Cigna Open Access Plus out-of-network coverage depends on your plan version. A standard Open Access Plus plan covers out-of-network doctors, but at a reduced benefit level, so you pay more. For example, a plan might pay 80% in network but only 60% out of network. An Open Access Plus In-Network plan covers out-of-network care only for emergencies and urgent care. In both cases, federal law protects you from most surprise bills in emergencies.
- Standard OAP covers out-of-network care at a higher cost. OAP In-Network does not, except emergencies.
- Out-of-network providers can bill you for amounts above what Cigna allows.
- The No Surprises Act protects you from most surprise bills for emergencies and some care at in-network facilities.
- You may need to file out-of-network claims yourself.
How Cigna Open Access Plus Out-of-Network Coverage Works
| Situation | Open Access Plus | OAP In-Network |
|---|---|---|
| Routine out-of-network doctor visit | Covered at a higher cost | Not covered |
| Out-of-network specialist | Covered at a higher cost | Not covered |
| Emergency care anywhere | Covered | Covered |
| Urgent care out of network | Covered at a higher cost | Covered |
| Preventive care out of network | Often not covered | Not covered |
Not sure which version you have? Read Cigna OAP vs. OAP In-Network.
What Out-of-Network Care Really Costs
Out-of-network care costs more in three ways:
- Higher coinsurance. For example, the plan pays 60% instead of 80%.
- A higher out-of-pocket maximum. In one sample plan, it's $5,950 out of network versus $3,500 in network.
- Balance billing. Out-of-network providers can bill you for the difference between their charge and Cigna's allowed amount. That extra usually doesn't count toward your out-of-pocket maximum.
Learn more in our guide to in-network vs. out-of-network costs.
Before seeing an out-of-network provider, ask for their price in writing. Then call Cigna to ask what it will allow. The gap between the two is roughly what you'll owe on top of coinsurance.
Your Surprise-Bill Protections
The No Surprises Act protects you from most surprise out-of-network bills in three situations:
- Emergency care, including at an out-of-network ER
- Certain non-emergency care from out-of-network providers at an in-network hospital, outpatient department or surgery center
- Air ambulance services
In those cases, you generally pay your in-network cost share. However, the law doesn't cover care you choose to get from an out-of-network doctor's office. Questions about a bill? Call 888-730-6031.
A licensed Vivna agent can help you understand your coverage and options, at no cost.
How to File an Out-of-Network Claim
- Get an itemized bill. It should list diagnosis and procedure codes.
- Download the claim form. You'll find it in myCigna.
- Submit it. Upload or mail the form with the itemized bill.
- Watch for your Explanation of Benefits. It shows what Cigna paid and what you owe.
- Appeal if needed. If a claim is denied, you have the right to appeal.
Need help tracking it? See how to check your claim status and how claim appeals work.
Ways to Pay Less
- Find an in-network match. Search the Cigna provider network for a similar specialist.
- Ask your doctor to join. Some providers apply to join networks when patients ask.
- Request a network exception. If no in-network provider can treat you, Cigna may cover the care at in-network rates.
- Use virtual care. Many plans include low-cost video visits.
Cigna Open Access Plus Out-of-Network: FAQs
Does Cigna OAP cover out-of-network doctors?
Standard OAP does, at a higher cost. OAP In-Network covers only emergencies and urgent care.
Is there a separate out-of-network deductible?
Many plans have one. Some share a deductible. Check your Summary of Benefits and Coverage.
Can an out-of-network doctor bill me extra?
Yes, in most non-emergency cases. That's called balance billing.
Are out-of-network ER visits covered?
Yes. Emergency care is covered, and federal law limits surprise bills.
Do out-of-network costs count toward my out-of-pocket maximum?
Usually toward a separate, higher out-of-network maximum. Balance-billed amounts typically don't count.
We'll compare networks on individual, short-term and supplemental plans. Call Monday through Friday, 9am to 6pm.
Sources
- Cigna for Health Care Professionals: OAP and OAP In-Network
- Cigna: Open Access Plus plans
- CMS: Your rights and protections against surprise medical bills
- Sample Cigna OAP benefits summary (Otero County, CO)
Out-of-network rules vary by employer plan and state. Your Summary of Benefits and Coverage has the final word. Vivna Insurance is a licensed, independent agency (NPN 19168641) and an appointed broker with Cigna for select products. We are not Cigna and don't administer employer plans.
Related guides
Find Local Health Insurance Help
Plans, prices and help programs change by state and even by county. These local guides show what is available near you.
More local help: the Texas health insurance guide, plus guides for Florida, Georgia, North Carolina and every state we serve.
Prefer to talk it through? Call 888-730-6031 Monday through Friday, 9 a.m. to 6 p.m. Eastern, for free help from a licensed agent.
