Medical options available under the CIGNA Plan for Medicare Supplemental Coverage

For Medicare eligible members covered by the Health Fund through self-pay contributions, Medicare is generally the primary payer of medical expenses and Medicare does not allow the Fund to offer OAP participation. Medicare sets the fees paid to doctors and other providers under the Medicare program and will not recognize the arrangements negotiated by the OAP. The fees set by Medicare are significantly lower than the usual, customary and reasonable charge amounts that CIGNA accepts under the Major Medical indemnity plan so in some sense Medicare is a OAP.

Certain benefits provided by the Fund to Medicare eligible self-pay members, such as drug, and optical benefits, are not covered by Medicare. The Fund does offer OAP type arrangements for these benefits.

For Medicare eligible members who are eligible for the Health Fund through covered employment, the OAP is available. This is because the Health Fund provides primary medical coverage and Medicare is secondary. That is, the Fund is responsible to pay first based on the Fund benefit provisions and Medicare only fills in Fund deductibles and co-insurance amounts. For a simplified example, for a doctor’s visit under the Major Medical indemnity plan (assuming the deductible has been previously met) the Fund pays 70% and Medicare pays the remaining 30%. Using the OAP for a doctor’s visit , the Fund pays the doctor fees except for the $25 co-pay. The member can submit a receipt for the $25 OAP co-pay to Medicare for reimbursement..

The following are benefit summaries that dictates the benefit options available under the Cigna Plan for Medicare eligible covered by the Health Fund through self-pay contributions.

This summary applies to any medical provider or hospital claim that are incurred.

CIGNA Benefit Plan Summary for Medicare Eligibles (PDF, 191K) cignamedbensum09.pdf