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CERTIFICATE OF COVERAGE

CGHC, like other insurance carriers, updates its Certificate of Coverage every year. The Certificate of Coverage is the insurance contract we hold with our members that describes what is covered and not covered. We have made the following changes that we hope will clarify our coverage in 2018:

  • For 2018, all individual plans are changing from Preferred Provider Organization (PPO) to Exclusive Provider Organization (EPO) plan designs meaning out-network care is not covered except in limited circumstances including urgent care services outside of our service area and emergencies. For more details review the 2018 Certificate of Coverage.
  • If there are no in-network providers qualified to provide a medically necessary service, members can work with their in-network provider to submit a referral to an out-of-network provider for care or treatment. Out-of-network care or treatment that is approved by CGHC under this process will be covered subject to the benefits of your plan. However, please know that because we do not have a contract with out-of-network providers, they may balance bill you for charges above our maximum allowable that we will pay for a service.
  • We have updated our list of services that require prior authorization for certain services including hospice and oral surgery. We have also removed some services that formerly required Prior Authorization. Services that no longer require prior authorization in 2018 include habilitation services, home healthcare, and occupational, speech and physical therapy including manipulation.
  • We have updated our durable medical equipment exclusions list.
  • Tier 3 prescriptions apply to the deductible and coinsurance for many of our 2018 plans. In addition, copays will no longer apply to non-formulary prescriptions. In 2018, all non-formulary prescriptions granted exceptions will apply to your deductible and coinsurance.

Please know this is not a complete list of changes, and we encourage you to review the 2018 Certificate of Coverage before renewing your coverage with us. Click here to view your 2018 certificate of coverage.

If you get your health insurance through the
marketplace or directly with CGHC,

click the links below to view your Certificate of Coverage.

If you get your health insurance through your employer,
click the links below to view your Certificate of Coverage.