Out of Network

Many of the group health insurance policies and employee health benefit plans that Cigna administers cover expenses incurred for services from health care professionals or facilities who do not participate in the Cigna health care professional network. Those policies and plans include Maximum Reimbursable Charge ("MRC") provisions that may limit the amount of an out-of-network charge that will be considered by Cigna in calculating reimbursement. The plan sponsor (your employer or other organization) may choose one of the following MRC provisions:

MRC Option I

Under this option, a data base compiled by FAIR Health, Inc. (an independent non-profit company) is used to determine the billed charges made by health care professionals or facilities in the same geographic area for the same procedure codes using data. The maximum reimbursable amount is then determined by applying a percentile (typically the 70th or 80th percentile) of billed charges, based upon the FAIR Health, Inc. data. For example, if the plan sponsor has selected the 80th percentile, then any portion of a charge that is in excess of the 80th percentile of charges billed for the particular service in the same relative geographic area (as determined using the FAIR Health, Inc. data) will not be considered in determining reimbursement and the patient will be fully responsible for such excess.

MRC Option II

This option uses a schedule of charges established using a methodology similar to that used by Medicare to determine allowable fees for services within a geographic market or at a particular facility. The schedule amount is then multiplied by a percentage (110%, 150% or 200%) selected by the plan sponsor to produce the MRC.

In the limited situations where a Medicare-based amount is not available (e.g., a certain type of health care professional or procedure is not covered by Medicare or charges relate to covered services for which Medicare has not established a reimbursement rate), the MRC is determined based on the lesser of:

  1. the health care professional or facility's normal charge for a similar service or supply; or
  2. the MRC Option I methodology based on the 80th percentile of billed charges.

There is no MRC with respect to services for which there is not enough charge data in a geographic area to determine a MRC charge.

Average Contracted Rate ("ACR")

Under this option, the MRC is determined based on the lesser of:

  1. the health care professional or facility's normal charge for a similar service or supply; or
  2. the Average Contracted Rate - i.e., the average percentage discount applied to all claims in a geographic area paid by Cigna during a recent 6 month period for the same or similar service/supply provided by health care professionals or facilities participating in the Cigna network. The ACR is updated by Cigna on a semiannual basis. The geographic area used by Cigna is either a Metropolitan Statistical Areas (MSA) or an area within governmental boundaries (e.g. state, county, zip code).

In some cases, the ACR amount will not be used and the MRC is determined based on the lesser of:

  1. the health care professional or facilities' normal charge for a similar service or supply; or
  2. the MRC I methodology based on the 80th percentile of billed charges.

Whether the MRC I, MRC II or ACR methodology is used, the customer is responsible for all charges over the MRC amount, as well as any applicable deductible and coinsurance amounts for charges that do not exceed the MRC. The claim is also subject to all other exclusions and limitations in the applicable benefit plan.

If you are enrolled in a Cigna-administered plan, you and your authorized representatives can find the MRC for a particular procedure and geographic location by calling the 800 number on your ID card.

If you use a health care professional who is not in the Cigna network, be sure to check your plan documents to make sure that your plan covers out-of-network services. If you have a Flexible Spending Account, you may be able to use that money for out-of-network services.