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Frequently Asked Questions
Point of Service Plans FAQs |
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Q: The Oxford Point-of-Service (POS) Plan and CIGNA POS Plan look very similar to me. Which plan should I choose?
A: The two plans are designed to be substantially the same; however, there are differences, so be sure to review the plan descriptions included in Benefits in Brief. In choosing between the plans, you should consider four main issues.
First, consider the providers associated with each plan's network. It may make sense to choose the Oxford POS Plan if you have a relationship with a certain provider who may not be available through the CIGNA POS Plan, or vice versa.
Second, consider how behavioral health treatment is covered. This is one of the coverage areas that differs the most between the two plans. Benefits in Brief gives a summary of how the two plans cover this service.
Third, consider how care for dependents living out of state is covered.
Finally, consider the cost of coverage. Contribution levels for each plan are listed in Benefits in Brief.
Q: Can I switch plans during the year if my provider leaves the network?
A: Due to IRS rules that govern our benefit plans, you can only make benefit changes during the year if you have a qualified status change, such as marriage, birth of a child, or change in employment. Your provider leaving your health plan´s network does not qualify as a status change. We will continue to monitor the number of providers leaving the network. If we find that a significant number of providers leave a network, we will develop alternatives to respond to the problem. Before you enroll, you may want to check with your provider to find out if he or she participates in either network.
Q: Do I need to select a Primary Care Provider (PCP) under the POS Plan?
A: Yes. You should choose a PCP for yourself and one for each family member you enroll in the plan. providers you can choose as PCPs include family practitioners, general practitioners, internists, and pediatricians.
Q: Can a woman select an OB/GYN as her PCP?
A: No, but a woman can see an OB/GYN at any time, without getting a referral from her PCP
Q: How do I know if my provider is part of the CIGNA POS or Oxford POS Plan network?
A: There are many sources:
You can review paper copies of the following provider directories (which are available at the Benefairs and your local Human Resources office), which include a listing of network providers and facilities:
- CIGNA POS Plan directory
- Oxford POS Plan directory
- A supplemental directory, which includes a listing of Columbia Presbyterian Provider Network (CPPN) providers who will participate in the CIGNA POS Plan
You can access the health plan Web sites through Columbia Human Resource´s Web site. In addition, the Columbia HR Web site includes a listing of CPPN providers who participate in the CIGNA POS Plan.
If your provider is not listed in one of these directories, you should call him or her directly. He or she may already be participating, may be in the application process, or may still be deciding.
Q: My current provider is a PCP under the Oxford POS Plan but is only available as a specialist under the CIGNA POS Plan. Can I select a CIGNA POS specialist as a PCP?
A: In some cases. Some specialists will serve as PCPs for their current patients. Otherwise, a specialist cannot serve as a PCP. You are encouraged, though, to check with your provider to see if he or she is interested in becoming a PCP with CIGNA or with Oxford.
Q: Is a referral needed to see a specialist within the CIGNA POS network?
A: Yes.
Q: If I'm pregnant or have a serious illness and decide to change from the Oxford POS Plan to the CIGNA POS Plan, do I have to change my provider if he or she is not in the CIGNA POS network?
A: You may be eligible to continue care with your current provider and receive in-network benefits if, you are in the third trimester of pregnancy or are receiving treatment for a life-threatening or chronic condition (such as cancer, cardiac treatment, or mental health services). You'll need to contact the new POS Plan and apply for transition of care. Each case is reviewed on an individual basis to ensure that all issues are being fully considered. If moving to another provider poses any danger, you will be allowed to stay with your current provider. If you´re approved for transition of care benefits, you'll be able to continue to see your current provider on an in-network basis for a limited period of time (up to a maximum of 180 days). At the end of your transition period, you´ll need to select a new provider under the plan to continue to receive in-network benefits.
If your situation is not eligible for special transition of care coverage, keep in mind, you can always use out-of-network services. This means you can continue to see your current provider and receive reimbursement for care at the out-of-network level.
Q: How do I apply for transition of care?
A: You need to call the "new" health plan directly. That is, you should call the plan in which you want to be enrolled for more details. See your Benefits in Brief for health plan phone numbers.
You'll receive an application, which you'll need to complete and return to the health plan. Your situation will be reviewed on an individual basis and you'll be notified directly.
Q: What happens if I want to elect the CIGNA POS Plan but want to continue to see a behavioral health practitioner who is part of the Oxford POS Plan (but not the CIGNA POS Plan)?
A: If you want to stay with this behavioral health practitioner on a long-term basis, you can continue to see him or her on an out-of-network basis. This means you can continue to see your current provider and receive reimbursement for care at the out-of-network level. You will not be eligible for special transition of care coverage unless you qualify.
See transition of care.
Q: Why do you call "mental health" services by the term "behavioral health"?
A: Behavioral health is a broader term, intended to include treatment for mental health, as well as substance abuse.
Q: What is the coverage for behavioral health under the CIGNA POS Plan and the Oxford POS Plan?
A: The difference between behavioral health benefits under the CIGNA POS Plan and Oxford POS Plan is that outpatient care received outside the plan's network is covered under the CIGNA POS Plan, but not the Oxford POS Plan. In addition, you are eligible for an unlimited number of group therapy visits under the CIGNA POS Plan (for a $10 copay per visit); the group therapy benefit under the Oxford POS Plan is limited to 60 visits per year (with a $10 copay for the first 10 visits and a $25 copay for the remaining visits). See your Benefits in Brief for more details on benefits provided under the plans.
Q: How do travel benefits work under the CIGNA POS Plan and Oxford POS Plan?
A: Under the CIGNA POS Plan, you'll be able to receive in-network care benefits for urgent care, while you're traveling, as long as you can call CIGNA Member Services when you need care. The same process will now be used under the Oxford POS Plan too. Before, under the Oxford POS Plan, you had to call Member Services before you traveled to ensure you received in-network benefits for urgent care in the event you needed it. Now, if you need to receive urgent care while you're away, simply call Oxford when you need it and you'll be covered at the in-network level of benefits. This new and improved feature is called Oxford-On-Call®. It's a 24-hour hotline that you can call to precertify your care or get health care advice. Keep in mind, if you have an emergency, seek care immediately, then call Member Services.
Q: How does the CIGNA POS Plan guest services benefit work?
A: If you have a dependent who lives outside the CIGNA POS Plan service area, such as a child who attends an out-of-state college, special "guest services" may be available. That means your eligible dependent can enroll as a "guest" of another CIGNA POS Plan and continue to receive in-network benefits. All you need to do is call CIGNA and find out if a CIGNA network is available where your dependent lives. If so, you'll receive a CIGNA provider directory for that area.
Q: What are CIGNA's standards for paying claims?
A: On average, CIGNA processes 90% of claims within 10 business days and 98% of claims within 15 days. However, some claims may become "pended" because additional information is required from the provider or patient before the claim can be paid.
Q: Can you define some important terms that describe a POS plan?
A: In-network -- When you go to your PCP for care or are referred by your PCP to another in-network provider. When you receive in-network care, your out-of-pocket costs are lower because you have small copays to make and no deductibles to meet. In addition, you have no claim forms to submit -- your network provider does it for you. Out-of-network -- When you receive care from a provider who is not part of the POS network or if you go to a network provider without first getting a referral from your PCP (except a network OB/GYN for routine care). When you receive out-of-network care, your out-of-pocket costs are higher because you generally pay 20% of the cost of care and have a deductible to meet. And, you have to submit a claim form for reimbursement each time you receive care. Referral -- Your PCP's approval to see a specialist for care. With a referral from your PCP, your out-of-pocket costs are lower and you do not have to file claim forms. Reasonable and customary -- The maximum amount your plan pays for specific health care services when provided by providers and facilities that are not part of the POS network. The reasonable and customary amount is determined by comparing what all the providers in your local area actually charge for their specific services. The severity of the condition, complications, or any other circumstances that may require additional time, expertise, or skill are also considered when determining reasonable and customary charges. Rx Prime -- RxPrime is the administrator of the CIGNA POS Plan's prescription drug program. Under the program, you pay $5 for generic drugs and $15 for brand-name drugs (up to a 30-day supply), when you fill your prescriptions at a participating retail pharmacy. DPS -- DPS is the acronym for Diversified Pharmaceutical Services, which is the administrator of the Oxford POS Plan's prescription drug program. Under the program, you pay $5 for generic drugs and $15 for brand-name drugs (up to a 30-day supply), when you fill your prescriptions at a participating retail pharmacy.
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