This is a summary of benefits for your CIGNA Medicare Surround (Part A & B) plan.
CIGNA HealthCare Benefit Summary
Medigap Plan F
CIGNA Medicare Surround (Part A & B) Plan
The Roman Catholic Church of the Diocese of Phoenix – Retired Priest Plan
BENEFIT HIGHLIGHTS Medicare Pays CIGNA pays Lifetime Maximum
Applies to all expenses; Part A and Part B expenses cross
accumulate to the lifetime maximum Not Applicable Unlimited
Calendar Year Maximum
Applies to all expenses; Part A and Part B expenses cross
accumulate to the calendar year maximum Not Applicable Unlimited
Coinsurance Levels
Part A Expenses 100% after Part A deductible
and copayments
100% of the amount approved by Medicare but not paid by Medicare
Part B Expenses Generally 80% after Part B
deductible
100% of the amount approved by Medicare but not paid by Medicare Part B excess charges
Above approved Medicare amounts Not covered
100% up to the Medicare limiting charge or the maximum reimbursable charge
whichever is less Calendar Year Deductible
Applies to Part B expenses
Individual $155 Part B Deductible Not Applicable
Out-of-Pocket Maximum
Applies to Part B expenses only and includes mental health and substance abuse Part B expenses
Not Applicable Not Applicable
Includes Plan Deductible, Coinsurance, and Maximum
Part A Expenses
Inpatient Hospital - Facility Services
Semi-private room and board, general nursing and miscellaneous services and supplies. A new benefit period begins each time the member is out of the hospital more than 60 days.
First 60 days per benefit period:
All but $1,100 deductible 100% of the amount approved by Medicare but not paid by Medicare 61st-90th day per benefit period:
All but $275 a day copayment 100% of the amount approved by Medicare but not paid by Medicare 91st day and after per benefit period:
while using 60 lifetime reserve days All but $550 a day copayment 100% of the amount approved by Medicare but not paid by Medicare Inpatient Hospital - Facility Services – Buy Up
BENEFIT HIGHLIGHTS Medicare Pays CIGNA pays Inpatient Services at Other Health Care Facilities
Includes Skilled Nursing facility; Rehabilitation Hospital; and sub-acute Facilities
Medicare requires that a beneficiary must have been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital.
First 20 days per benefit period: 100% $0 payable after Medicare
21st thru 100th day per benefit period:
All but $137.50 a day 100% of the amount approved by Medicare but not paid by Medicare Inpatient Services at Other Health Care Facilities – Buy
Up
101st thru 365th day: Not covered Not covered
Hospice/Inpatient Respite Care
Medicare requires that the patient is terminally ill to be
eligible for hospice benefits 100% except $5 per outpatient prescription and 5% of
inpatient respite care
100% of the amount approved by Medicare but not paid by Medicare
Part B Expenses
Outpatient Physician Services
Primary and Specialty Care Physician Office Visit Services include:
Surgery Performed in Physician’s office Second Opinion Consultations
Allergy treatment/injections
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare
Preventive Care
Medicare covered services(limited) Generally 80% 100% of the amount approved by
Medicare but not paid by Medicare
Non Medicare covered preventive services Not covered Not covered
Early Cancer Detection Screenings
Medicare covered services Generally 80% 100% of the amount approved by
Medicare but not paid by Medicare Outpatient Facility Services
Operating room, Recovery Room, Procedures Room and Treatment Room
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare Blood and Blood Product Fees
First 3 pints in a calendar year: Not covered 100%
Additional amounts per calendar year: 100% $0 payable after Medicare
Inpatient Hospital Doctor’s Visits/Consultations
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare Inpatient Hospital Professional Services
Surgeon/ Assistant Surgeon Radiologist
Pathologist Anesthesiologist
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare
BENEFIT HIGHLIGHTS Medicare Pays CIGNA pays Outpatient Professional Services
Surgeon Radiologist Pathologist Anesthesiologist
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare
Emergency and Urgent Care Services
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare Ambulance
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare Laboratory and Radiology Services
(includes Pre-AdmissionTesting and Advanced Imaging)
80% after Part B deductible except 100% for Clinical
Laboratory Services
100% of the amount approved by Medicare but not paid by Medicare Outpatient Short Term Rehabilitation and Chiropractic
Care
Maximum: Unlimited
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare Home Health Care
Maximum: Unlimited
100% if covered under Part A 80% after Part B deductible if
covered under Part B
$0 payable after Medicare 100% of the amount approved by Medicare but not paid by Medicare
At Home Recovery Services
Not covered Not covered
Durable Medical Equipment
Maximum: Unlimited 80% after Part B deductible 100% of the amount approved by
Medicare but not paid by Medicare External Prosthetic Appliances
Maximum: Unlimited
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare Diabetic Supplies and Services
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare Part B Covered Prescription Drugs
Additional Coverage with Diocesan Caremark Plan
80% after Part B deductible 100% of the amount approved by Medicare but not paid by Medicare
Caremark Retail: Generic $5 Preferred Brand $30 Non-Preferred Brand $50
Home Delivery (90 Day Supply)
Generic $10 Preferred Brand $60 Non-Preferred Brand $100 Mental Health and Substance Abuse
(Alcohol and Drug)
Inpatient Same as Hospital Inpatient
services noted above, but limited to 190 days of care in
your lifetime in a specialty psychiatric hospital
Same as medical benefits
BENEFIT HIGHLIGHTS Medicare Pays CIGNA pays Foreign Travel
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
Calendar year deductible Not covered Covered w/ $250 deductible
Remainder of charges Not covered Covered at 80% after deductible to a
lifetime maximum of $50,000
Benefit Exclusions (by way of example but not limited to):
Your plan provides coverage for medically necessary services. Your plan does not provide coverage for the following except as required by law:
Additional coverage limitations determined by plan or provider type are shown in the Schedule. Payment for the following is specifically excluded from this plan:
1) Any expense that is:
a) Not a Medicare Eligible Expense; or
b) beyond the limits imposed by Medicare for such expense; or
c) excluded by name or specific description by Medicare; except as specifically provided under the “Covered Expenses” section
2) Any portion of a Covered Expense to the extent paid or payable by Medicare;
3) Any benefits payable under one benefit of this plan to the extent payable under another benefit of this plan; 4) Covered Expenses Incurred after coverage terminates;
5) Medical treatment for a person age 65 or older, who is covered under this plan as a retiree, or their Dependent, when payment is denied by the Medicare plan because treatment was received from a nonparticipating provider.
In addition, the following exclusions apply to any service that is a Covered Expense under this plan, but is not covered by Medicare.
6) Expenses for supplies, care, treatment, or surgery that are not Medically Necessary.
7) To the extent that you or any one of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid.
8) To the extent that payment is unlawful where the person resides when the expenses are incurred.
9) Charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected Injury or Sickness.
10) For or in connection with an Injury or Sickness which is due to war, declared or undeclared.
11) Charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan.
12) For or in connection with experimental, investigational or unproven services.
Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance abuse or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by the utilization review Physician to be:
a) not demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating or diagnosing the condition or sickness for which its use is proposed;
b) not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed for the proposed use;
c) the subject of review or approval by an Institutional Review Board for the proposed use except as provided in the
“Clinical Trials” section of this plan; or
d) the subject of an ongoing phase I, II or III clinical trial, except as provided in the “Clinical Trials” section of this plan. 13) cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance. 14) unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required for
health reasons including, but not limited to, employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations.
15) court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed as covered in this plan.
16) private Hospital rooms and/or private duty nursing.
17) personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness.
20) massage therapy.
21) to the extent that they are more than Maximum Reimbursable Charges.
22) Charges made by any covered provider who is a member of your family or your Dependent’s family.
23) Expenses incurred outside the United States unless you or your Dependent is a U.S. resident and the charges are incurred while traveling on business or for pleasure.
This Benefit Summary highlights some of the benefits available under your plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your Group Service Agreement or Certificate.
Benefits are insured and/or administered by Connecticut General Life Insurance Company.
“CIGNA HealthCare” refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, CIGNA Vision Care, Inc., Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. "CIGNA Tel-Drug" refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., which are also operating subsidiaries of CIGNA Corporation.
