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Health Insurance

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Members can choose from the following health insurance options (if you qualify).

Each option has different cost sharing—your out-of-pocket costs for copays, deductibles, coinsurance and out-of-pocket maximums. For all options, you won’t pay anything for eligible preventive care — it’s covered at 100 percent as long as you use an in-network provider.

Premier PPO  

Highest premiums, but you pay less for copays at the doctor's office and pharmacy than the PPOs and less coinsurance.

Standard PPO  

Lower premiums than the Premier PPO, but you pay more for copays at the doctor’s office and pharmacy. 

Limited PPO

(local education and local government members only)  Lower premiums than the other PPOs, but you pay more for copays at the doctor’s office and pharmacy.

CDHP/HSA   

Lower premiums and lower out-of-pocket maximum, but you have a higher deductible. You get a HSA — to use for qualified healthcare expenses, including your deductible and to save for retirement. State puts $250 employee only/$500 family tiers* in HSA if eligible (if enrolled prior to Sept. 2, 2018). 

*The state HSA funding will be $250 employee-only/$500 for all other tiers. If your insurance coverage starts on or after Sept. 2, 2018, the state will not contribute funds to your HSA in 2018.

Local CDHP/HSA 

Local education and local government members only:  Lower premiums, but you have a higher deductible. You get a HSA — to use for qualified healthcare expenses, including your deductible and to save for retirement.

    Click here for a benefit comparison for state and higher education.

    Click here for a benefit comparison for local education and local government.

    All healthcare options cover the same services and treatments, but medical necessity decisions may vary by network carrier.

    Need information on behavioral health?

    Behavioral health benefits are provided by Optum. Click here to go to the behavioral health page.

How plan options work

CDHP
Consumer-driven health plan, a type of medical insurance or plan that generally has a higher deductible and lower monthly premiums. Typically, you take responsibility for covering your health care expenses until your deductible is met. Once you meet your deductible, coinsurance applies up to the out-of-pocket maximum.  
Deductible All options include an annual deductible. You pay this amount out of pocket before the plan pays for services that require coinsurance.  
Coinsurance Some services require that you pay coinsurance after you meet a deductible. Coinsurance is a percentage of the total cost.  
Cost Sharing
The share of costs covered by your insurance that you pay out of your own pocket.  
Copay
Some services require that you pay a copay (instead of a deductible and coinsurance). A copay is a flat dollar amount, like $25 for a doctor's visit.  
Network A group of doctors, hospitals and other healthcare providers contracted with a health insurance carrier to provide services to plan members for set fees.  
Out-of-Pocket Maximum The out-of-pocket maximum is the most you will pay for your copays and coinsurance each year. Once you reach your out-of-pocket maximum, the plan pays 100% of covered medical expenses.  
In-Network vs. Out-of-Network Providers You can see any doctor or go to any healthcare facility you want. However, if you use an "in-network" provider, you will always pay less. That's because an in-network provider agrees to provide services to our members at discounted rates. Broad networks of doctors and hospitals are available.  
Plan Provides or pays a portion of the cost of medical care and determines how much you pay in premiums, copays and coinsurance.  
PPO Preferred provider organization, gives plan participants access to a network of doctors and facilities that charge pre-negotiated (and typically discounted) fees for the services they provide to members. Plan participants may self-refer to any doctor or specialist in the network. The benefit level covered through the plan typically depends on whether the member visits an in-network or out-of-network provider when seeking care.  

For more detailed information, member handbooks are available on the Publications page.

BCBST
Cigna

Network Options

You have three insurance networks of doctors and facilities to choose from:

  • BlueCross BlueShield Network S
  • Cigna LocalPlus
  • Cigna Open Access Plus (monthly surcharge applies)

All three networks have providers available across Tennessee. Doctors and facilities in the networks can change. Check the networks carefully for your preferred doctor or hospital when making your selection.

Medical service appeals

If you are a plan member in disagreement with a decision or the way a claim has been paid or processed, you or your authorized representative should first call member services to discuss the issue:  BlueCross BlueShield of Tennessee 800-558-6213 or Cigna 800-997-1617.

First Level Appeal — If the issue cannot be resolved through member services, you or your authorized representative may file a formal request for internal review or member grievance by completing the appropriate form or as otherwise instructed. All requests must be filed within the specified timeframes. When your request for review or member grievance is received, you will get an acknowledgement letter advising you what to expect regarding the processing of your grievance. Once a determination is made, you will be notified in writing and advised of any further appeal options including information about how to request an external review of your case from an independent review organization (IRO).

Second Level Appeal — If the first level appeal is denied, you or your authorized representative may file a second formal request for internal review or member grievance by completing the appropriate form or as otherwise instructed. All requests must be filed within the specified timeframes. When your request for review or member grievance is received, you will get an acknowledgement letter advising you what to expect regarding the processing of your grievance. Once a determination is made, you will be notified in writing and advised of any further appeal options including information about how to request an external review of your case from an independent review organization (IRO).

External Review — If your first and/or second level internal appeal is denied, you or your authorized representative may choose to request that an IRO review the case and make a final determination. The IRO will communicate their decision to you. This decision will be final and binding on you, the plan and the carrier.

The appeals/grievance form can be found at www.bcbst.com/members/tn_state  or www.cigna.com/sites/stateoftn/index.html. Members will have 180 days to initiate an internal appeal following notice of an adverse determination. Notification of decisions will be made within the following time frames and all decision notices shall advise of any further appeal options:

  • No later than 72 hours after receipt of the claim for urgent care
  • 30 days for denials of non-urgent care not yet received
  • 60 days for denials of services already received