Cigna Tiered Benefits
Cigna Tiered Benefits is a plan benefit that was developed as a tool to steer customers to higher-performing providers who have been evaluated for quality, cost efficiency, and volume. It is available to customers in 74 service areas across 36 states who are enrolled in employer-sponsored plans that contain this benefit. It enables eligible customers who use Tier 1 providers to take advantage of lower out-of-pocket costs beyond the standard in-network benefit level.
Tier 1 providers. For the purposes of Cigna Tiered Benefits, a subset of network-participating physicians in certain specialties are identified as Tier 1 providers. Tier 1 includes all physicians who have earned the Cigna Care Designation, although it is important to note that not all Tier 1 providers have the Cigna Care Designation. Cigna Care Designation is a program that distinguishes physicians in certain specialties who meet specific quality and cost-efficiency measures.
Customers' use of other network-participating providers. Other network-participating physicians that are not Tier 1 providers may be used by customers who have this benefit, and the care will be considered in-network. However, the claims will be processed and paid at the standard in-network benefit level and not at the enhanced Tier 1 level.
Customers can identify Tier 1 providers in the Cigna provider directory.
Cigna Tiered Benefits is offered as a plan benefit option in the service areas listed below.
|Arkansas Little Rock Metro||Indiana Indianapolis only||New York Metro New York||Texas Dallas, Ft. Worth and Houston|
|Arizona||Kansas/Missouri Kansas City ONLY||New Jersey Northern and Southern New Jersey||Utah Wasatch Front|
|California Bakersfield, Central California, Los Angeles, Northern California, Orange County, Sacramento, San Diego, San Francisco, and Ventura||Louisiana||North Carolina||Virginia|
|Colorado Colorado Springs and Denver||Massachusetts||Ohio Northern, Central and Southern Ohio||Wisconsin|
|Connecticut||Maryland Maryland and Washington, DC||Oregon Portland||West Virginia|
|Delaware||Maine||Pennsylvania Philadelphia, Pittsburgh, and Eastern and Western Pennsylvania||Washington|
|Florida Jacksonville, Ocala, Orlando, South Florida, and Tampa||Michigan (HAP)||Rhode Island|
|Georgia||Nevada||South Carolina markets vary|
|Illinois Champaign, Chicago Metro, and Urbana||New Hampshire||Tennessee Memphis, Nashville, Knoxville, and rural Tennessee|
Selection Criteria for Tier 1 providers
All physicians who are identified as Tier 1 providers practice in one of the 21 specialties listed below. Note that care rendered to eligible customers by network-participating physicians that are not Tier 1 providers – including hospital-based physicians, hospitals, ancillary providers, and physicians in specialties not listed – will still be considered in-network. However, their claims will be processed at the standard in-network benefit level.
|Allergy and immunology||Cardiology||Cardio-thoracic surgery|
|Dermatology||Ear, nose and throat||Endocrinology|
|Family practice||Gastroenterology||General surgery|
|Neurology||Neurosurgery||Obstetrics and gynecology|
|Ophthalmology||Orthopedics and surgery||Pediatrics|
Providers in these specialties are evaluated at least every other year to determine if they will be Tier 1 providers.
Cigna Care Designation
In the geographic areas where Cigna Tiered Benefits are available, all physicians in the 21 specialties with the Cigna Care Designation will be Tier 1 providers, along with other select providers. Cigna Care Designation quality and cost-efficiency criteria are summarized below.
A physician's quality is based on the measures listed below, if available.
- National Committee for Quality Assurance (NCQA) recognition for diabetes care, cardiac and stroke care, back pain care, physician practice connections, or patient-centered medical home
- Adherence to select evidence-based quality measures
- Group board certification criteria
We determine how a physician’s cost efficiency compares to other physicians in the same specialty category in the same service area. The results are based on a comparison of fee schedules, utilization patterns, and referral patterns (i.e., use of hospitals and other facilities).
To learn more about Cigna Care Designation, read the white paper at https://Cigna.com/CignaCareDesignation.
How to identify customers with this benefit
If "Tiered Benefits" is printed on the patient's Cigna ID card, and care is needed in one of the specialties listed above, the following will apply:
- When receiving care for covered services from specialists who are Tier 1 providers, the in-network benefit level and lower copayment or coinsurance level will apply.
- When receiving care for covered services from specialists who are not Tier 1 providers, in-network benefit level and the higher copayment or coinsurance level will apply.
For coverage of the specialty services at the enhanced coverage level, Customers with Cigna Tiered Benefits must receive care from Tier 1 specialists. They can find these providers by searching the provider directory at myCigna.com or Cigna.com. Customers may also receive care from other network-participating providers, but it will be covered at the standard in-network level and not at the enhanced benefit level.