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The Claims Administrators for medical will be Medicare instead of Cigna when Medicare covers the expense. The Claims Administrator for the Prescription Drug Program, CVS Caremark, supplies the network of retail and mail service pharmacies. It is important to keep in mind that the MILA Prescription Drug Program provides retail coverage on both an In-Network and an Out-of-Network basis at the benefit levels noted on the MILA Medicare Wrap-Around Plan Benefits Summary on the MILA Medicare Wrap-Around Plan chart.

Because the Cigna network generally is not available in this Plan, the Trustees have decided that the benefits should be similar to “Out-of-Area” benefits in the Premier Plan. The only time when In-Network benefits will be available to you is when you access the Member Assistance Plan (MAP) or when a service is not covered by Medicare but it is covered by the Plan. This will happen very infrequently. See the explanation of the Out-of-Area benefits here.

Most hospitals and other institutions are contracted in the Medicare “network” under Part A and MILA will pay the balance of these costs which you incur and Medicare covers as indicated in the Medicare Wrap-Around chart.

Medicare covers physician’s services under Part B and this Plan will supplement those payments as indicated in the MILA Medicare Wrap-Around Plan chart. There are three categories of physicians in the Medicare “network” and the majority of physicians participate in one of these three categories. Medicare controls the prices which these physicians may charge and the type of physician you use controls your cost and MILA’s cost.

  • Physicians who “accept assignment” are physicians who will accept Medicare’s payment as payment in full. When you use physicians who accept assignment, you and MILA will have no cost for their services after your Medicare Part B deductible has been satisfied for the calendar year.

For example, assume you have satisfied Medicare’s deductible. Then, you visit a physician who accepts assignment and he bills $200. Medicare determines that $100 is the covered charge and it pays $80 to the physician who accepts assignment. That physician will accept this as “payment in full.” Your Medicare Explanation of Benefits (EOB) will tell you this.

  • The majority of physicians “participate in Medicare.” This means that they accept Medicare’s fee determination. Medicare will pay 80% of its allowable charge leaving 20% as the eligible charge for MILA to consider. After the MILA Plan deductible, MILA will pay 80% of that balance (80% times 20% = 16%) leaving 4% for you to pay.

For Example

Assume the same facts as above except the physician participates in Medicare. Of the $100 covered charge, Medicare would pay the same $80. Your Medicare EOB would tell you that you are responsible for $20. Then, MILA would pay $16 (80% of the $20 balance) and you would owe your physician $4.
  • Some physicians do not participate in Medicare. They still are subject to Medicare’s price controls but, because they will not work with Medicare, Medicare reduces what it will pay these physicians but it allows them to charge you more as shown in your Medicare Explanation of Benefits. In this situation, both MILA and you will pay more.

There is a fourth category of physician called an “opt-out physician.” This type of physician has signed a special agreement with Medicare which allows him to charge you whatever he or she likes and Medicare will pay him or her nothing. To qualify to do this, the physician must give each patient served a separate contract which states that he or she has opted out of Medicare, that Medicare will not pay any portion of the fee and that you must pay all the billed charges. If you sign this type of agreement, MILA will pay the amount it would have paid if the physician had participated in Medicare and you will have to pay the entire balance.

Whenever you are selecting a physician, you should ask the physician how he or she participates in Medicare.


When you are covered by Medicare, you may select any physician. Medicare does not require physicians to have credentials in order to participate in their network. However, if you select a Cigna provider, you will know that the quality of this provider’s medical practice has been reviewed and has been approved.