This article provides easy-to-understand definitions of common words that are used in Medicare Plans.
Program that helps you get the care you need at the right time and place. A dedicated case manager works with you and your providers to access services that can help you prevent complications, improve health outcomes and create a better health care experience.
An amount you may be required to pay as your share of the cost for services or prescription drugs. Coinsurance is usually a percentage (for example, 20%).
An amount you may be required to pay as your share of the cost for a medical service or supply, such as a provider’s visit, hospital outpatient visit or a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a provider’s visit or prescription drug.
Any attribute of a benefit that describes the financial responsibility between a customer and the plan administrator as it relates to the payment for a service. See coinsurance, copay and deductible.
The person who is enrolled in a Cigna plan. Once you enroll, you are a customer of Cigna.
The amount you pay for covered services before your plan begins to pay. You may not need to pay a deductible before you can get coverage under the plan. Please refer to your Evidence of Coverage for deductible information.
Focuses on helping customers manage long-term or chronic health conditions. This program is a part of Care Management.
Evidence of Coverage (EOC)
The document that explains your coverage, rights and protections under the plan. Please read this document carefully.
Explanation of Benefits (EOB)
A written explanation that reports the final decision of a claim. The EOB goes to the customer (subscriber or patient) and shows what was paid by the insurance company, as well as the customer’s responsibility.
Health Maintenance Organization (HMO)
An HMO contracts with Medicare, providing you with access to a network of providers and hospitals that coordinate your care, with an emphasis on prevention. With an HMO, your care may not be covered if you go outside the HMO network without obtaining prior approval.
Identification (ID) Card
The card from Cigna that verifies you are a customer of Cigna and eligible for coverage. This card has your primary care provider name and phone number on it. If you lose this card, please call Customer Service.
Independent Physician Association (IPA)
An IPA is designed to provide a team of primary care and specialty physicians who can manage your health care needs. If your medical condition should ever require you to seek care outside the IPA, your primary care provider will continue to assist you in the coordination of any needed services outside of the IPA. Not available in all markets.
Late Enrollment Penalty (LEP)
The LEP is added to your monthly Part D premium (even if your premium is $0) for as long as you have Medicare prescription drug coverage. Your LEP amount may change every year as Medicare recalculates rates on an annual basis. You will have to pay it each month as long as you have Medicare prescription drug coverage, even if you change your Medicare drug plan. The cost of the LEP depends on how long you went without Part D or creditable prescription drug coverage.
Low Income Subsidy (LIS)
Also known as Extra Help. A Medicare program designed to help people with limited income and resources pay Medicare prescription drug premium costs.
Maximum Coverage Amount
The total amount Cigna will pay for a benefit or service within a specific time period. Once the maximum coverage amount is reached, the customer is responsible for the remaining cost.
Medicare Advantage Plan
Also known as Medicare Part C. A Medicare Advantage plan provides coverage to people with Medicare Part A (hospital coverage) and Part B (medical coverage). Cigna is a Medicare Advantage plan.
Medicare Part D
The Medicare prescription drug coverage benefit is called Medicare Part D. To get the Medicare Part D benefit, you must join a plan through an insurance company approved by Medicare.
Cigna offers Part D coverage with many of our plans. Each plan can vary in cost and drugs covered.
A health care professional or health care facility contracted to be a part of Cigna’s network. This type of provider can also be referred to as an in‑network provider or participating provider.
A health care professional or health care facility that is not contracted with Cigna’s network. This type of provider can also be referred to as an out‑of‑network provider or non‑participating provider. Depending on your plan, you may have the option to see non‑network providers. Please refer to your Evidence of Coverage for more information.
The Medicare plan that allows you to go to any Medicare‑approved provider, health care professional or health care facility. Many people have this plan, and it is the one most people are familiar with. You have to pay a yearly deductible, a coinsurance and certain copays.
There are two parts to Original Medicare: Part A (hospital coverage) and Part B (medical coverage).
A type of plan decision that, if approved, allows you to get a drug that is not on the plan’s prescription drug list or get a non-preferred drug for a lower cost-sharing amount. You may also request an exception if the plan requires you to try a certain drug before receiving one you are requesting, or the plan limits the quantity or dosage of a drug you are requesting.
Physician Organized Delivery (POD) Systems
A POD represents a network of physicians with similar referral patterns, organized to administer health care services to the plan’s membership. If you select a primary care provider (PCP) who belongs to a POD, your PCP will refer you to specialists affiliated with the same POD with whom they work closely to coordinate your care. Not available in all markets.
Point of Service (POS) Plan
Depending on your POS plan, you may have the option to select a provider, clinic or outpatient facility which is not in your plan’s service area and/or network of providers. Your out-of-pocket expense for this benefit must go through our Customer Service department for prior approval.
You will typically save money by using preferred pharmacies. Your prescription drug costs (like copays or coinsurance) will typically be less at a preferred network pharmacy because it has an agreement with your plan. Visit CignaMedicare.com for the most current Pharmacy Directory.
Preferred Provider Organization (PPO)
A PPO provides access to a network of doctors and hospitals that coordinate your care. PPOs have a network of doctors and facilities, but also allow you to use any doctor or hospital outside of the network for a higher copay or coinsurance.
Prescription Drug List
A list of prescription drugs, both generic and brand name, used by health care providers to identify drugs that provide the best overall value. For a complete list of prescription drugs covered by Cigna, please visit CignaMedicare.com.
Primary Care Provider (PCP)
Also known as primary care physician. Your PCP is the team leader for all of your health care needs, so he or she knows your entire health picture. Your PCP will refer you to the right specialists and hospitals, and work with them to manage your health care.