The Differences Between Cigna Open Access and PPO

Provider Choice

The CIGNA PPO does not require that employees choose a primary care physician and lets employees visit any licensed health care provider they ch oose. PPO customers also do not need a referral to visit a specialist. Open Access customers must choose a PCP to receive the maximum benefits, but they are not required to do so to participate in the plan. Open Access customers do not need a referral to visit an in-network specialist, but they must pay the out-of-network rates to visit an out-of-network specialist.

Available Services

Both plans cover patients routine health maintenance tasks, such as physical exams and treatment for minor illnesses and injuries. A patient who has Open Access must visit his designated PCP to receive the full benefits. Both plans cover emergency care, regardless of whether the hospital is in or out of network. Patients under Open Access plans requiring non-emergency hospital stays must have their requests “pre-certified” by CIGNA. The pre-certification process allows CIGNA to determine if the patient's services will be covered under the plan.

Deductibles and Co-Payments

A health insurance plan deductible is the amount the patient must pay before the policy covers any advanced services. The plan deductibles for the CIGNA PPO range from $700 to $1,800 for in-network hospitals and from $1,400 to $3,600 for out-of-network hospitals. The deductibles under the Open Access plan range from $1,000 to $3,000 for in-network hospitals and from $2,000 to $6,000 for out-of-network hospitals. The co-payment is the out-of-pocket expense the patient pays for a routine service, such as a visit to a physician or a prescription. For the CIGNA PPO, patients pay up to $30 for in-network visits and $50 to $70 for out-of-network visits. For the Open Access plan, patients pay $20 to $35 for in-network visits and $60 to $90 for out-of-network visits.

Co-Insurance Payments

A co-insurance payment is the patient's share of the costs of a covered service. Insurers calculate the co-insurance payment as a percentage of the amount of the service. For the CIGNA PPO, patients typically pay 20 percent for in-network co-insurance and 40 percent for out-of-network co-insurance. For the Open Access plan, patients normally pay 20 percent for in-network services and 50 percent for out-of-network services. These percentages may change if the patient's charges haven't met the deductible amount.