Health Insurance Marketplace/Exchange

January 2020

  • General information
    1. What is a Health Insurance Marketplace/Exchange?

      A Health Insurance Exchange, is operating in every state as an option for individuals who wish to purchase health insurance in accordance with the Patient Protection and Affordable Care Act (PPACA). The Exchanges became operational in each state on January 1, 2014. Additionally, small employers with fewer than 50 employees are able to purchase health insurance through the Small Business Health Options Program (SHOP) Health Insurance Exchange. Per PPACA guidelines states can:

      – Establish a state–based Exchange
      – Establish or operate a state–partnership Exchange
      – Defer to the federally–facilitated Exchange

    2. Is Cigna participating in Marketplaces/Exchanges?

      Yes. Cigna is participating in ten public individual Exchanges in 2020:

      • Arizona
      • Colorado
      • Florida
      • Illinois
      • Kansas
      • Missouri
      • North Carolina
      • Tennessee
      • Utah
      • Virginia

    3. What is a qualified health plan?

      A qualified health plan is coverage offered to individuals and small employers through a Exchange. Qualified health plans cannot have pre–existing condition limitations, lifetime maximums, or annual limits on the dollar amount of their essential health benefits.

    4. What does "off–Exchange" or "off–Marketplace" mean?

      Insurers can continue to market their plans off–Exchange in the general market as they do today.

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  • Benefits and networks
    1. What type of plans is Cigna offering through the Marketplace/Exchange?

      Cigna offers individual health plans at three different levels on the Exchanges – Bronze, Silver, and Gold. Plans sold through Exchanges are categorized this way to represent the approximate percent of expenses each plan with cover. For example, a Bronze plan will cover approximately 60% of plan costs, whereas a Gold plan will cover approximately 80%.

    2. What network will the on– and off–Marketplace/Exchange plans use?

      The on and off Exchange plans will use the Connect network.

    3. How does a health care professional know if he or she participates in the network for an Individual and Family Plan?

      Health care professionals can check the online Health Care Professional Directory, available on, to verify their network status.

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  • Caring for customers with Individual and Family Plan coverage
    1. Will a health care professional be able to tell when a patient has coverage through an on- Marketplace/Exchange plan?

      No. Health care professionals will not be able to distinguish between patients with coverage through an individual policy or through their employer. How a patient obtained coverage will not change the tools and resources available to health care professionals in order to manage patient care. Health care professionals can verify eligibility, benefits, and claim status through the same methods as they do today – on the Cigna for Health Care Professionals ( website or through the electronic data interchange (EDI) eligibility and benefit inquiry and response (270/271), or by calling Cigna Customer Service at 1.800.88Cigna (882.4468).

    2. Is there a dedicated phone number and claims mailing address for on–Marketplace/Exchange patients?

      There is no one phone number for individual and family plan customers. Rather, as with other patients with Cigna coverage, providers should refer to the phone number and claims mailing address on the Cigna ID card for information such as eligibility and benefits.

    3. What happens when a Marketplace/Exchange customer does not pay their premiums but has utilized services?

      The Patient Protection and Affordable Care Act mandates a three-month grace period for individual customers who purchase an on-Exchange health plan, are eligible for a premium subsidy from the government, and are delinquent in paying their portion of premiums.

      During the first 30 days of the grace period, Cigna will continue to pay claims and will not seek reimbursement, even if the policyholder is later terminated. For days 31–90, Cigna will pend claims until the entire owed premium is paid. If the premium is paid in full, then all pended claims will be paid. If the premium is not paid in full, then all pended claims will be denied.

    4. How can health care professionals ensure that services provided will be reimbursed by Cigna?

      Health care professionals should always verify a patient's eligibility at the time of service, either on the website or through the electronic data interchange (EDI) eligibility and benefit inquiry and response (270/271) to determine whether a patient is covered based upon the eligibility information available to Cigna at that time.

      The following information will be provided on or through the 271 transaction alerting the health care professional that a consumer is within their extended grace period:

      • "Eligibility pending for verification of premium payment" will appear on the Coverage Details screen of
      • "S1" remark code will appear for claims pended in the claim details screen with "Suspend Missing Information Letter to Insured" noted
      • "5" is the code that will be passed on 271 transactions which has the definition of "Active – Pending Investigation"

    5. What if a health care professional provides services to an individual whose eligibility is pending due to failure to pay their premium?

      A health care professional who provides service to an individual who is within his or her extended grace period accepts the risk of non-payment. Health care professionals cannot bill individuals during the extended grace period. If this individual's plan is terminated for non-payment of premium, the health care professional will not be reimbursed by Cigna for the services rendered during the extended grace period. Cigna is not liable for the payment.

    6. Will precertifications be considered for individuals who are in days 31-90 of a grace period?

      Yes. Prior authorizations will be considered for individuals in the three–month grace period. However, such authorizations will not guarantee payment for the services. Patients must be enrolled in the plan and eligible for benefits on the date they receive the service. Eligibility information, including whether a patient is in their extended grace period, is available as outlined above.

    7. If a health care professional contacts Cigna to request a prior authorization, will the representative responding to the request notify the health care professional that the customer is in a three–month grace period?

      Cigna Customer Service representatives responding to requests for precertification will not provide information about the status of a customer's premium payment or the three-month grace period. Information regarding eligibility, including whether a patient is in his or her extended grace period, is available as outlined above.

    8. If a service is precertified and is provided during days 31-90 of the individual's three-month grace period, will the claim be paid?

      Claims for dates of service during days 31-90 of the three-month grace period will be pended until the premium is received. Once the individual pays his or her portion of the premium due, all claims for dates of service in days 31-90 will be reopened and processed (including claims for prior authorized services). If the individual does not pay his or her portion of the premium by the end of the three-month grace period, claims for dates of service in days 31-90 of the grace period will be denied and the individual will be responsible for payment of these services.

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  • Risk adjustment
  • Risk adjustment is a PPACA market-stabilization program designed to spread the financial risk that health plans (insurers or carriers) assume for their enrolled populations – on and off the Exchanges. It is designed to provide payments to health insurance issuers that attract higher-risk populations, such as those with chronic conditions, funded by payments from those that attract lower-risk populations.

    • All customers are risk adjusted based on demographics, duration on plan, plan category (formerly plan metal)
    • Only customers with a claim (Medical and/or Rx) are allowed to be risk adjusted based on CMS's hierarchical condition category (HCC) and/or prescription drug utilization factors (RXC)
    • Risk adjustment is done at the state level and all states regardless of if they run a state based or federally based exchange must participate
    • Carriers that have a low health risk population will pay into the risk adjustment pool
    • Carriers that have a high health risk population will receive payments out of the risk adjustment pool
    • Financial impact of risk adjustment to carriers can vary significantly depending on population selection, market, market environment, number of carriers

    Risk adjustment is accounted for when pricing ACA products.

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