In-Network – Cigna contracts with many providers in Maine and across the United States, known as “in-network” providers. Cigna has special rates with these providers, so if you go to an in-network doctor or hospital you will be able to pay less out of pocket.
Out-of-Network – With the Cigna Open Access Plus Health Plan, you do not have to go to an in-network provider if you do not wish to. However, because out-of-network providers do not have a contract with Cigna, it will cost more for both you and the College. It is important to understand that if you receive services from an out-of-network doctor or hospital, the health plan will pay benefits based on the “maximum allowances.” This means that any amount that an out-of-network doctor or hospital charges that is above the maximum allowance will be billed to you directly before the out-of-network benefits begin to pay. This can mean significantly higher out-of-pocket costs to you. For example, if an out-of-network doctor charges $175 for an office visit and the maximum allowance is $100, you will have to pay $75 before the deductible and coinsurance are applied.
Deductible - The deductible is the amount of money you need to pay before the insurance pays. The in-network deductible is $750 for an individual and $1,500 for a family. For many of the services covered by the health plan, you will need to meet your deductible before the benefit applies.
Copayment (Copay) – For some services and for prescription drugs, you will have to pay a copay. A copay is the amount of money you pay for a service, separate from your deductible. Your copay is usually a small percentage of the overall cost. For example, if you go to an in-network primary care doctor for an office visit, you pay $20 and the insurance company pays the rest. Copays are a set dollar amount.
Coinsurance – Coinsurance is the percent of the cost of your care that you need to pay after you have paid your deductible. For in-network services it is 20% and for out-of-network services it is 40%.
Out-of-Pocket Maximum – The “out-of-pocket” maximum is the total amount of money (deductible plus coinsurance plus medical co-payments) that you will pay for medical services in a benefit year (calendar year). Benefits are paid at 100% for the remainder of the calendar year once you have reached your out-of-pocket maximum. There is a separate out-of-pocket maximum for prescription drug copayments: $5,700/individual and $11,400/family. Out-of-network charges that are in excess of the maximum allowance do not count toward your out-of-pocket maximum. The in-network out-of-pocket calendar year limit is $3,000 per individual/$6,000 per family.