Participant Access to Care

The Vermont Department of Financial Regulation requires Cigna Behavioral Health to maintain Vermont specific policies and procedures outlining travel and wait times for participants accessing care. Cigna Behavioral Health maintains the following standards in Vermont.

Travel times for participants under normal conditions from their residence or place of business, generally should not exceed the following:

  • Thirty (30) minutes to a network professional;
  • Thirty (30) minutes to an outpatient facility for mental health or chemical dependency; and
  • Sixty (60) minutes inpatient psychiatric services.

Waiting times for appointments should generally not exceed the following:

  • Immediate access to emergency care for conditions that meet the definition of emergency medical condition;
  • In Vermont, Cigna Behavioral Health shall use the following definition of emergency: a condition or illness of a participant, if not treated immediately, presents a serious risk of harm to himself or herself, others or property.
  • Twenty-four (24) hours for urgent care;
  • Two (2) weeks for the initial treatment of non-emergency or non-urgent care, with prompt follow-up care as necessary, including referrals for specialty services.

Annually, Cigna Behavioral Health analyzes data on where plan participants live and compares that to the location of our contracted network. We evaluate the availability of psychiatrists, non-physician therapists and facilities against geographic standards for rural and urban/suburban market areas. We also review the number of professionals available per covered participant.

In 2003 Cigna Behavioral Health measured geographic convenience by drive time for the State of Vermont. The time standards include: 1 professional within 30 minutes,1 outpatient facility within 30 minutes and 1 inpatient facility within 60 minutes.

Cigna Behavioral Health met all time standards for the State of Vermont

Providing Clinical Information

Cigna Behavioral Health strives to obtain all necessary clinical information from the professional and/or facility in order to make a utilization review decision. If there is insufficient information on which to make a determination, Cigna Behavioral Health will ensure there are at least three attempts to obtain needed information over no more than two business days. When additional information is not available, the determination must be made based on available information.

In cases where the professional or participant will not release the necessary information, Cigna Behavioral Health may not authorize coverage. In no event, will Cigna Behavioral Health penalize a professional for failing to provide a participant’s medical records when the participant has not authorized release of the records and the professional is not otherwise obligated by law or regulation to disclose the records.

Facility Standards

Cigna Behavioral Health-credentialed facilities must have one of the following in order to be considered for network participation: Accreditation from a nationally recognized and Cigna-approved accreditation organization (e.g. JCAHO, CARF), a state survey certification, or designation as a rural location as identified by the U.S. Census Bureau. Cigna Behavioral Health actively monitors the accreditation status of its network facilities.