Cigna Healthcare in California

Overview

General Information

In California, Cigna Healthcare^SM offers a number of products, services, tools and capabilities to a wide variety of clients and to individuals.

Our HMO and Network plans are offered by Cigna HealthCare of California, Inc. Our Point-of-Service plans are offered by Cigna HealthCare of California, Inc. (in-network), or Cigna Health and Life Insurance Company (out-of-network). Our Cigna Health Access, OAP, PPO, Indemnity, HRA, HSA, and Voluntary plans are offered and/or administered by Cigna Health and Life Insurance Company.

If you are offered a Cigna Healthcare plan through your employer and would like a better understanding of the benefit plan(s) offered to you, look for general descriptions in our Products and Services section.

Accessing Medical Services

Cigna Healthcare offers a broad network of health care professionals and facilities throughout California. Our interactive Provider Directory can show you the participating physicians, hospitals and pharmacies located in the area you specify. If you are enrolled in a Cigna HealthCare of California, Inc. plan, and you select a Primary Care Physician that is affiliated with a medical group, please be aware that your provider will refer you within that medical group for specialty care and some services. To find out which providers are in the networks of Cigna Healthcare, please view our Provider Directory by clicking on the "Find a Doctor" button at the top of the page. Customer's can also login to myCigna.com to get personal results for their specific medical plan.

Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call Cigna Healthcare at the number on your ID card to ensure that you can obtain the health care services you need.

You may contact Cigna Healthcare by calling customer service if you wish to obtain a list of the facilities with which the health care service plan is contracting for sub-acute care and/or transitional inpatient care.

Accessing Vision, Pharmacy and Mental Health and Substance Use Services

Some plans include vision, pharmacy and mental health and substance abuse services.

If you are currently enrolled in a Cigna Healthcare plan, and would like to learn more about what mental health services are available under your plan, which doctors are in the network and how to obtain services, please call the number on your ID card.

For information about optometry services, please call the number on your ID card.

Drug List: For information about which drugs are considered "Formulary" or "Preferred" and generally cost you less out-of-pocket, click on the following link: Prescription Drug List

Language Assistance

English:

Cigna Healthcare provides language assistance services free of charge to customers who live in California and customers who live outside of California and who are covered under a policy issues in California. The below documents are in multiple languages.

Spanish:

Cigna Healthcare proporciona servicios de asistencia de idiomas sin cargo a los asegurados que viven en California y a los asegurados que viven fuera de California y que están cubiertos por una póliza emitida en California. Los documentos que se indican a continuación están disponibles en varios idiomas.

Traditional Chinese:

Cigna Healthcare 免費提供語言協助服務給住在加州以及加州之外，和受保於加州保險政策範圍內的客戶。以下文件包含多種語言

Notice of Language Assistance [PDF]

California Customer Interpreter Card [PDF]

Language Assistance Survey (fillable) [PDF]

Nondiscrimination Notice

Notice for Medical and Behavioral coverage

English [PDF] | Español [PDF] | 繁體中文 [PDF]

Notice for Dental coverage

English [PDF] | Español [PDF] | 繁體中文 [PDF]

Notice for Vision coverage

English [PDF] | Español [PDF] | 繁體中文 [PDF]

Notice for Cigna Onsite Health

English [PDF] | Español [PDF] |  繁體中文 [PDF]

Transition of Care and Continuity of Care

If you are a new Cigna HealthCare of California, Inc. (HMO or Network Plan) enrollee living in California and meet certain criteria, you may be able to continue to receive services from a health care professional who is not in the Cigna Healthcare network. Please see our Transition of Care Brochure: English [PDF] | Spanish [PDF] | Chinese [PDF]

If you are currently a Cigna HealthCare of California, Inc. (HMO or Network Plan) enrollee living in California and your health care professional or facility has left our network, you may be able to continue to receive services from that health care professional or facility if you meet certain criteria. Please see our Continuity of Care Brochure: English [PDF] |  Spanish [PDF]| Chinese [PDF]

If you have been notified by your employer that you may qualify for Continuity of Care after your Cigna HealthCare of California, Inc. (HMO or Network Plan) coverage has terminated. Please see our Continuity of Care Brochure: English [PDF] | Spanish [PDF] | Chinese [PDF]

Coverage After Your Group Coverage Ends

Cal-COBRA Continuation

If you began federal COBRA on or after January 1, 2003, and have recently exhausted that continuation coverage, you may be eligible to continue your Cigna HealthCare of California coverage through Cal-COBRA continuation. Please refer to your plan booklet for more information. You should receive notice of the availability of Cal-COBRA when your COBRA coverage ends. If you qualify for Cal-COBRA or are unsure whether you qualify, please call us at call us at . We will confirm you are eligible to apply and will send you an application if you weren't provided with a copy. You have 60 days from the date of the notice to apply.

Additional Non-Cigna Healthcare Coverage Options

Covered California
You can buy health insurance through Covered California. The State of California set up Covered California to help people and families, like you, find affordable health insurance. You can use Covered California if you do not have insurance through your employer, Medi-Cal or Medicare.

You must apply during an open or special enrollment period. The California Open Enrollment period for Off Exchange Plans starts November 1 of the preceding calendar year, through January 31 of the benefit year. If you have a life change such as marriage, divorce, a new child or loss of a job, you can apply during a special enrollment period.

Through Covered California, you may also get help paying for your health insurance:

• Receive tax credits: You can use your tax credit to help pay your monthly premium.
• Reduce your out of pocket costs: Out-of-pocket costs are how much you pay for things like going to the doctor or hospital or getting prescription drugs.
• To qualify for help paying for insurance, you must:
• Meet certain household income limits
• Be a U.S. citizen, U.S. national or be lawfully present in the U.S.
• Other rules and requirements apply.

Medi-Cal Is Changing Too
Free health insurance is available through Medi-Cal. Medi-Cal is California's health care program for people with low incomes. Starting in 2014, you can get Medi-Cal if:

• You are less than 65 years old
• Your income is low
• You are a U.S. citizen, U.S. national or lawfully present in the U.S.

Your eligibility is based on your income. It is not based on how much money you have saved or if you own your own home. You do not have to be on public assistance to qualify for Medi-Cal. You can apply for Medi-Cal anytime.

To qualify for Medi-Cal if you are over 65, disabled or a refugee, other rules and requirements apply.

For More Information
To learn more about Covered California or Medi-Cal, visit http://www.coveredca.com/ or call toll free at . You can also call or visit your county social services office.

Medical Review of Requested Services or Supplies

Covered Expense

Covered Expenses are expenses for services or supplies which are not excluded from your benefit plan, are recommended by a Physician, and are Medically Necessary for the care and treatment of an Injury or a Sickness.

Prior Authorization

Prior Authorization means the approval that must be received prior to services being rendered, in order for certain services and benefits to be covered expenses under your policy. The Prior Authorization review may include benefit verification and a clinical review to determine whether the service or supply is medically necessary. When you are seeking services or supplies from a contracted Cigna Healthcare Physician or other Provider, that provider will determine whether a prior authorization review is required and submit the service/supply request for a prior authorization decision. Approval decisions will be communicated to the Physician/Provider, and denial decisions will be communicated to you and the Physician/Provider in writing.

Medically Necessary/Medical Necessity

Medically Necessary Covered Services and Supplies are those determined by the Medical Director to be:

• required to diagnose or treat an illness, injury, disease or its symptoms;
• in accordance with generally accepted standards of medical practice;
• clinically appropriate in terms of type, frequency, extent, site and duration;
• not primarily for the convenience of the patient, Physician or other health care provider; and rendered in the least intensive setting that is appropriate for the delivery of the services and supplies. Where applicable, the Medical Director may compare the cost-effectiveness of alternative services, settings or supplies when determining least intensive setting.

Behavioral Health Review of Request Services or Supplies

Receiving Assistance

If we administer administers your behavioral health benefits, our staff can answer your benefit questions and assist you in getting behavioral health care and can assist you or your provider with the claim submission process or help answer questions about how claims have been processed.  Just contact us by dialing the number on your ID card.

Open Access to Outpatient Benefits

For routine outpatient office visits for behavioral care with an in-network psychiatrist or therapist, you do not need to contact us before your treatment appointment. To find an in-network psychiatrist or therapist, use our online directory or call us at the number listed on your member benefit card.

Be sure you understand the difference between in-network and out-of-network coverage. Seeing an in-network psychiatrist or therapist means you'll pay less and do not have to file a claim for reimbursement of covered expenses. In addition, psychiatrists or therapists are required to be licensed and meet quality guidelines for behavioral health.

Prior Benefit Authorization Required for Other Care

For any other type of behavioral care, you must contact us to pre-authorize benefit coverage to receive the maximum amount payment for your claims. Call the toll-free phone number on your health plan identification card to reach our staff. An Advocate or Care Manager will be happy to help. Have your insurance ID card number available when you call.

Our phones are staffed 24 hours a day, seven days a week. When you contact us, you'll be connected with the staff who can best meet your needs. Our Customer Service and Advocate staff can answer benefit or network questions and our licensed Care Managers can help to select the type and level of care you need.

If you don't understand what is and isn't covered under your plan, please contact us. We can help explain your coverage, deductibles and copays, and tell you how to access the kind of care you need. Also, carefully read your benefit plan materials from your employer or health plan for details on your coverage.

Timely Access to Care

Cigna Healthcare is committed to providing you access to care on a timely basis. We follow these standards for access as established by the State of California.

If you are not provided care within the following timeframes, please call the number on the back of your Cigna Healthcare ID card and assistance will be provided to ensure you receive timely access to care.

Medical Access Standards 

• Urgent care appointments for services that do not require prior authorization - within 48 hours
• Urgent care appointments for services that require prior authorization - within 96 hours
• Non-urgent appointments for primary care - within 10 business days
• Non-urgent appointments with specialist physicians - within 15 business days
• Triage or screening services by telephone 24 hours per day, 7 days per week - within 30 minutes

Dental Access Standards

• Urgent appointments - within 72 hours
• Non-urgent appointments - within 36 business days
• Preventive dental care appointments - within 40 business days

Routine Vision Access Standards

• Routine (non-urgent) appointments - within 30 calendar days
• Urgent appointments - within 48 hours

Behavioral Access Standards

• Urgent care appointments for services that do not require prior authorization - within 48 hours
• Urgent care appointments for services that require prior authorization - within 96 hours
• Non-urgent appointments for primary care - within 10 business days
• Non-urgent appointments with specialist physicians - within 15 business days
• Triage or screening services by telephone 24 hours per day, 7 days per week - within 30 minutes

Cigna Healthcare, Grievances, and Appeals

Cigna Healthcare Grievance Procedure

We want you to be satisfied with the care that you receive. That's why we've established an internal grievance process for addressing your concerns and resolving your problems. Grievances include both complaints and appeals. Complaints can include concerns about people, quality of service, quality of care, benefit exclusions or eligibility. Appeals are requests to reverse a prior denial or a modified decision about your care.

California Grievance Brochure: English [PDF] | Spanish [PDF] | Chinese [PDF]

How to File a Grievance

You can notify us of complaints or appeals in one of the following ways:

1. Call us at or at the toll-free telephone number for mental health/substance abuse services on your ID card. The hearing impaired may call the California Relay Service dialing 711.
2. Write to us at:
   Cigna HealthCare Appeals Unit
   P.O. Box 188011
   Chattanooga, TN 37422
3. If you prefer, you can print and complete our Medical GRIEVANCE FORM: English [PDF] | Spanish [PDF] | Chinese [PDF]. Simply mail the form to the address above or fax it to .
4. Submit a GRIEVANCE FORM.

If you are enrolled in a Cigna HealthCare of California, Inc. plan and the member  is a minor or is incompetent or unable to exercise rational judgment or give consent, the parent, guardian, conservator, relative or other legal representative acting on behalf of the customer, as appropriate, may submit a grievance to Cigna Healthcare or to the California Department of Managed Health Care as the agent of the customer.

A participating health care professional or any other person you identify may join with or assist you or act as your agent in submitting a grievance to Cigna Healthcare or the DMHC.

A. Complaints

If you are concerned about the quality of service or care you have received a benefit exclusion or an eligibility issue you should contact us to file a verbal or written complaint. If you contact us by telephone to file a complaint, we will attempt to document and/or resolve your complaint over the telephone. If we are unable to resolve your complaint on the day your call was received, or if we receive your complaint in the mail, we will investigate your complaint and will notify you of the outcome within 30 calendar days, unless your complaint is regarding the treatment you received. These complaints will be investigated by a clinician. If appropriate the complaint may go before a committee of physician reviewers. The outcome of these types of investigations must be kept confidential according to California law.

B. Appeals

If you are not satisfied with the outcome of a decision that was made about your care and are requesting that Cigna Healthcare reverse a previous decision, you should contact us to file a verbal or written appeal within one year of receiving the denial notice. Be sure to share any new information that may help justify a reversal of the original decision. We will tell you who to contact at Cigna Healthcare should you have questions or if you would like to submit additional information about your appeal. We will make sure that your appeal is handled by someone who has authority to take action. We will investigate your appeal and notify you of our decision within 30 calendar days. You may request that the appeal process be expedited if the timeframes under this process would seriously jeopardize your life or health or your ability to regain maximum functionality, or if you are experiencing severe pain. A competent Cigna Healthcare medical professional, in consultation with your treating physician, will decide if an expedited appeal is necessary. When an appeal is expedited, Cigna Healthcare will respond orally and in writing with a decision within 72 hours.

Language Assistance

For all customers who request language services through the grievance process, Cigna Healthcare provides interpretation (oral) or translation services (written) in the customer’s preferred language to both notify Cigna Healthcare of a complaint or appeal and to receive information from Cigna Healthcare about their complaint or appeal. If you have request for language assistance please call member services using the number on your ID card.

You Have Additional Rights Under State Law

If you are a Cigna HealthCare of California customer:

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (1-800-244-6224 (Dial 711 (TTY) for the hearing and speech impaired) or the toll-free telephone number on your identification card) and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

If you are a Cigna Health and Life Insurance Company customer:

You have the right to contact the California Department of Insurance for assistance at any time. The Commissioner may be contacted at the following address and fax number:

California Department of Insurance
Claims Service Bureau
300 South Spring Street
Los Angeles, CA 90013
Or fax to 213-897-5891

Voluntary Mediation

If you have received an appeal decision from Cigna Healthcare that you are not satisfied with, you may also request voluntary mediation with us before exercising the right to submit a grievance to the DMHC (if you are enrolled in a Cigna HealthCare of California plan) or to the California Department of Insurance (if you are enrolled in a Cigna Health and Life Insurance Company plan) or participate in the IMR process. In order for mediation to take place, you and Cigna Healthcare each have to voluntarily agree to the mediation. Cigna Healthcare will consider each request for mediation on a case-by-case basis. Each side will equally share the expenses of the mediation. To initiate mediation, please submit a written request for mediation to:

Cigna HealthCare of California, Inc.
PO Box 188011
Chattanooga, TN 37422

Mandatory Binding Arbitration

To the extent permitted by law, Cigna Healthcare contractually requires the use of binding arbitration when disputes are left unsettled by other means. Arbitration may be initiated by a Demand to Arbitrate served on Cigna HealthCare of California, Inc. Binding arbitration is not mandatory for disputes pertaining to coverage plans governed by the Employee Retirement Income Security Act of 1974 (ERISA). If your plan is governed by ERISA, you have the right to bring civil action under Section 502(a) if you are not satisfied with the outcome of the appeal procedure. In most instances, you may not initiate a legal action until you have completed the Cigna Healthcare internal appeal process.

Cigna Dental Health of California, Inc., Grievances and Appeals

How to File a Grievance

You can notify us of complaints or appeals concerning the Cigna Dental Care (DHMO) Plan in one of the following ways:

1. Call Customer Service at .
2. Write to us at:
   Cigna Dental Health of California, Inc.
   P.O. Box 188047
   Chattanooga, TN 37422-8047
3. If you prefer, you can print and complete our Dental GRIEVANCE FORM: English [PDF] | Spanish [PDF] | Chinese [PDF]. Simply mail the form to the address above or fax it to .
4. Submit a dental GRIEVANCE FORM.
   
   For specific information regarding the Cigna Dental Health of California, Inc., grievance process, please
   • refer to your Combined Evidence of Coverage and Disclosure Form in your plan booklet; or
   • contact our Customer Service Department.

Evernorth Behavioral Health of California, Inc., Grievances and Appeals (Formerly Cigna Behavioral Health of California, Inc.)

How to File a Grievance

You can notify us of complaints or appeals concerning behavioral health services in one of the following ways:

1. Call us at  or at the toll-free telephone number for mental health/substance use services on your Cigna Healthcare ID card. The hearing impaired may call the California Relay Service at or .
2. Write to us at:
   Evernorth Behavioral Health
   Central Appeals Unit
   P.O. Box 188064
   Chattanooga, TN 37422
   Fax #
3. If you prefer, you can print and complete a Behavioral Health GRIEVANCE FORM: English [PDF] | Spanish [PDF] | Chinese [PDF]. Simply mail the form to the address above or fax it to the Complaint/Appeal Department at .
4. Submit a Behavioral Health GRIEVANCE FORM.

For more specific information about these grievance procedures, please refer to your Group Service Agreement or contact our Customer Services Department.

If the Behavioral Health customer is a minor or is incompetent or unable to exercise rational judgment or give consent, the parent, guardian, conservator, relative or other legal representative acting on behalf of the member, as appropriate, may submit a grievance to Evernorth Behavioral Health or the California Department of Managed Health Care (DMHC or "the Department") as the agent of the member.

In addition, a participating provider or any other person you identify may assist you or act as your agent in submitting a grievance to Behavioral Health or the DMHC.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (1-800-244-6224 (Dial 711 (TTY) for the hearing and speech impaired) or the toll-free telephone number on your identification card) and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

Product Disclosures

General Information

IMPORTANT NOTICE:

Please note that the products and services described on the websites of Cigna Healthcare may not be applicable to you or available to you under your employer’s plan. Please refer to your plan documents for information that is applicable to your specific plan.

If you are offered a Cigna Healthcare plan through your employer and are a plan member or customer, or planning to become a plan member or customer, we recommend reading any disclosure that’s applicable to you so that you can become more familiar with your plan and any state-specific mandates. If you are considering becoming a plan member or customer and have questions about your plan coverage, please contact your employer.

While reviewing the information on this page, it’s important to note:

• The disclosures provided here are general and your plan documents may contain additional disclosures which are required by your state and/or specific to your plan. The disclosures in your plan documents take precedence.
• Certain mandates may only apply to certain plan types.
• State mandates may not apply to employer-funded (or self-funded) plans. Please contact your employer if you need to know whether your plan is self-funded and whether any state mandates apply to your plan.

Exclusions and Limitations

All plans may have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Rates may vary by plan and are subject to change. For a complete list of both covered and not covered services under your plan or policy, including benefits required by your state, see your evidence of coverage, plan booklet, insurance certificate or your employer's summary plan description.

For additional plan or product disclosures that may be applicable to you, please visit our Product Disclosures page.