be available through the CIGNA GUEST PRIVILEGES PROGRAM. Contact Member Services for additional information about this program by calling the toll-free number on your CIGNA ID card.
Well Woman Care, and Special Surgery Benefits
The CIGNA HMO plan allows members direct access in-network to obstetrical/gynecological physicians of their choice (for most routine services) without having to obtain a referral from their PCPs. However, if an individual member’s PCP belongs to a network "medical group", then an OB/GYN physician from within the same medical group must be selected. In certain cases a PCP’s referral is still necessary in order to qualify for special OB/GYN in-network benefits (e.g., gynecological endocrinology).
The HMO medical plan also covers surgery, prosthesis, and reconstruction of the breast(s) following services for a mastectomy. Such services are covered benefits under the plan when a member elects reconstructive surgery, based on consultations between the member and her attending physician.
Services for Mental Health and Substance Abuse
Mental health and substance abuse services, as well as "employee assistance", are provided by CIGNA Behavioral Health, one of CIGNA’s companies. To access personal and confidential attention concerning these matters, you may call (24 hours a day, 7 days a week) the toll-free number listed on your CIGNA ID card.
Prescription Drugs
The HMO medical plan provides for prescription drugs, subject to CIGNA’s formulary. A "formulary" is a comprehensive list of covered medications provided under your plan. The drugs on the formulary have been evaluated to ensure that they meet the needs of patients by being safe, appropriate and cost effective. Both brand name and generic drugs are included on the formulary. Normally, the prescribed generic drug is your benefit. However, not all brand name drugs have a generic equivalent and, therefore, when prescribed from CIGNA’s formulary by your PCP, are a covered benefit under your plan.
If your doctor prescribes a non-formulary drug, and there is a medically necessary reason for you to have that non-formulary drug, your physician will need to obtain an authorization from CIGNA in order for you to have that drug covered. If the CIGNA authorization is obtained, then you are only responsible for your co-payment. For you to receive benefits, your prescription must be written by your PCP (or a specialist referred by your PCP) and filled by a CIGNA network participating pharmacy.
Prescriptions drugs include oral contraceptives, and diabetic supplies and medications, including insulin, needles and syringes, glucose test strips (blood or urine), lancet and lancet puncture devices, glucagon, oral agents for controlling blood sugar and pen delivery systems for administration of insulin. Blood glucose monitors, insulin pumps, and insulin infusion devices are not covered under the prescription drug benefit, but are covered under the durable medical equipment benefit.
If you are taking maintenance drugs for chronic conditions such as asthma, high blood pressure, or diabetes, you may want to utilize CIGNA’s mail order prescription drug program "Tel-Drug." Under this program you can obtain a 90-day supply of your prescription for only $25 co-payment for generic or $85 co-payment for brand name drugs. The normal HMO co-payment is $10 for generic and $30 for brand name drugs for each 30-day’s supply. Additional information about this program is available from CIGNA Member Services (call the toll-free number on your CIGNA ID card) or from the Postodoctoral Services Office.
Hospital CoPayment (HMO)
If you are admitted to the hospital and stay overnight as an inpatient in the hospital facility, you must pay a $500 copayment for each hospital admission. If you are discharged from the hospital but readmitted to the hospital within 30 days, you will not have to pay a second hospital admission copayment. The copayment will be waived for the second admission.
Emergency Services
The CIGNA HMO plan provides coverage for emergencies 24 hours a day, 7 days a week. You are covered whether you are at home or away from home (e.g., traveling on vacation). An "emergency" is defined as a serious accident or sudden illness that, if not treated immediately, could result in a long term medical problem or loss of life. If you utilize the emergency room facilities of an in-network provider, there is a $75 co-payment for Emergency Room (ER) services. However, the "$75 co-payment per ER visit" is waived if you are immediately admitted as an inpatient. Note: Any follow-up care should be coordinated through your PCP, NOT the emergency room.
In the event that you must seek emergency care from a physician other than PCP, your services will be treated as an in-network plan benefit provided your medical need meets the definition of an "emergency" as described above.
Provisions that apply to both HMO and PPO plans:
Exclusions and Limitations
The following is a partial list of major exclusions and limitations under this Plan. In general non-medically necessary services are not covered.
Charges are covered for the diagnosis and treatment of an illness or injury. Questions and inquiries should be directed to CIGNA. Your Plan does not cover costs for the following:
Miscellaneous Information
Overseas Travel
In the event that you are traveling overseas and need to access medical care or treatment, you will need to settle all financial aspects of your bill with the physician or facility. However, please obtain an itemized bill and diagnosis for the services rendered. Contact our member services department upon your return, and they will assist you in filing a claim form for reimbursement.
What do I do if I get a bill?
If you receive a bill for medical services, please call the member services number on your ID card. CIGNA will verify whether we have received a bill for these services or will assist you in filing a claim form. Please be sure to keep copies of all bills for your files.
Special Care Management Services
In cases involving severe or catastrophic illness or injury, the CIGNA Case Management Consulting Services program may be appropriate. This special, voluntary program is free-of-charge to EPP/PPO participants. You may obtain information and/or access this program by contacting Member Services at the number shown on your CIGNA ID card.
Coordination of Benefits ("COB")
When you have medical coverage under both the CIGNA HMO Plan and another group insurance plan, services and benefits of the CIGNA plan are coordinated with the other group insurance plan so that the combination of benefits under the two plans will not exceed the expenses incurred. Coordination of benefits under the CIGNA Plan is also applicable to your dependent coverage. Please note that when one of the carriers involved (e.g., in a dual coverage situation) is a health maintenance organization (i.e., a HMO network), coordination of benefits may not be applicable. For example, office visit co-payments charged by the other plan may not be reimbursed under this plan.
Member Services
CIGNA's member services line is open during normal business hours Monday through Friday. You may contact member services with questions regarding your plan, your benefits or your claims. In addition, they can assist you in choosing a provider, changing your primary care physician or ordering you a new/replacement ID card.
Internet Website
CIGNA has a website available which offers health articles, information on providers, pharmacy listings, formulary drug list and other features. Please visit www.cigna.com for more information.
Links to Tel-Drug and our Healthy Rewards discount program are also available through the website. You may also change your primary care physician over the website, as well as contact CIGNA with questions about your plan.
Subrogation
CIGNA reserves the right to recover (subrogate) expenses for illness/injury received in an accident in which a third party may be liable, whether by settlement, judgment or arbitration.
External Review
In the event that any of your medical claims are denied, and you have exhausted all the normal appeal processes through CIGNA, you also have the right to appeal the decision through an independent external review process. Details regarding this process will be provided to you by CIGNA at the time your claim is denied.
Right to Amend or Terminate
This medical plan and its benefits are being provided at the sole discretion and election of Stanford University Postdoctoral Services which expressly reserves the right to terminate, modify, or otherwise amend this Plan, its benefits provisions, its eligibility conditions, and/or to change Claims Administrators at will.
COBRA (Continuation of Coverage)
If you terminate employment with Stanford or your dependent becomes
ineligible under the plan, you may continue coverage under Federal
COBRA provisions. Your coverage will continue to the end of the month
in which you terminate. You will then receive official notification
upon termination, along with details on the cost of the plan, and
procedures on how to enroll for this coverage. If your dependent
is no longer eligible, please notify the Office of Postdoctoral Affairs within 60 days of the qualifying event, so that proper notification
of their COBRA provisions may be sent to their attention.