Citi Benefits Handbook
Typical Plan Design Features of an HMO Offered by Citi
You must use in-network providers. If you do not use participating providers — except in an emergency — the HMO will not cover that care, and you will be responsible for paying the full cost of that care.
You must choose a primary care physician (PCP) from the list of providers before obtaining any medical services. You may also choose a pediatrician as the PCP for your child. Women may also select an OB/GYN without a referral from their PCP.
Your deductible is $500/individual and $1,000/family maximum. After meeting your deductible, the HMO will pay covered services at 80% while you will pay 20% (your coinsurance). Your annual out-of-pocket maximum is $3,000/individual and $6,000/family maximum.
Each HMO offers prescription drug coverage. Contact the HMO for the name of the prescription drug benefits manager.
Preventive care is covered at 100% without having to meet the deductible.
Routine vision exams are covered at 100% in all HMOs except Coventry Health Care of Iowa and Health Plan HawaiiPlus (HMSA).
As a reminder, benefits vary depending on the HMO.
For more information, review the Certificate of Insurance or call your HMO.
If you have questions or concerns about specific covered services, call the HMO in which you are enrolled directly. Visit "2017 Insured HMOs" for information HMO contact information.
In general, as a participant in an HMO, your PCP provides and coordinates all of your in-network care. In most cases, if you need to visit a specialist, your PCP will refer you to in-network specialists and facilities. Consult your PCP whenever you have questions about your health.
Many HMOs will require each covered family member to select a PCP. You will find PCPs listed in the HMO's provider directory, which are listed under "2017 Insured HMOs." Generally, if you do not choose a PCP, one will be selected for you until you select one.
Your options for choosing a PCP depend on the HMO you select. For instance, your PCP could be a general practitioner, an internist, or a family practitioner. You may choose a pediatrician as your child's PCP. In addition to choosing a PCP for other health care needs, women may select a gynecologist without a referral from their PCP for their routine gynecological checkups.
When you need a specialist, most HMOs will require you to obtain a referral from your HMO or the services will not be covered. With most HMOs, your PCP is responsible for providing these specialist referrals. Certain services may require both a referral from your PCP and pre-certification from your HMO. Your PCP may help to coordinate any required authorizations.
If your HMO requires a referral and you visit a specialist without one, you may be responsible for the full cost of your care. Generally, you cannot request referrals after you have received the care, except in emergencies. You should contact the HMO directly or see the HMO's Certificate of Insurance for a detailed explanation of the referral procedures.
Most HMOs cover preventive care services and health screenings. Such services may include:
- Routine physical exams, including well-child care and adult care;
- Routine health screenings, including gynecological exams, mammograms, sigmoidoscopy, colonoscopy, and PSA (prostatic-specific antigen) screenings;
- Routine vision exams; and
- Routine hearing exams.
Generally, hospital care — both inpatient and outpatient — requires a copayment or coinsurance. If you use an in-network provider or lab, but are not referred by your HMO, you may be required to pay for the services. Generally, hospital services require advance approval from the HMO. Your PCP may help to coordinate the approval.
See the HMO Certificate of Insurance listed under "2017 Insured HMOs" for more information about hospital coverage.
Most HMOs cover physician and hospital care for both the mother and the newborn child, including prenatal care, delivery, and post-natal care. Generally, you will need a referral for your first visit to a participating obstetrician. However, you will not need a referral for the remaining visits during your pregnancy.
The mother and the newborn child are covered for a minimum of 48 hours of inpatient care following a vaginal delivery and 96 hours following a cesarean section. Some HMOs provide coverage for home health care visits if your doctor determines that you and your child may be safely discharged after a shorter stay.
The 48/96-hour minimum stay after childbirth is required by federal law. State laws may provide additional requirements for maternity coverage. See the HMO Certificate of Insurance listed under "2017 Insured HMOs" for more information about maternity coverage.
Call the Citi Benefits Center through ConnectOne at 1 (800) 881-3938 (see the For More Information section for detailed instructions, including TDD and international assistance) within 31 days of the child's birth to add your newborn child to your coverage. The health plans will not cover the child after 31 days.
Benefits are always available in a medical emergency, whether you use in-network or out-of-network providers. A medical emergency is generally defined as a sickness or injury that, without immediate medical attention, could place a person's life in danger or cause serious harm to bodily functions.
If you have a true medical emergency, you should go to the nearest emergency facility. Most HMOs require you to contact your PCP or the HMO within certain time limits, generally 48 hours. If you are unable to do this, you should have a family member contact your HMO.
Most HMOs require a copayment for each emergency room visit. If you are admitted to the hospital, the copayment is generally waived. Non-emergency services provided in an emergency room are not covered.
See the HMO Certificate of Insurance "2017 Insured HMOs" for more information, including your HMO's definition of a true medical emergency.
Covered services, exclusion, and limitations vary by HMO. Check with the HMO prior to enrolling to ensure that you fully understand the provisions of the HMO.