broker resource guide 2004 - oxford health plans · overview your oxford broker resource guide the...

Broker Resource Guide 2004

overview

Your Oxford Broker Resource Guide

The purpose of the guide is to make doing

business with Oxford easier and to provide you

with useful information about Oxford at your

fingertips including:

• Frequently used phone numbers and addresses

• Product charts

• Online functionalities for all audiences

• Small and Large Group eligibility requirements

• Member eligibility requirements

And many more topics.

Now for 2004: Handy indicates web

functionality.

Use this guide along with the Oxford broker site

at www.oxfordhealth.com to access the information

you need. As always, contact your Oxford sales

representative with any questions you may have.

Please note: The information in the Broker Resource Guide is current as of January 2004.

www

1 Customer Service for BrokersGroup Services DepartmentOxford Express® IVR for Brokers and Benefits AdministratorsImportant Phone Numbers and Addresses

5 Commissions Commission BasicsBroker of Record

7 Web site: www.oxfordhealth.comBroker, Employer, Member and Provider sitesSign Up TodayGet AcquaintedWhat You Can Doidea Management SystemSM

Access to the oxfordhealth CenterOnline AdministrationOxford Benefit ManagementSM

13 Oxford ProductsService Area MapOxford Products

17 Oxford Benefit Management, Inc.OBM Prepackaged BenefitsOxfordFlexSM

19 Oxford ProgramsHow We Help You Stay HealthyManaging Chronic ConditionsHealthy BonusSM

Pharmacy Programs

25 Group Enrollment and EligibilityLarge Group Eligibility by StateSmall Group Eligibility by StateIndividual Enrollment and Eligibility

table of contents

headtable of contents

35 Billing and PaymentsBilling BasicsMember Effective/Termination Dates and Premiums DueRemittance AdviceCheck Billing on the Web and Oxford Express®

Frequently Asked Billing Questions

37 Member Enrollment and EligibilityLarge Group Member Eligibility by StateSmall Group Member Eligibility by StateIndividual and Mandated Products

63 Renewalsidea Management SystemSM

Contract RenewalOxford Renewal Process

65 ClaimsClaim SubmissionClaim Filing Deadlines

67 Miscellaneous ItemsBrokers Acting on Behalf of Benefits AdministratorsConfidentiality PolicyHIPAACOBRARate Quote for Large/Executive AccountsTermination and DisenrollmentGroup ConversionsTax Forms

Custom

erService

Customer Service

head

1

customer service for brokers

Group Services DepartmentMonday through Friday, 8:00 AM to 5:00 PM . . . . . . . . . . . . . . . . . . . . . . . . . . . 888-201-4216

What is Group Services?• Primary customer service contact for brokers and all group accounts

• Supports brokers and benefits administrators regarding all aspects of plan administration:

• Verifies enrollment and eligibility status for both Members and groups• Facilitates small group renewals• Responds to general inquiries on Member benefits• Assists with billing questions• Advises on policies and procedures

[email protected] • [email protected] is an e-mail box created specifically for both benefits

administrators and brokers to interact with Oxford Health Plans for issue resolution andmake general inquiries.

• This e-mail address offers a service distribution channel for our customers to further enhance the overall accessibility of service provided by Group Services.

• For confidentiality, all e-mails are verified using the e-mail address of the sender.Only general information can be obtained from this e-mail address unless the sender isclearly identified as an authorized broker1 or benefits administrator.

Types of inquiries sent to [email protected]• Any group service related inquiry can be sent to the e-mail box. The following are some

examples of issues that would be well served via the e-mail box:1

• Benefits Administrators or contact name changes• Corrections/missing information on Member Enrollment Forms (i.e., date of hire,

date of marriage, Social Security number, complete address, gender, etc.)• Requests for materials, copies of invoices, and renewal rate options• Eligibility verification

Turnaround time for inquiries sent to [email protected]• Oxford’s Group Services team will generally respond within 24 hours of receiving an

e-mail. This response will either provide an answer to the question posed or state thatthe inquiry is being processed.

1Brokers need to obtain a consent form to act on behalf of the BA and the group. Please see Brokers Acting onBehalf of Benefits Administrators on page 67 of this guide.


2

Oxford Group Services 888-201-4216 8 AM to 5 PM, Mon-Fri

Commissions 888-666-6844 8 AM to 4:30 PM, Mon-Fri

Customer Service 800-444-6222 8 AM to 6 PM, Mon-Fri

Web Help Desk 800-811-0881 8 AM to 6 PM, Mon-Fri

Oxford Express® 888-201-4216 24 hours/7 days a week

Oxford On-Call® 800-201-4911 24 hours/7 days a week

Oxford Behavioral Health 800-201-6991 8 AM to 6 PM, Mon-Fri

Asian Broker Unit 212-801-1995 9 AM to 5 PM, Mon-Fri

Provider Services 800-666-1353 8 AM to 6 PM, Mon-Fri

Individual Products 800-216-0778 9 AM to 5 PM, Mon-Fri

Medco Health 800-905-0201 24 hours/7 days a week (Pharmacy Benefit Manager) (except Thanksgiving & Christmas)

Oxford Medicare Advantage 800-303-6720 8 AM to 5:30 PM, Mon - Fri

Important Phone Numbers

Oxford Express® IVR for Brokers and Benefits Administrators The Oxford Express Interactive Voice Response (IVR) system allows you to access the following by telephone:

• Member eligibility status information such as Member ID number, effective date of coverage, plan and network, dependent information when subscriber number is entered.

• Billing and payment information such as current balances, last payment amount, lastfive checks posted, and copies of past invoices.

• Group status and benefit information such as valid tier types, employee contribution percentage, group deductibles and coinsurance, and group pharmacy copayment.

• Broker status including phone and fax numbers on file and Broker of Record status(only brokers are given this option).

• Material requests such as ID cards, rosters, claim forms, and self-help literature.

• General Oxford addresses.

The Oxford Express IVR system is just one more avenue for our customers to obtain theinformation they need, when they need it. If you have any questions, please contactGroup Services or e-mail us at [email protected].

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3

Commissions: Oxford Health PlansAttn: Broker Commissions & Licensing Department48 Monroe TurnpikeTrumbull, CT 06611

Member Enrollment: Oxford Health PlansAttn: Enrollment DepartmentP.O. Box 7085Bridgeport, CT 06601-7085

Claims: Oxford Health PlansAttn: Claims DepartmentP.O. Box 7082Bridgeport, CT 06601-7082

Oxford MyPlanSM Health Reserve Account Claims DepartmentP.O. Box 1021Eatontown, NJ 07724

Mail Order Medco Health HomePharmacy Service: Delivery Pharmacy Service™

P.O. Box 747000Cincinnati, OH 45274-7000

Clinical Appeals: Oxford Health PlansAttn: Clinical AppealsP.O. Box 7078Bridgeport, CT 06601

New Group Submissions: Oxford Health PlansAttn: Group Enrollment14 Central Park DriveHooksett, NH 03106

Group Renewals/ Oxford Health Plans Group Changes Attn: Group Enrollment

P.O. Box 7085Bridgeport, CT 06601-7085

Important Addresses


4

Large Group Billing

New York: Oxford Health PlansP.O. Box 10275Newark, NJ 07193-0275

New Jersey: Oxford Health PlansP.O. Box 10273Newark, NJ 07193-0273

Connecticut: Oxford Health PlansP.O. Box 10274Newark, NJ 07193-0274

Small Group Billing

New York: With or without remittance advice, send to:Oxford Health PlansPO Box 1368Newark, NJ 07101-1368

New York: With or without remittance advice, send to:Oxford Health InsuranceP.O. Box 1697Newark, NJ 07101-1697

New Jersey: With or without remittance advice, send to:Oxford Health PlansPO Box 1349Newark, NJ 07101-1349

Connecticut: With or without remittance advice, send to:Oxford Health PlansPO Box 1360Newark, NJ 07101-1360

Pennsylvania: With or without remittance advice, send to:Oxford Health InsuranceP.O. Box 1697Newark, NJ 07101-1697

Delaware: With or without remittance advice, send to:Investors Guaranty LifeGeneral Post OfficeP.O. Box 27108New York, NY 10087-7108

Important Addresses

Address for OHP ProductsFreedom Plan®

Liberty PlanSM

Freedom Plan® SelectSM

Liberty Plan SelectSM

Healthy NY

Address for OHI ProductsFreedom Plan® MetroSM

Liberty Plan MetroSM

Exclusive Plan MetroSM

Freedom Plan® DirectSM

Liberty Plan DirectSM

Oxford USASM

Address for all OHI & OHP Products

Address for all OHI & OHP Products

Address for all OHI Products

Address for all OHI Products

Commissions

Com

missions

commissions

5

Commission BasicsCommissions are paid by the 15th of each month. A broker must be licensed and appointedas a agent of Oxford to solicit, negotiate, and effect coverage. No broker will be installed ona group or paid commissions until they are licensed as well as appointed with Oxford.

• Commission statements and checks are mailed to brokers by the 15th of the month following the month in which the group premium is received. Questions regarding brokerand commissions status should be directed to the following address/phone number:

Oxford Health PlansAttn: Broker Commissions & Licensing Department48 Monroe TurnpikeTrumbull, CT 06611Phone: 888-666-6844Hours: 8 AM to 4:30 PM, Monday to Friday

Broker of RecordHow to become licensed and appointed with Oxford:• Broker submits a fully completed and fully executed Oxford Broker Contract and W-9

Form to the Commissions Department along with copies of his or her current statehealth insurance license(s).

• The Commissions Department will set up the broker in our system, send a licenseappointment form to the respective state Department of Insurance office, and assign thebroker an Oxford Broker Code (Vendor ID No.).

• A welcome letter is mailed to the broker with the assigned Oxford Broker Code. Thiscode should be used on all correspondence to Oxford from the broker, particularly inthe Broker section of the Group Enrollment Application.

What is a Broker of Record?• The Broker of Record is the broker designated by the group as the current servicing

broker. The Broker of Record’s name and Oxford Broker Code must be specified clearlyon the initial Group Enrollment Application.

How to become a Broker of Record:• Broker of Record letters must be on company letterhead and signed by the President,

Officer, or other decision maker of the employer group and should include a fax number for confirmation purposes. Letters of authorization that are not on companyletterhead will not be accepted.

• Oxford Health Plans does not recognize “Letters of Authorization” from an inforcegroup allowing other brokers, besides the Broker of Record, to access information on anexisting Oxford client.

• The Broker of Record letter must be confirmed by the Commissions Department by thelast business day of the month in order for the new Broker of Record to be eligible forcommissions effective the first of the following month.

commissions

6

• The Broker of Record letter must be SENT DIRECTLY to the Commissions Department(please route the original letter through your General Agent if you are required to doso). Broker of Record letters may be mailed to:

Oxford Health Plans Attn: Commissions Department48 Monroe TurnpikeTrumbull, CT 06611

• We cannot guarantee your Broker of Record change unless it is mailed directly to theCommissions Department.

• Upon receipt of the Broker of Record letter, the Commissions Department will sendconfirmation of the effective date of assignment to both the new and the previous broker. If you have not received your confirmation within 48 hours of submission, contact the Commissions Department at 888-666-6844. Broker of Record letters must beconfirmed by the Commissions Department or they will not be honored.

• The previous broker has 10 days from the date of the confirmation notice to disputethe new assignment. Oxford sales management will settle such disputes.

• All cases sold by a direct Oxford representative are vested for one year. Any Broker of Record letter submitted after a group’s coverage begins will becomeeffective upon the renewal date.

Check Commissions Online Visit the broker site at www.oxfordhealth.com by logging on with your user name and password.

www

Web Site

Web Site:www.oxfordhealth.com

web site: www.oxfordhealth.com

7

Check: Billing, Eligibility, Benefits, Oxford’s Drug Formulary, CommissionsRequest: ID Cards, Small Group Rate Quotes, MaterialsChange: E-mail address, User Name, Password Search for: Doctors & Specialists, Hospitals & Health Facilities, Complementary

& Alternative Care Additional Features & Functionality: idea Management SystemSM, Oxford’s Drug List,

medcohealth.com, Oxford Benefit ManagementSM, oxfordhealth Center, Subimo Healthcare Advisor®

Broker, Employer, Member and Provider sites contain transaction and reference information. To visit these sites, visitors must authenticate by entering their selected username and password on the Oxford home page.

Brokers can:

Check: Billing, Eligibility, Benefits, Oxford’s Drug FormularyEnroll: An employee/spouse/dependent; Terminate a MemberRequest: Subscriber/Member lists, Materials, ID Cards Change: Member information, E-mail address, User Name, PasswordSearch for: Doctors & Specialists, Hospitals & Health Facilities, Complementary

& Alternative CareAdditional Features & Functionality: idea Management SystemSM, Oxford’s Drug List,medcohealth.com, Oxford Benefit Management, oxfordhealth Center, Subimo Healthcare Advisor®

Employers can:

Check: Benefits, Claims, Referrals, Oxford’s Drug FormularyNotify Us: Pregnancy/BirthRequest: Materials/ID CardsChange: Physician/OB-GYN, Address, E-mail address, User Name, PasswordSearch for: Doctors & Specialists, Hospitals & Health Facilities, Complementary

& Alternative Care, Participating PharmaciesAdditional Features & Functionality: Oxford’s Drug List, medcohealth.com,

oxfordhealth Center, Subimo Healthcare Advisor®

Members can:

Check: Eligibility, Benefits, Claims, Referrals & Precert Status, Oxford’s Drug FormularySubmit: Referrals, Precert Request, ClaimsRequest: MaterialsChange: Address, E-mail address, User Name, PasswordSearch for: Doctors & Specialists, Hospitals & Health Facilities, Complementary

& Alternative CareAdditional Features & Functionality: Oxford’s Drug List, MD online,

athenahealth.com, oxfordhealth Center

Providers can:


8

Sign Up TodayBrokers who do not have a user name and password can register online atOxford’s home page, www.oxfordhealth.com.

1. Go to www.oxfordhealth.com2. Click on “Sign up for the benefits of Oxford Online today!”3. Fill in the requested information4. Begin to manage your account

Brokers can also call the web site help desk at 1-800-811-0881 for assistance in obtaining auser name and password.

Get AcquaintedOnline Tours for All AudiencesTour our award-winning web site to learn more about our credentialed provider network and the self-service options you can access 24 hours a day, seven days a week.

Here’s your ticket to tour our award-winning web site where you can view the benefits of joining Oxford:1. Log on to www.oxfordhealth.com.2. Click on “Discover Oxford” located on the center of Oxford’s home page. 3. Learn about Oxford’s Preventive Resources, Access to Care and Practical Resources.

Then test drive Oxford by clicking on the tour you would like to take.

At any time during the tour, simply click on “Get a User Name & Password now!” andyou’ll be on your way to experiencing the conveniences and benefits of online access.Log on to www.oxfordhealth.com, and test drive Oxford today!

What You Can DoVisit the newly revamped Business CenterOxford has revamped the broker web site to give you another key tool when sellingOxford. Our enhanced Business Center, located in the center of the broker homepage,makes it easy to search product information via convenient pull down menus. Search forinformation by:

• State – Connecticut, New Jersey, New York, Pennsylvania, or Delaware• Group size/type – Small, Large, Individual, or State Mandated• Search criteria – Product Information, How to Sell, or Forms

The new Featured Product section located in the blue box in the Business Center changesperiodically to highlight new Oxford plans. Check the date in the upper right hand cornerof the box to see when the section was last updated.

Access Forms and Materials OnlineBrokers have a quick, easy, and convenient way to get forms and request materials fromtheir Your AccountSM page on www.oxfordhealth.com. Requested materials can be sent to theBroker’s mailing address, or be mailed directly to their clients.

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9

Stay informed. View Recent Communications online.Go to the For Your Convenience section on Your AccountSM page for the latest listing ofOxford Communications, Pharmacy Information, Service Area information and much more.

Check Commissions• Inquire about Commissions and Commission History going back three months.• Select desired month. Click on Current “Commission Calculation” or “Adjustments

this Period.” View commissions for all groups or a specific group.

View Summary of Benefits onlineBrokers and employer groups can access Member Summaries of Benefits quickly and easily online.

• Simply click on “Check Benefits” from your personalized home page, and enter avalid Oxford Member ID number or Social Security number.

Check Member EligibilitySimply enter the Member’s Oxford Member I.D. number or Social Security number andget instant status of the Member’s eligibility.

Check Billing• View Invoice Summaries for your groups simply by entering the Employer’s

Oxford ID number.• Select a billing group you would like to view. Note that non-group COBRA

billing groups are not included.• Once you have selected a billing group, you will be taken to the latest Invoice

Summary for that group. To inquire about payments received since the invoice was generated, click on “Payment Inquiry.”

Brokers Acting on Behalf of the Benefits Administrator Brokers or employer groups can make updates to Members’ accounts for those Membersassigned to the benefits administrator’s (BAs) billing groups. The following updates canbe made:

• Change name (first name, last name, middle initial, suffix)• Update gender if “unknown” was selected on enrollment form• Change DOB• Change SSN• Change subscriber address and e-mail information• Change subscriber home and business phone numbers • Make initial PCP and OB/GYN selection• Change Member contract specific package (CSP) and billing group• Change Member coverage information• Enroll and/or terminate dependents

Brokers acting on behalf of the benefits administrator will only have access to the BA Self-Administration function through the Employers’ site. See “Brokers Acting on Behalf ofthe Benefits Administrator” section, page 67 of this guide.


10

Oxford seeks to provide you with programs and services above and beyond those offered by ordinaryhealth plans. Our online service, idea ManagementSystemSM (Interactive Distribution & ElectronicAdministration), helps you get quick, accurate andcomplete information, making it even easier to findthe right Oxford plan for your clients.

Small Business Services Available for groups with 2-50 enrolling employees

idea for Brokers

Get an Instant Quote Enter group information, design a benefit plan, get rates,compare designs and rates, create and send a proposal

Create Rate Tables Create your own generic rate tables for reference and communication (NY & CT only)

Your Proposals Retrieve and review quotes that are in progress

Your Groups’ Renewals Review your groups that are in their annual renewal cycle,create optional plan designs and submit the request forchanges to Oxford

Enroll Online Coming in First Quarter 2004. Fill out the new group application online, receive real-time status updates andview/download finalized application and related documentation.

idea for Employer GroupsThe idea renewal tool is also available to employer groups. An idea icon will appear onthe employer group's home page 60 days prior to their renewal. The benefits administratorcan create new business quotes, review their renewal, examine plan options prepared bytheir broker and finalize the renewal option of their choice. It’s that easy.

Log on to idea today.

OOxford xford Health alth PlaPlans®

idea


11

Access to the oxfordhealth CenterThe oxfordhealth Center is another feature accessible from the “My Oxford” and “YourAccount” personalized home pages for Brokers, Benefits Administrators, and Members. It provides access to a wealth of information about the benefits, programs, and resourcesavailable to Oxford Members, and empowers them to live healthier lives. Logging on towww.oxfordhealth.com affords the user access to preventive exam reminders, exercise discounts, wellness programs, complementary and alternative medicine (CAM) information, and resources for new parents and Members with chronic conditions.Research health topics, current news articles and get information on everything fromchoosing a hospital to the latest reports on vitamins, supplements and natural products.

Online Administration is Fast and EfficientHere are some great uses of www.oxfordhealth.com for you and your clients.

• Online Enrollment – Employer Groups can save time and cut down on paperwork byenrolling employees, dependents and spouse online. Terminating a Member is alsoeasy – takes just a few clicks! Encourage your clients to use these timesaving tools.

• Oxford’s Drug List is available without need to authenticate – simply visit DiscoverOxford. Oxford’s Drug List is easy to understand, with a legend that clearly distinguishes between generic and preferred drugs.

Oxford Benefit Management, Inc.Log on to www.oxfordbenefitmanagement.com, asingle source solution for specialty benefits and flexible spending accounts. Go to page 17to learn more about Oxford BenefitManagement, Inc. products.

Oxford Benefit ManagementSM

®

Products

Products

service area map

13

Hunterdon

Montgomery

Cumberland

Bergen

Hudson

Delaware

Philadelphia

Middlesex

Morris

Passaic

Somerset

Sussex

Union

Warren

Bucks

Nassau

Kings

Queens

Putnam

Richmond

Rockland

SuffolkBronx

New York

Ocean

Mercer

Atlantic

Burlington

Camden

Gloucester

Salem

Litchfield

New Haven

Hartford

Fairfield

New London

TollandWindham

Middlesex

NY

PA

NJ

CT

Berks

Orange

Dutchess

Westchester

Chester

Cape May

DE

New Castle

Kent

Sussex

Ulster

Sullivan

Essex

Monmouth

oxford products

14

New York New Jersey

HMO/Liberty Network

HMO Select/Liberty Network

Oxford Exclusive PlanSM

Oxford Exclusive PlanSM Metro

Freedom Plan®

Liberty PlanSM

Freedom Plan® ClassicSM

Liberty Plan ClassicSM

Freedom Plan® MetroSM

Liberty Plan MetroSM

Freedom Plan® AccessSM

Liberty Plan AccessSM




Liberty Plan SelectSM

Oxford MyPlanSM

Oxford Consumer Options

SuiteSM ****

Oxford USASM **

Healthy NY

NY Personal HMO/Liberty

Network

NY Personal Plan/Liberty

Network

Oxford Medicare AdvantageSM


Essential


Signature


Balance


Plus

HMO/Freedom Network

HMO/Liberty Network

HMO Select/Freedom Network

HMO Select/Liberty Network

Freedom Plan®

Liberty PlanSM

Freedom Plan® ClassicSM

Liberty Plan ClassicSM


Liberty Plan AccessSM



Oxford MyPlanSM


SuiteSM ****

Oxford USASM **

NJ Individual Plans


Please log on to www.oxfordhealth.com using your user name and password for more details on Oxford’s products, or contact your sales representative.

x

x

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x x

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L S Ix

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L S I

L = Large GroupS = Small GroupI = Individual

In-Network Only

Point-of-Service

Open Access

Consumer-

Driven

Health Plans

Out-of-Area

Mandated

Medicare +

Choice***

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oxford products

15

Connecticut Pennsylvania Delaware

HMO/Freedom Network

HMO Select/Freedom Network

HMO LaurelSM

HMO Laurel SelectSM

Freedom Plan®

Freedom Plan® LaurelSM

Freedom Plan® Classic




Freedom Plan® Value OptionSM

Freedom Plan® Laurel SelectSM

Oxford MyPlanSM


SuiteSM ****

Oxford USASM **

Connecticut Blue Ribbon


Not applicable

Not applicable

Freedom Plan® Direct SM *

Oxford MyPlanSM

Oxford USASM **

Basic Indemnity

Standard Indemnity

Not applicable

Not applicable

Not applicable

Freedom Plan® Direct SM *

Oxford MyPlanSM

Oxford USASM **

Not applicable

Not applicable

x

x

x

x

x

x

x

x

x

x

x

x

x

x

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L S I

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L S I

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L S I

* MultiPlan® is an affiliate network for Freedom Plan Direct products in Pennsylvania and Delaware.** The First Health® Network is the affiliate network for all Oxford USA products. *** Oxford Medicare AdvantageSM plans are not available in all counties. **** Oxford Consumer Options Suite is an electronic tool that provides employers and employees

with flexibility in both pricing and plan design selection. By offering three plans: FreedomPlan Access, Freedom Plan Classic and Freedom Plan Direct, we offer a wider range ofoptions to meet the diverse needs of your clients.

Please Note: All productinformation is based on a1/1/04 effective date.

OB

M

Oxford Benefit Management, Inc.

oxford benefit management, inc.

17

Name Discount Insured Voluntary Employer

Sponsored

OBM Preventive Plan x x x

OBM Preventive Plan x x xEnhanced

OBM Preventive Plus Plan x x x

OBM Advantage Plan x x

OBM Advantage Plus Plan x x

OBM Advantage Plus x xPlan (MAC)

OBM Advantage Plus x xPlan (R&C – Option I)

OBM Advantage Plus x xPlan (R&C – Option II)

OBM Advantage Plus x xPlan (R&C – Option III)

Big Company Benefits for All Size CompaniesOxford Benefit ManagementSM, Inc. (OBM), a wholly owned subsidiary of Oxford HealthPlans, Inc., offers employers and employees a wide array of products including both discount and insured prepackaged plans that cover dental, vision, hearing, work/life services, pharmacy, complementary and alternative medicine and fitness. With OxfordFlexSM,our flexible spending account, companies can give their employees the benefits of pretax savings for eligible healthcare, dependent care, transit and parking expenses.

OBM Prepackaged Benefits

Oxford Benefit ManagementSM is the future of specialty benefits. It is an exclusive partnership of leading third-party vendors designed to offer employees an innovativeselection of quality healthcare products.

Availability: All plans available for both large and small groups in NY, NJ and CT All plans available for small groups in PA and DE

For more information, contact your Oxford sales representative or call 888-200-1150 or log on to www.oxfordbenefitmanagement.com.

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oxford benefit management, inc.

18

OxfordFlexSM

OxfordFlexSM plans are flexible spending accounts that allow Members to set money asideon a pretax basis to be used for reimbursement of certain expenses considered taxdeductible by the IRS. There are four types of OxfordFlex plans, including healthcare,dependent care, transit and parking. Businesses of almost any size can take advantage ofOxfordFlex since participation is open to groups with five or more enrolled employees,and is not limited to Oxford’s core service area.

OxfordFlex plans can be purchased in many combinations. There is a price advantage to purchasing certain plans together. Employers can purchase the OxfordFlex Healthcare andOxfordFlex Dependent Care plans together for the same price they would pay for just one of theplans. This also holds true for the OxfordFlex Transit and OxfordFlex Parking plans. There aresome restrictions. A client can only purchase an OxfordFlex Transit and/or OxfordFlex Parkingplan when purchasing either an OxfordFlex Healthcare or OxfordFlex Dependent Care plan.

For more information, contact your Oxford sales representative or call 888-200-1150 or log on to www.oxfordbenefitmanagement.com.

Please note: Groups may want to consult a tax advisor prior to enrolling in a flexiblespending account or transit and parking account.

Eligible Expenses OxfordFlex OxfordFlex OxfordFlex OxfordFlex

Healthcare Dependent Care Transit Parking

Office visit copayments xPrescription drug copayments xOver-the-counter medications xVision xDental xHearing xHealth Plan deductibleand coinsurance x

Baby sitter and/or companion wages xDaycare costs xNursery school costs xAdult care facility costs xHousekeepers wages (if applicable) x

Commuter highway expenses xMass transit expenses(token, farecard, and voucher) x

Parking garage costs xParking meter costs x

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oxford programs

19

How We Help You Stay HealthyOxford knows our Members want to stay healthy, so we promote healthy lifestyles. That’swhy we’ve come up with several ways to help our Members feel their best. Our preventiveprograms feature various services to help Members prevent getting sick.

Oxford On-Call® offers healthcare guidance from registered nurses 24 hours a day, sevendays a week.1

Complementary & Alternative Medicine Program offers access to a comprehensive network of approximately 2,400 credentialed alternative medicine providers in New York,New Jersey and Connecticut — from massage therapists to chiropractors.2

Oxford Healthy Mother, Healthy Baby® complements the care that expectant Members receivefrom their doctor by providing educational information on prenatal and newborn care.Expectant mothers who notify us of their pregnancy and/or delivery will receive these materials.

Reminder mailings are sent to Members who have not received a preventive exam withinthe recommended time period, based upon clinical guidelines, to remind Members tomake appointments for the preventive care they need.

Healthy Mind Healthy Body® magazine features articles on prevention, exercise, nutritionhealth and wellness. It also includes information about accessing Oxford resources andexternal support organizations, as well as updates on administrative policies and procedures.Healthy Mind Healthy Body is sent to our commercial Members twice a year.

Managing Chronic ConditionsOxford’s Active Partner® Education and Outreach programs are designed to assist Memberswith chronic conditions such as asthma or heart disease. These programs help Memberstake an active role in managing their condition. Additional information is available on www.oxfordhealth.com at the oxfordhealth Center.

Better Breathing® ProgramOxford’s asthma program is designed to help educate children and adults who haveasthma. Members participating in this program receive information about the triggers ofasthma and how to avoid them, as well as the proper way to administer medication. Inaddition, we send free peak flow meters to Members newly diagnosed with asthma to helpmonitor their condition

Living with DiabetesSM ProgramOxford’s diabetes program emphasizes patient education to improve self-management and tokeep physicians informed about the current guidelines of the American Diabetes Association.We send healthy cookbooks to Members newly diagnosed with diabetes to help them eat right.

Heart SmartSM ProgramThe Heart Smart program supports Members with cardiovascular disease (CVD) and congestive heart failure (CHF) by promoting patient education and lifestyle modification.CHF nurse case managers help Members (when needed) to better understand and manage their condition, which can lead to a better quality life.1 Oxford On-Call is available to Members who reside in CT, NY, and NJ.2 Provider type and rider availability vary by state, company size, and plan.

oxford programs

20

Healthy Bonus®

Our Healthy Bonus® Member discount program is so popular with our Members that wejust added ten new offerings, providing Members the opportunity to receive special values in addition to our regular discounts on vision care, weight loss, fitness, nutrition,and spa services.

• Brookstone — 15 percent discount on select innovative products.

• Puritan’s Pride Vitamins® — 10 percent savings off their already low prices on over 1,400 products.

• STOTT PILATESTM — 20 percent off suggested retail prices on STOTT PILATES videos and equipment.

• Safe Beginnings — 20 percent discount on its large selection of childproofing items,including safety gates, cabinet locks, outlet covers, and window guards.

• OMNIfitness — 10 percent off home fitness equipment and free delivery, valued up to $150.

• Magazine subscriptions — Health, 10 issues for $10, Cooking Light, 11 issues for only $16

• Yoga Journal — 7 issues for just $11.

• Spa Finder® — $15 discount off of a $100 gift certificate purchase. Additionally, OxfordMembers are eligible for a free trial issue of Spa Finder Magazine, as well as free shippingon their gift certificate purchase.

• Princeton Ski Shops — Show your Oxford Member ID card to receive $20 off any purchase of $100 or more.

• Tiger Schulmann’s Karate — a free introductory class and a one-month membership package for $149, including up to eight group classes, one private lesson, a TSK workoutuniform, and an instructional video or DVD.

Oxford’s Healthy Bonus program is just one more example of our ongoing commitment to helping Members keep their body, mind, and spirit healthy. For more information on the discounts available, log on to www.oxfordhealth.com and click on the oxfordhealth Center. Once in the oxfordhealth Center, go to theOxford features section and select Member Discounts.

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Pharmacy ProgramsOxford’s prescription drug plan is comprised of a comprehensive package of benefits thatincludes a complete drug formulary and pharmacy management programs. These programsare updated as new drug products are approved by the Food and Drug Administration(FDA) and when new pharmaceutical information becomes available. Together with MedcoHealth, our pharmacy benefit manager, Oxford has established programs to encouragedrug therapy that is appropriate and economical for our Members. These programs arelargely based on guidelines established by the Food and Drug Administration (FDA).

Medco Health Solutions, Inc. 800-905-0201 24 hours/7 days a week (Pharmacy Customer Service) (except for Thanksgivingwww.medcohealth.com and Christmas)

Frequently Asked Questions regarding Oxford’s Pharmacy Program:1. Where can Members go to find out more about prescription drugs?

Members can log on to www.oxfordhealth.com and select Oxford’s Drug List fromthe left navigation bar or click on the Medco Health link to learn more aboutmedication pricing and coverage. Members may also log on to Medco’s web site,www.medcohealth.com.

2. What’s the difference between a two-tier and three-tier plan?Oxford offers pharmacy coverage as a rider in two variations: a two-tier or a three-tierplan. If Members have a two-tier drug plan, they will have one copayment amount forbrand drugs, and a lower copayment amount for generic drugs.

Some examples of Oxford’s two-tier pharmacy copayment levels. Generic Drug Copayment Level Brand Drug Copayment Level$5.00 $10.00$5.00 $15.00$7.00 $20.00

For Members with a three-tier copayment plan, lower copayments are applied to genericand preferred brand drugs, which are designated as being on the “preferred drug list”.This list is provided to offer Members a choice from a wide selection of preferred drugsand to help keep the cost of prescription drug benefits affordable. The copayment forpreferred brand drugs is more than the copayment for a generic drug, but less than thecopayment for a non-preferred brand drug.

Some examples of Oxford’s three-tier pharmacy copayment levels. Generic Drug Preferred Brand Drug Non-preferred Brand DrugCopayment Level Copayment Level Copayment Level$5.00 $15.00 $35.00$7.00 $20.00 $50.00$10.00 $25.00 $50.00

(Please note: Copayment levels will vary depending on the pharmacy benefits selected bythe employer group.)

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3. Why does Oxford require precertification or prior approval on certain drugs? Based on plan design, selected high-risk or high-cost medications may require precertification by Oxford to be eligible for coverage. Precertification, also known as prior authorization, requires that the Member’s physician formally submit a requestto and receive approval from Medco Health in order to receive coverage for a prescription for certain medications. Precertification criteria have been establishedby our Pharmacy and Therapeutics Committee with input from plan physicians and in consideration of the current medical literature. The goal is to encourage drug therapy that is appropriate and economical for our Members. To obtain precertification,Members can call Medco Health directly at 800-753-2851, Monday through Fridayfrom 8:00 AM to 9:00 PM (eastern standard time).

4. Why does Oxford limit the quantity covered at one time for certain medications?For certain medications, and based on plan design, a limitation in the quantity covered at one time may be in place, often reflecting the maximum FDA-recommended dosage for a medication or use of the most efficient dosage strengthfor the fully prescribed daily dose. In these situations, an electronic message specifying quantity limit will be sent to the pharmacist instructing that the prescriptionbe reviewed with the prescribing physician. In all cases, the goal is to encourage medically appropriate and economic use of medications for our Members.

5. What’s a formulary and what does it mean to a Member’s coverage? The formulary is developed by the Oxford Health Plans, Inc. Pharmacy andTherapeutics Committee (P&T Committee). This committee, composed of physiciansfrom various medical specialties and pharmacists, reviews the medications in all therapeutic categories based on Members’ medical needs and out-of-pocket costs.Oxford’s P&T Committee will regularly review new and existing medications so that theformulary remains responsive to the needs of our Members and providers. The contents of the formulary represent outpatient prescription drugs that may be coveredfor Members under their Oxford Health Plans’ Drug Benefit. It is important to notethat the listing of a drug does not guarantee coverage, as certain products are excludeddue to benefit plan design limitations specific to Members’ individual or group benefits.The formulary only applies to outpatient prescription medications dispensed by participating pharmacies. The formulary does not apply to inpatient medications or tomedications obtained from and/or administered by a physician.

6. Can a Member order prescriptions by mail? Oxford offers Members the ability to obtain up to a 90-day supply of certain medications within several therapeutic categories of medications through the MedcoHealth Home Delivery Pharmacy Service™. Maintenance medications are prescription medications associated with the treatment of certain chronic conditions,such as diabetes, epilepsy, and hypertension. In order to get prescriptions filledthrough Oxford’s mail-order pharmacy, the employer must purchase pharmacy coverage that includes mail-order coverage. Prescriptions can be ordered online, bytelephone, or by mail. If a Member has mail-order pharmacy coverage, they can visit www.medcohealth.com for specific instructions on filling prescriptions by mail. It isimportant to note that only certain maintenance medications can be filled throughthe mail order benefit.

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Oxford's Low Cost Pharmacy Option: New York• $15/ $30/ $60 (Generic/ Preferred Brand/ Brand)

• Includes the following features:

• Mandatory $100 deductible (waived for generics)• Mandatory generic substitution for chemically equivalent brand drugs• Mandatory mail order for maintenance medications (subject to 2X retail

copayment for generic/preferred brand and 3X for Brand name)• $3000 Annual maximum

What does “mandatory generic coverage” mean? What if I need a drug that doesn’t have a generic available?Your plan includes a mandatory generic program. This means that if your physician prescribes a drug for which there is a generic equivalent available, you will only be covered for the generic drug. If you purchase a brand name drug when a generic drug isavailable, you will pay the full cost of the brand name drug. If your physician prescribes abrand name drug for which there is no generic equivalent available, you will be covered forthe brand name drug. However, if you are a Member of a Connecticut plan and yourphysician indicates, “dispense as written” (DAW) on the prescription and/or it is medically necessary for you to obtain the brand name drug (for which a generic equivalent is available), you will be covered for the brand name drug, subject to theapplicable copayment.

What is step therapy? Shouldn’t my doctor be making all of the final decisions about my medications?In an attempt to help keep the costs of prescription drugs affordable, your employer haspurchased a plan with several cost-containing components, one of which is step therapy.In step therapy, your plan requires the use of generic drugs before your plan will covercertain brand name prescription drugs. These generic drugs are approved by the Foodand Drug Administration (FDA) and used to treat the same conditions as the brand nameprescription drug. All decisions about your prescription care are up to you and your physician. If it is medically necessary for you to obtain a step therapy drug as an initialmedication (such as in cases of therapeutic failure), your physician can request initial coverage as an exception to the step therapy program.

How is my home delivery (mail order) coverage going to work? If you are taking certain long-term maintenance medications, you may use the participatingretail pharmacy for your initial prescription and one refill. If you remain on that medication, you will need to use the Medco Health Home Delivery Pharmacy Service™ in order to continue to receive coverage. If you continue to obtain certain long-term medications through your retail pharmacy, you will be responsible for the entire cost ofthe medication. Note: This applies to Members of New York plans only.

Group

Enrollment

Group Enrollment

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25

Large Group Eligibility Requirements By State:

New York Large Group

All group enrollment forms are available on the broker site at www.oxfordhealth.com.

New York Large

51 or more full-time employees

51 or more eligible employees

Full-time employees must work the minimum hours set by the group and no less than 30 per week

Residence out of country (Contact an Oxford sales representative regarding eligibilityof union, 1099, COBRA, and part-time employees)

Must be at least 50%

12 months

Manual: Based on plan design, effective date, location, industry and demographics (generally 51-100 lives)Experience: Based on the group’s experience and in mostcases blended with manual rates (generally 100+ lives)Community (Liberty HMO): Based on benefits chosen, effective date, and location of business

Full Conversion: 75% participation of in-area eligibleemployeesOffering: Minimums may apply

Must not be a P.O. BoxMust have a home or branch office in Oxford’s NY service area

Go to page 13 for Oxford’s complete service area map

Eligibility Requirements

# of employees

# of eligible employees

Full-time hours

Ineligible employees

Employer contributions

Length of contract

Rates

Plan participation

Primary address

Service area

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New Jersey Large Group


New Jersey Large






12 months

Manual: Based on plan design, effective date, location,industry and demographics (generally 51-100 lives)Experience: Based on the group’s experience and in mostcases blended with manual rates (generally 100+ lives)

Full Conversion: 75% participation of in-area eligible employeesOffering: Minimums may apply

Must not be a P.O. BoxMust have a home or branch office in Oxford’s NJ service area



# of employees


Full-time hours



Length of contract

Rates

Plan participation

Primary address

Service area

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Connecticut Large Group


Connecticut Large






12 months

Manual: Based on plan design, effective date, location,industry and demographics (generally 51-100 lives)Experience: Based on the group’s experience and in mostcases blended with manual rates (generally 100+ lives)

Full Conversion: 75% participation of in-area eligibleemployees.Offering: Minimums may apply

Must not be a P.O. BoxMust have a home or branch office in Oxford’s CT service area



# of employees


Full-time hours



Length of contract

Rates

Plan participation

Primary address

Service area

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Small Group Eligibility Requirements By State: New York Small Group


1 COBRA employees and retirees are not included in the employee count but can still be enrolled.


# of employees


Full-time hours



Length of contract

Rates

Plan participation

Primary address

Service area

Pre-existing conditions

Effective Dates

New York Small

50 or fewer full-time employees

Minimum of two eligible employees, at least one enrolled inOxford Health Plans

Full-time employees must work the minimum number of hoursset forth by the group, but not less than 20 hours per week

Employees not eligible and not in the employee countinclude: union, 1099, COBRA1, part-time, and residence out of country

No state mandated employer contributions

If the initial effective date is on the first of the month, thegroup will renew on the first of the same month each year (12 months); If the initial effective date is on the 15th of themonth, the group will renew on the first of the followingmonth (12.5 months)

Community rated based on: benefits chosen, effective date,and location of business

No minimum percentage of participation required.• At least one active eligible employee must be enrolled

• No more than 30% of enrollees may reside outside the service area

Must not be a P.O. BoxPrimary business address must be within Oxford’s New Yorkservice area


See New York Small Group Member Eligibility section onpage 40 for pre-existing rules

May choose the 1st or the 15th of the month. Packets mustbe received on or before the chosen effective date

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Healthy NY Small Group Eligibility Requirements



State mandated HMO product offered to New York small groups who meet the following requirements:

• 50 or fewer eligible employees

• One-third of the employees must earn wages of $32,000 or less

• Employer must certify that they have not contributed towards the premiums forboth medical and hospital coverage for their employees during the last 12-monthperiod preceding the requested effective date on the Healthy NY Application.

• 50% of the eligible employees must participate in the program and at least oneparticipant must earn annual wages of $32,000 or less

• Employer is responsible for contributing to at least 50% toward the premium forfull-time employees.

• Business must be located within New York State

• Businesses enrolled in the New York State Health Insurance Partnership Program(NYSHIPP) during the past 90 days prior to the application effective date areautomatically eligible

Note: The small group is allowed to have provided "limited" health insurance benefits (either medical or hospital but not both) or “arranged for” group coveragebut did not contribute more than $50 per employee per month towards premium.

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New Jersey Small Group




# of employees


Full-time hours



Length of contract

Rates

Plan participation

Primary address

Service Area


Effective Dates

New Jersey Small

2-50; Employee groups of one are not covered in NJ

Minimum of two eligible employees, at least one enrolled inOxford Health Plans

Full-time employees must work a minimum of 25 hours per week

Employees not eligible and not in the employee countinclude: union, COBRA2, part-time, and residence out of country

State mandates 10% minimum of employer contributiontowards employee premiums

If the initial effective date is the first of the month, thegroup will renew on the first of the same month each year.Any effective date after the first of the month, the group willrenew on the first of the following month.

Manually rated based on: benefits chosen, location of business, number of employees, age and sex of employees,contract (tier) type

Minimum of 75% of the group must participate in one ofthe group’s health plans or must have waived coverage dueto other coverage

Primary address can be P.O. Box, however, the NJ SmallEmployer Certification Form must contain group’s physical address within New JerseyPrimary business address must be in the State of New Jersey


See New Jersey Small Group Member Eligibility section onpage 43 for pre-existing rules

May choose any day of the month. Packets must be receivedon or before the chosen effective date.

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Connecticut Small Group


3 Company must be in effect for three consecutive months from their effective date of business as registered with the State of CT whenapplying for their CT State Tax ID.

4 COBRA employees are not included in the employee count but can still be enrolled.


# of employees


Full-time hours



Length of contract

Rates

Plan participation

Connecticut Small

50 or less full-time employees 3

Minimum of one eligible enrolled; State mandate providesfor coverage for sole proprietorship

Full-time employees must work a minimum of 30 hours per week

Employees not eligible and not in the employee countinclude: union, 1099, COBRA4, part-time, and residence out of country

Oxford requires 50% minimum of employer contributiontowards employee premiums only

If the initial effective date is on the first of the month, thegroup will renew on the first of the same month each year (12 months); If the initial effective date is on the 15th of the month, the group will renew on the first of the following month (12.5 months)

Based on benefits chosen, effective date of coverage,location of business, industry type, number of eligibles,enrolling age of the employee at the time of the effectivedate and contract type

Your company must have at least three subscribers to offermore than one plan design.The company must be in business for three consecutivemonths prior to the requested effective date. • No more than 10% of enrollees may be retirees.• No more than 30% of enrollees may reside outside the

service area. • Groups with one life require 100% enrollment. • Groups with 2-9 lives require 75% enrollment from active

eligible employees (Note: 2-life group that is husband/wiferequires 50% enrollment).

• Groups with 10-50 lives require 65% enrollment fromactive eligible employees.

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CT Blue Ribbon Small Group Eligibility Requirements



• State mandated product offered to CT small groups who meet the following definitions:

• Small employer with 50 or fewer employees, including groups of one person

• Self-employed person who must be actively in business in Connecticut for three consecutive months and work a minimum of thirty hours a week

• A one person group may be eligible for other CT products, but most often isplaced on a Blue Ribbon product


Primary address

Service area


Effective Dates

Connecticut (continued)

Must not be a P.O. BoxPrimary business address must be in the State of Connecticut


No pre-existing conditions apply

May choose the 1st or the 15th of the month. Packets mustbe received on or before the chosen effective date.

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Pennsylvania Small Group



# of employees

# of eligible employeesFull-time hours



Length of contract

Rates

Plan participation

Primary address

Service area


Effective Dates

Pennsylvania Small

2-99 employeesMinimum of two eligible employees, both enrolledFull-time employees must work a minimum of hours set forthby the group, but not less than 20 hours per weekEmployees not eligible and not in the employee count include:union, 1099, COBRA5, part-time, residence out of countryOxford requires 50% minimum of employer contributiontowards employee premiums onlyIf the initial effective date is on the first of the month, the groupwill renew on the first of the same month each year (12 months);If the initial effective date is on the 15th of the month, the groupwill renew on the first of the following month (12.5 months)Manually rated based on selection of benefits, effective dateof coverage, location of business, industry type, number ofeligibles, enrolling age of the employee at the time of theeffective date, and medical underwritingThe company must be in business for three consecutivemonths prior to the requested effective date. • No more than 30% of the enrolling population may reside

outside the service area. • No more than 10% of enrollees may be COBRA/State

Continuation.• Full replacement groups with 2-99 lives must have 75% of

the active eligible employees enrolled, excluding thosewaived with spousal coverage.

• Offering groups (Oxford is not the sole carrier) with 2-99 eligible employees will be medically underwritten and finalrates will be based on the actual membership enrolled.

Must not be a P.O. BoxPrimary business address must be in Oxford’s PA service area


See Pennsylvania Small Group Member Eligibility section on page 50 for pre-existing rules



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Delaware Small Group



# of employees# of eligible employeesFull-time hours



Length of contract

Rates

Plan participation

Primary address

Service Area


Effective Dates

Delaware

50 or fewerMinimum of oneFull-time employees must work a minimum of hours set forthby the group, but not less than 30 hours per weekEmployees not eligible and not in the employee countinclude: union, 1099, COBRA6, part-time, residence out of countryState mandates employer must contribute minimum of 50% towards premiums of each employee only If the initial effective date is on the first of the month, thegroup will renew on the first of the same month each year (12 months); If the initial effective date is on the 15th of themonth, the group will renew on the first of the followingmonth (12.5 months) Based on selection of benefits, effective date of coverage,location of business, industry type, plan design, number ofeligible employees, enrolling age of the employee at the time of the effective date, and medical underwriting The company must be in business for three consecutivemonths prior to the requested effective date. • No more than 30% of the enrolling population may reside

outside the service area. • No more than 10% of enrollees may be COBRA/State

Continuation. • Full Replacement groups with 1- 50 lives must have 75% of

the active eligible employees enrolled, excluding thosewaived with spousal coverage.

• Offering groups with one to 50 eligible employees will bemedically underwritten and final rates will be based on theactual membership enrolled.

Must not be a P.O. BoxPrimary business address must be in Oxford’s DE service area


See Delaware Small Group Member Eligibility section onpage 53 for pre-existing rules



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Billing &

Paym

ents

Billing & Payments

billing and payments

35

Billing BasicsOxford is a prepaid health plan – groups receive a bill each month for the followingmonth’s coverage.

• Each month’s payment should include:

• A remittance advice for each invoice, with the payment amount for that billinggroup noted in the appropriate space; and

• A check for the total amount due for each invoice. You may submit a single checkfor multiple invoices. If you do so, please clearly state the amount you would likeapplied to each invoice.

• Please be advised that Oxford may terminate coverage for any group that does not remitfull payment by the end of the grace period on which payment is due. Oxford will terminate groups at the end of the month (which corresponds to the grace period).

• Oxford will not pay claims incurred after the termination date, and we will not reinstategroups that have been terminated due to a delinquent payment history.

Example of the Monthly Billing Cycle for September:• Premium is due on September 1st. The grace period begins on this date.

• Groups that did not remit full payment during grace periods ending in the previousmonth (August) are terminated effective as of the end of the grace period.

• On approximately the 10th of the month, bills are generated for the following month (October).

• Between the 15th and 18th of the month, automatic reminder letters are sent to groupsthat have not paid for September and have a balance due of $1 or more.

Member Effective/Date of Termination End of Month Rule

• If the Member becomes Effective between the 1st and the 15th of the month, the groupis charged for the entire month

• If the Member becomes Effective between the 16th and the last day of the month, thegroup will not be charged for that month.

• If the Member requests a termination date between the 1st and the 30th of the month,the Member receives a termination date for the end of the month and the group ischarged for the entire month.

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36

Remittance Advice:• The group should indicate, in the appropriate box on the front of the form,

the amount they are sending in.

• The group should indicate, on the back of the form, how they would like their paymentapplied. If this is not indicated, payment will be applied to the oldest open invoice.

• How to submit payment:• Include the remittance advice and payment only• Indicate the group number and invoice number on the check• Make sure payment is sent in on or before the due date

Check Billing on the Web and Oxford Express®

• With a user name and password, Brokers can check a group’s billing status at www.oxfordhealth.com.

• With IVR, brokers can check:• Current balance• Last payment amount• Date the last payment was credited• Past invoice (fax back available)• General billing addresses (fax back available)

Frequently Asked Billing Questions:Q: Who should a broker call to assist their group with a discrepancy with their bill?A: They should call Group Services if there is a discrepancy.

Q: If there is a problem with a bill, do groups have to pay in full?A: Yes. All invoices should be paid as billed. Oxford will adjust for changes and will

credit/debit their next bill.

Q: Can groups submit additions, terminations, and changes with the monthly payment?A: No. Changes that are submitted to the payment location will not be processed. Please

submit all addition/termination/enrollment requests to the enrollment address listedin the Important Address section (page 3) of this guide.

Q: When will additions and terminations appear on a group’s Oxford bill?A: Changes that are entered prior to the 10th of the month will be reflected on the next

bill. If processed after the 10th, they will appear on the subsequent bill.

Q: If an employee resigns, is terminated, or becomes ineligible for health benefits per the company’s policies or the provisions of the Oxford coverage, what should be submitted to Oxford?

A: An Addition/Termination/Change Form must be signed within 31 days of the termination date by the benefits administrator. The form can be mailed to the enrollment address listed in the Important Address section (page 3) of this guide.

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Mem

berEnrollm

ent

Member Enrollment

member enrollment and eligibility

37

Large Group Member Eligibility Requirements for NewYork, New Jersey, and Connecticut:

Eligibility

Methods of enrollment

Sign/receipt time framePre-existing conditionsRetirees

Eligibility

When a spouse can be enrolled

Methods ofenrollment

Sign/receipt time frame

Eligibility

When a dependent can be enrolled

Full-time employee meeting the eligibility requirements of the group• Online: www.oxfordhealth.com• Member Enrollment and Physician Selection Form (MEF)• Tape: Groups with 100+ employees should contact an

Account Manager for more informationSigned by the employer and employee. Received at Oxfordwithin 31 days of the effective date Does not applyCoverage for retirees must be specified in the contract

• Legal spouse • Domestic partner – only if group purchased Domestic

Partner Rider• Open enrollment• Date of marriage• Date of U.S. immigration on passport• Date of HIPAA event (See HIPAA Section)• Domestic partner – date they meet the required

relationship time frame, as specified by the group• At the same time as the subscriber• Online: www.oxfordhealth.com• EDI – Groups 100+ should contact an Account Manager• Addition/Termination/Change Form (ATC) • Family Health Statement (FHS) with HIPAA Certificate (only

if enrolled for loss of coverage)• Domestic Partner Affidavit (only if enrolled as a

domestic partner)Signed by the employer and employee. Received at Oxfordwithin 31 days of the requested effective date

• Unmarried child under age 19 (unless otherwise specifiedin the Summary of Benefits)

• Unmarried child between 19 and 23 years of age (unlessotherwise specified in the Summary of Benefits), providedthe child is a full-time student (see Student Verification)

• Regardless of age, any child who is disabled with proof of disability

Dependent may be added to an existing policy effective for:• Open enrollment• Date of birth• Date of adoption or permanent placement in the home• Date of HIPAA event

Enrollment: Employee/Subscriber

Spouse

Dependent

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Student verification

Newborn

Adoption


Sign/receipttime frame

Types of changes

Methods of requesting change

Required for all dependents over age 19, but under the maximum age limit of the group.

Acceptable Proof of Verification• Student Verification Parent Affidavit Form that is to be

completed by the parent

Student verification is the subscriber’s responsibility andmust be submitted within 60 days of Oxford’s request; otherwise, the dependent will be automatically terminated

• NJ/CT: Coverage is automatically provided for the first 31days from date of birth; for coverage to continue beyondthe first 31 days, an ATC form to enroll the newborn mustbe received within 31 days of the birth; no premium isrequired for the first 31 days

• NY: Coverage for a newborn is provided ONLY if the childis enrolled within 31 days of the birth

• NJ/CT: All adopted children under the age of 18 are eligible for coverage from the date of acceptance or permanent placement in the home

• NY: Same provision for newborns applies to newly bornadopted children

• Online: www.oxfordhealth.com• Addition/Termination/Change Form (ATC) with HIPAACertificate (only if enrolled for loss of coverage)

• Adoption: The subscriber must also submit a copy oflegal adoption papers

• Tape: Groups with 100+ employees should contact anAccount Manager for more information

Signed by the employer and employee. Received at Oxfordwithin 31 days of the requested effective date

Any change that needs to be made to the Member’s per-sonal information (i.e. address, name, date of birth, etc.)

• Addition/Termination/Change Form (ATC)• Online: www.oxfordhealth.com

Dependent (cont.)

Changes to Existing Member Information

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Health Insurance Portability and Accountability Act (HIPAA)

Special enrollmentperiod



Eligibility

Methods ofterminationSign/receipt time frameDates of termination

Spouse/dependent dates of termination

Members may be added to the plan off-cycle for the effective date of any of the following:1. Loss of coverage under another health plan for any of thefollowing reasons:

• Divorce/separation• Death• Termination/reduction in hours• Termination of group coverage/change in contribution• COBRA or continuation has been exhausted

2. Change in family status:• Marriage• Birth of child/adoption or placement of child in home

• Online: www.oxfordhealth.com• If subscriber is electing coverage:

• Member Enrollment Form (MEF)• HIPAA Certificate (only if enrolled for loss of coverage)

• If adding spouse and/or dependent to existing policy:• Addition/Termination/Change Form (ATC) • HIPAA Certificate (only if enrolled for loss of coverage)• Domestic Partner Affidavit – if enrolling a domestic partner• Adoption paperwork


If employee resigns, is terminated, or becomes ineligible forhealth benefits per the group’s policies or the provisions ofthe Oxford coverage

• Online: www.oxfordhealth.com• Addition/Termination/Change Form (ATC)

Signed by the employer. Received at Oxford within 31 days ofthe requested date of termination

Groups have one of two lags:1. End of month – coverage will be terminated effective the lastday of the month in which the Member terminated employment2. Date – coverage will be terminated for the same date

employment was terminated

• Divorce/cessation of domestic partner relationship• Reaching the age limit set by group• Loss of full-time student status (this includes failing to

submit completed Student Verification materials)• Loss of dependent status due to marriage

Termination of Coverage

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40

Small Group Member Eligibility Requirements by State:

New York Small Group Member Eligibility

Eligibility




Retirees

Eligibility





Any full-time employee working 20+ hours per week canenroll as an Oxford Member: Eligibility effective dates:• A new employee can enroll on the date the employee meets

eligibility lag (your company’s eligibility waiting period)• All employees can enroll during your Open Enrollment

period (lag still must be met to enroll for Open Enrollment)• An employee with a HIPAA Certificate can enroll on the

date of the HIPAA event (see HIPAA Section)

• Online: www.oxfordhealth.com• Member Enrollment and Physician Selection Form (MEF) with

Health Coverage History Form (HCHF)

Signed by the employer and employee. Received at Oxfordwithin 31 days of the effective date

Applicable if Member had less than 12 months of continuouscoverage or a gap in coverage greater than 63 days

Coverage for retirees must be specified in the contract

Legal spouse only

• Same time as subscriber• Open enrollment • Date of marriage• Date of U.S. immigration on passport• Date of HIPAA event

• Online: www.oxfordhealth.com• Addition/Termination/Change Form (ATC) with

Health Coverage History Form (HCHF) andHIPAA Certificate (only if enrolled for loss of coverage)




Spouse

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Eligibility



Newborn

Adoption




Types of changes




• Regardless of age, any child who is disabled and can provide proof of disability

• Same time as subscriber• Open enrollment• Date of birth• Date of HIPAA eventRequired for all dependents over age 19, but under themaximum age limit of the group Student Verification Parent Affidavit Form to be completed bythe parent Student verification is the subscriber’s responsibility andmust be submitted within 60 days of Oxford’s request; otherwise, the dependent will be automatically terminated Coverage for a newborn is provided ONLY if the child isenrolled within 31 days of the birth and any applicable premiumis submitted to the group within 31 days following the birth • Subscribers with individual coverage: 31 days from the date

of birth to change the coverage to family and enroll the child• Subscribers with family coverage: An enrollment form is not

required. However, Oxford must be notified of the birthand the pertinent details to accurately enroll the newborn(name, sex, date of birth, PCP and Social Security number)

Same provision applies to newly born adopted children• Online: www.oxfordhealth.com• Addition/Termination/Change Form (ATC) with

Health Coverage History Form (HCHF) (not required for newborn) andHIPAA Certificate (only if enrolled for loss of coverage)

Adoption: The subscriber must also submit a copy of legaladoption papersSigned by employee and employer. Received at Oxfordwithin 31 days of the effective date


Any change that needs to be made to the Member’s personalinformation (i.e. address, name, date of birth, etc.)

• Addition/Termination/Change Form (ATC) (received within31 days of the change)

• Online: www.oxfordhealth.com


Dependent

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Special enrollment periods



Eligibility

Methods of terminationSign/receipt time frame

Dates of termination


Members may be added to the plan off-cycle for the effectivedate of any of the following:1. Loss of coverage – under another health plan for any ofthe following reasons:




• Member Enrollment and Physician Selection Form (MEF)• Health Coverage History Form (HCHF), if not included

on MEF • HIPAA Certificate (only if enrolled for loss of coverage)

• If adding spouse and/or dependent to existing policy:• Addition/Termination/Change Form (ATC) • Health Coverage History Form (HCHF) (not required for

newborn enrollment)• HIPAA Certificate (only if enrolled for loss of coverage)

Signed by employer and employee. Received at Oxfordwithin 31 days of the requested effective date

If employee resigns, is terminated, or becomes ineligible forhealth benefits per the group’s policies or the provisions ofthe Oxford coverage• Online: www.oxfordhealth.com• Addition/Termination/Change Form (ATC)Signed by employer. Received at Oxford within 31 days ofthe requested date of terminationGroups have one of two lags:1. End of month – coverage will be terminated effective the

last day of the month in which the Member terminatedemployment

2. Date – coverage will be terminated for the same date employment was terminated

• Divorce• Reaching the age limit set by group• Loss of full-time student status (this includes failing to submit completed Student Verification materials)

• Loss of dependent status due to marriage

HIPAA


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New Jersey Small Group Member Eligibility

Eligibility




Late enrollee

1099 employees

Retirees

Any full-time employee working 25+ hours per week canenroll as an Oxford Member. Full-time employee working 25+ hours per week. Members can also enroll for a futureeffective date as long as OXHP receives that form prior tothe requested effective date.

• Online: www.oxfordhealth.com• New Jersey Small Group Employer Benefits Enrollment Form

Signed by employee onlyReceived at Oxford within 31 days of the effective date

• 2 – 5 life group: Pre-existing conditions will apply ifMember has less than 180 days of coverage or a gap in coverage greater than 90 days

• 6+ life group: Pre-existing conditions do not apply (Pre-existing conditions will apply if a Member has less than 180 days of coverage or a gap in coverage greater than 90 days)• Late enrollee

If an eligible employee, spouse, or dependent does notenroll within 31 days of their effective date, they may enrollany time; however, they may only be effective for one of thefollowing dates based on receipt of the request:• If request to enroll is received prior to the requested

effective date, Member will be enrolled for the requestedeffective date

• If request to enroll is received after the requested effectivedate, Member will be enrolled for the date the request wasreceived at Oxford

Must meet the following criteria to be eligible:• Performs a service for the employer for monetary or other

legal consideration• Works full-time for the employer (not on a temporary

basis), 25 hours or more per week• Serves a substantial business need of the employer and has

established an independent contractor relationship• Has completed and submitted the Employer’s Independent

Contractor Statement (as a 1099, they should have accessto this form required by the State of New Jersey)



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Eligibility


How to enroll aMember’s spouse

Sign/receipt time framePre-existing conditions

Eligibility



Newborn

Adoption

• Legal spouse only• Same time as subscriber• Open enrollment• Date of marriage• Date of HIPAA event• Late enrollee

• Online: www.oxfordhealth.com (only if adding to an existing policy)

• Addition/Termination/Change Form (ATC) with HIPAACertificate (only if enrolled for loss of coverage)

Signed by employer and employee. Received at Oxfordwithin 31 days of the requested effective date• 2 – 5 life group – pre-existing conditions will apply if

Member has less than 180 days of coverage or a gap in coverage greater than 90 days

• Late enrollee• 6+ life group – pre-existing conditions do not apply




• Same time as subscriber• Open enrollment• Date of birth• Date of HIPAA event• Late enrolleeRequired for all dependents over age 19, but under the maximum age limit of the groupStudent Verification Parent Affidavit Form to be completed by the parentStudent verification is the subscriber’s responsibility and mustbe submitted within 60 days of Oxford’s request; otherwise, the dependent will be automatically terminated Coverage is automatically provided for the first 31 days fromdate of birth; for coverage to continue beyond the first 31days, an ATC form to enroll the newborn must be receivedwithin 31 days of the birth Adoption: All adopted children under the age of 18 are eligiblefor coverage from the date of acceptance or permanent placement in the home: dependents who are being enrolledpursuant to a court order must enroll within 60 days of the dateof the court order; no evidence of good health is required

Spouse

Dependent

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Types of changes





• Online: www.oxfordhealth.com (only if adding to an existing policy):


• Adoption: The subscriber must also submit a copy oflegal adoption papers

Signed by the employer and employeeReceived at Oxford within 31 days of the requested date

• 2 – 5 life group: Pre-existing conditions will apply ifMember has less than 180 days of coverage or a gap in coverage greater than 90 days

• Late enrollee• 6+ life group: Pre-existing conditions do not apply


• Addition/Termination/Change Form (ATC)(received within 31 days of the change)


Members may be added to the plan off-cycle for the effectivedate of any of the following:

1. Loss of coverage – under another health plan for any ofthe following reasons:



• If subscriber is electing coverage:• New Jersey Small Group Employer Benefit Enrollment Form• HIPAA Certificate (only if enrolled for loss of coverage)

• If adding spouse and/or dependent to existing policy:• Addition/Termination/Change Form (ATC) • HIPAA Certificate (only if enrolled for loss of coverage)

Signed by the employer and employee. Received at Oxfordwithin 31 days of the requested date.

Dependent (cont.)



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Eligibility

Methods of termination





• Online: www.oxfordhealth.com• Addition/Termination/Change Form (ATC)

Signed by the employer. Received at Oxford within 31 daysof the requested date of termination.

Please refer to page 2 of your Group Enrollment Agreementto determine your group’s termination policy.

Groups have one of two lags:1. End of month – coverage will be terminated effective

the last day of the month in which the Member terminated employment

2. Date – coverage will be terminated for the same dateemployment was terminated

• Divorce• Reaching the age limit set by group• Loss of full-time student status (this includes failing to



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Connecticut Small Group Member Eligibility

Dependent


Spouse

Eligibility




Retirees

Eligibility





Eligibility


Any full-time employee working 30+ hours per week, unless noted otherwise in group contract, can enroll as an Oxford Member

• Online: www.oxfordhealth.com• Member Enrollment and Physician Selection Form (MEF) with

CT Family Health Statement (FHS) See sample enrollmentform in this guide and instructions


Does not apply


Legal spouse only

• Same time as subscriber• Open enrollment• Date of marriage• Date of U.S. immigration on passport• Date of HIPAA event

• Online: www.oxfordhealth.com• Addition/Termination/Change Form (ATC) with:

• Family Health Statement (FHS) and • HIPAA Certificate (only if enrolled for loss of coverage)


Does not apply



• Irrespective of age, any child who is disabled and can provide proof of disability

• Same time as subscriber• Open enrollment• Date of birth• Date of HIPAA event

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Newborn

Adoption




Types of changes


Required for all dependents over age 19, but under the maximum age limit of the group Acceptable Proof of Verification: Student Verification ParentAffidavit Form to be completed by the parent Student verification is the subscriber’s responsibility andmust be submitted within 60 days of Oxford’s request; otherwise, the dependent will be automatically terminated

Coverage is automatically provided for the first 31 days fromdate of birth; for coverage to continue beyond the first 31 days,an ATC request to enroll the newborn must be received within31 days of the birth

All adopted children under the age of 18 are eligible for cover-age from the date of acceptance or permanent placement in thehome; dependents who are being enrolled pursuant to a courtorder must enroll within 60 days of the date of the court order;no evidence of good health is required

• Online: www.oxfordhealth.com• Addition/Termination/Change Form (ATC) with CT Family

Health Statement (FHS) (not required for newborn enrollment) and HIPAA Certificate (only if enrolled forloss of coverage)

• Adoption: The subscriber must also submit a copy of legaladoption papers


Does not apply




Dependent (cont.)


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Eligibility

Methods of termination



Spouse/dependentdates of termination

Members may be added to the plan off-cycle for the effectivedate of any of the following:1. Loss of coverage under another health plan for any of thefollowing reasons:




• Member Enrollment Form (MEF) • Family Health Statement (FHS)• HIPAA Certificate (only if enrolled for loss of coverage)

• If adding spouse and/or dependent to existing policy:• Addition/Termination/Change Form (ATC) • CT Family Health Statement (FHS) (not required for

newborn enrollment) • HIPAA Certificate (if enrolled for loss of coverage)


If employee resigns, is terminated, or becomes ineligible forhealth benefits per the group’s policies or the provisions ofthe Oxford coverage• Online: www.oxfordhealth.com• Addition/Termination/Change Form (ATC)Signed by the employer. Received at Oxford within 31 days ofthe requested date of termination

Groups have one of two lags:1. End of month – regardless of the Member’s last day of

employment, coverage will be terminated effective the last dayof the month in which the Member terminated employment

2. Date – coverage will be terminated for the same date employment was terminated





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Pennsylvania Small Group Member Eligibility


Eligibility

Method of enrollment



Retirees

Eligibility



Sign receipt time frame


Eiligibility


Spouse

Any full-time employee meeting the eligibility requirementsof the group can enroll as an Oxford Member

Pennsylvania Member Enrollment Form (#5420)




• Legal spouse • Common law spouse


Addition/Termination/Change Form (ATC) with HIPAACertificate (only if enrolled for loss of coverage)







Dependent


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Newborn




Types of changes



Required for all dependents over age 19, but under the maximum age limit of the group.Acceptable Proof of Verification: Student Verification Parent AffidavitForm to be completed by the parent Student verification is the subscriber’s responsibility and must besubmitted within 60 days of Oxford’s request; otherwise, thedependent will be automatically terminated

Coverage is automatically provided for the first 31 days fromdate of birth; for coverage to continue beyond the first 31days, a request to enroll the newborn must be receivedwithin 31 days of the birth


• Adoption: The subscriber must also submit a copy of legaladoption papers.

Signed by the employee and employer. Received at Oxfordwithin 31 days of the effective date






1. Loss of coverage – under another health plan for any of the following reasons:





Dependent (cont.)

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Eligibility

Method of termination


Spouse/dependentdates of termination

• If subscriber is electing coverage:• Member Enrollment and Physician Selection Form (MEF)• Health Coverage History Form (HCHF), if not

included on MEF • HIPAA Certificate (only if enrolled for loss of coverage)

• If adding spouse and/or dependent to existing policy:• Addition/Termination/Change Form (ATC) • Health Coverage History Form (HCHF) (not required

for newborn enrollment)• HIPAA Certificate (only if enrolled for loss of coverage)



Addition/Termination/Change Form (ATC)

Please refer to page 2 of your Group Enrollment Agreementto determine your group’s termination policy.

Groups have one of two lags:

1. End of month – coverage will be terminated effective thelast day of the month in which the Member terminatedemployment2. Date – coverage will be terminated for the same dateemployment was terminated



HIPAA (cont.)



53

Delaware Small Group Member Eligibility

Eligibility




Retirees

Eligibility





Eligibility


Spouse

Any full-time employee meeting the eligibility requirementsof the group can enroll as an Oxford Member

• Delaware Member Enrollment Form (#5316)




• Legal spouse only






• Unmarried child between 19 and 23 years of age (unlessotherwise specified in the Summary of Benefits), providedthe child is a full-time student


• Same time as subscriber• Open Enrollment• Date of birth• Date of HIPAA event

Dependent



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Newborn




Types of changes



Required for all dependents over age 19, but under the maximum age limit of the group.

Acceptable Proof of Verification: Student Verification Parent AffidavitForm to be completed by the subscriberStudent verification is the subscriber’s responsibility and must besubmitted within 60 days of Oxford’s request; otherwise, thedependent will be automatically terminated

Coverage is automatically provided for the first 31 days fromdate of birth; for coverage to continue beyond the first 31days, a request to enroll the newborn must be received within31 days of the birth


• Adoption: The subscriber must also submit a copy of legaladoption papers.

Signed by the employee and employer. Received at Oxfordwithin 31 days of the effective date





Member may be added to the plan off-cycle for the effectivedate of any of the following:

1. Loss of coverage – under another health plan for any ofthe following reasons:





Dependent (cont.)

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Eligibility




• If subscriber is electing coverage:• Member Enrollment and Physician Selection Form (MEF)• Health Coverage History Form (HCHF), if not

included on MEF • HIPAA Certificate (only if enrolled for loss of coverage)

• If adding spouse and/or dependent to existing policy:• Addition/Termination/Change Form (ATC) • Health Coverage History Form (HCHF) (not required

for newborn enrollment) • HIPAA Certificate (only if enrolled for loss of coverage)



Addition/Termination/Change Form (ATC)

Groups have one of two lags:

1. End of month – regardless of the Member’s last day ofemployment, coverage will be terminated effective the last dayof the month in which the Member terminated employment

2. Date – coverage will be terminated for the same dateemployment was terminated



HIPAA (cont.)



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Individual and Mandated Products

New York and New Jersey Individual Product

Spouse

New York and New Jersey:

• Must reside in an Oxford Health Plans service area withinthe state they are applying for coverage in (proof required)

• Not be eligible for any other type of similar or group healthinsurance coverage

• Not have been terminated for non-payment of premiumwithin the past 12 months (New York only)

• Not be eligible for or currently on Medicare or Medicaid(New York only)

• Not be covered by any other similar health insurance coverage

Contact Oxford’s Inside Consumer Sales and MarketingDepartment at 1-800-216-0778 for an enrollment packet

Open enrollment for all Individual Product accounts is thefirst of every month for both New York and New Jersey

New York: Applicable if Member had less than 12 months ofcontinuous coverage or a gap in coverage greater than 63 days

New Jersey: Applicable if Member had less than 12 months ofcontinuous coverage or a gap in coverage greater than 31 days

For more information, please see chart on page <<#>>.

Legal spouse only

• Same time as subscriber• Open enrollment• Date of marriage• Date of HIPAA event

Addition/Termination/Change Form (ATC) with HIPAACertificate (only if enrolled for loss of coverage)

New York: Applicable if Member had less than 12 months ofcontinuous coverage or a gap in coverage greater than 63 days

New Jersey: Applicable if Member had less than 12 months ofcontinuous coverage or a gap in coverage greater than 31 days

Eligibility


Effective dates


Eligibility





Spouse


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Eligibility


Effective dates

Newborn

Adoption

• Natural child, stepchild, adopted and proposed adoptivechild, disabled child and newborn

• New Jersey only: In addition to the above, a childrelated to the policy holder by:

• Blood relationship• Legal relationship – depends on the policyholder for

most of his/her support and maintenance, and• Resides in the policyholder household

Dependent child must be:• Unmarried child under age 19 (unless otherwise specified

in the Summary of Benefits)• Unmarried child between 19 and 23 years of age (unless

otherwise specified in the Summary of Benefits), providedthe child is a full-time student (see Student Verification)



• Oxford should be notified of the child’s birth within 48hours of the birth to facilitate claims processing

• New York: Coverage is provided only if the child is enrolledwithin 31 days of birth and any applicable premium is submitted to the group within 31 days following the birth.

• Subscribers with individual coverage: 31 days from the dateof birth to change the coverage to family and enroll the child.

• Subscribers with family coverage: An enrollment form is notrequired. However, Oxford must be notified of the birthand the pertinent details to accurately enroll the newborn(name, sex, date of birth, PCP and Social Security number.

• New Jersey: Newborn coverage is provided for children of thesubscriber or the subscriber’s spouse for the first 31 days fromdate of birth; for coverage to continue beyond the first 31 days,a request to enroll the newborn must be received within 31days of the birth. No premium is required for the first 31 days.

• New York: Same provision for newborns applies to newlyborn adopted children.

• New Jersey: All adopted children under the age of 18 are eligi-ble for coverage from the date of acceptance or permanentplacement in the home. Dependents who are being enrolledpursuant to a court order must enroll within 60 days of the dateof the court order. No evidence of good health is required.

Dependent


58




Types of changes

Method of requesting change


Eligibility


Acceptable Proof of Verification: Student Parent Affidavit Formto be completed by the subscriber Student verification is the subscriber’s responsibility andmust be submitted within 60 days of Oxford’s request; otherwise, the dependent will be automatically terminated



New York: Applicable if Member had less than 12 months ofcontinuous coverage or a gap in coverage greater than 63 daysNew Jersey: Applicable if Member had less than 12 months ofcontinuous coverage or a gap in coverage greater than 31 days

Any change that needs to be made to the Member’s personalinformation (i.e., address, name, date of birth, etc.)Addition/Termination/Change Form (ATC) received within 31days of the change

Members may be added to the plan off-cycle for the effectivedate of any of the following:1. Loss of coverage – under another health plan for any of

the following reasons:• Divorce/separation• Death• Termination/reduction in hours• Termination of group coverage/change in contribution• COBRA or continuation has been exhausted

2. Change in family status:• Marriage• Birth of a child/adoption or placement of child in home

• Upon written notice from the subscriber by giving Oxfordone month’s advance written notice

• On the date the covered dependent fails to meet thedependent eligibility requirements

• For cause, if a Member:• Fails to pay required premium • Performs an act or practice that constitutes fraud or

made an intentional misrepresentation of a material fact• No longer resides, lives or works in the service area

• Member must provide written notice of termination

Dependent (cont.)

HIPAA




59

Healthy New York: Small Group/Individual/Sole Proprietor

Overview

Eligible

Eligibility requirements

• State-mandated HMO product designed to encourage smallemployers to offer health insurance coverage to theiremployees and to also make coverage available to uninsured employees whose employers do not providegroup health insurance

• Small Groups (2-50 eligible lives)• Sole Proprietors• Working uninsured individuals

Working Individuals:• Employer does not currently provide health insurance and

has not provided group health insurance during the 12-month period preceding application

• Gross household income level is at or below 250% of thegross federal poverty level

• Health insurance coverage has not been in effect for the12-month period preceding application or have lost thatcoverage due to a qualifying event

• Must be ineligible for Medicare• Must reside in New York State• Must be employed on a full-time, part-time or episodic basis• Oxford determines final eligibility

Sole Proprietor:• Uninsured for the 12-month period preceding application

or have lost their coverage due to a qualifying event• Gross household income level at or below 250% of the

gross federal poverty level• Ineligible for Medicare• Reside in New York State• Cannot currently work for an employer that provided

health coverage during the prior 12-month period• Eligibility criteria for small businesses is inapplicable to sole

proprietors• Oxford determines eligibility

Small Groups:• See New York Small Group Enrollment and Eligibility on

page 28.



60

Eligibility for Individualsor Sole Proprietors whohave had prior insurance


Effective dates


Eligibility



Eligibility

An individual or sole proprietor shall be eligible for theHealthy New York program without regard to the existenceof health insurance coverage or the availability of employerprovided coverage during the 12-month period precedingapplication if such health insurance coverage terminated due to one of the following:

• Loss of employment• Death of a family member• Change to a new employer• Change of residence• Discontinuation of a group health plan• Termination or cancellation of COBRA coverage• Legal separation, divorce or annulment• Loss of eligibility for group health insurance coverage• Reaching the maximum age for dependent coverage• Eligible or currently covered through COBRA or other

continuation type coverage, they may apply for Healthy NY

Contact Oxford’s Inside Consumer Sales and MarketingDepartment at 1-800-216-0778 for an enrollment packet

The 1st of every month


• Legal spouse

• Domestic partner riders available for sole proprietor andsmall group only. Individual contracts do not allow fordomestic partner coverage.

Addition/Termination/Change Form (ATC) with HIPAACertificate if enrolled for loss of coverage




• Irrespective of age, any child who is disabled and can provide proof of disability

Spouse

Enrollment: Employee/Subscriber (cont.)

Dependent


61

Effective dates

Newborn

Adoption



Pre-existing condition

Types of changes


• Same time as subscriber• Date of birth • Date of HIPAA event• Open enrollment

Coverage is provided only if the child is enrolled within 31days of birth and any applicable premium is submitted to thegroup within 31 days following the birth. • Subscribers with individual coverage: 31 days from the date of

birth to change the coverage to family and enroll the child.• Subscribers with family coverage: An enrollment form is not

required. However, Oxford must be notified of the birth andthe pertinent details to accurately enroll the newborn(name, sex, date of birth, PCP and Social Security number.

Same provision for newborns applies to newly born adoptedchildren.

Required for all dependents over age 19, but under the maximum age limit of the group.Acceptable Proof of Verification: Student Parent Affidavit Formthat is to be completed by the subscriberStudent verification is the subscriber’s responsibility andmust be submitted within 60 days of Oxford’s request; otherwise, the dependent will be automatically terminated



• Applicable if Member had less than 12 months of continuouscoverage or a gap in coverage greater than 63 days

Any change that needs to be made to the Member’s personal information (i.e., address, name, date of birth, etc.)

• Addition/Termination/Change Form (ATC) received within 31days of the change



Dependent (cont.)

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Eligibility



1. Loss of coverage – under another health plan for any ofthe following reasons:• Divorce/separation• Death• Termination/reduction in hours• Termination of group coverage/change in contribution• COBRA or continuation has been exhausted

2. Change in family status:• Marriage• Birth of a child/adoption or placement of child in home

• Coverage will terminate or not be renewed:• Upon written notice from the subscriber giving Oxford

one month’s advance written notice• On the date the covered dependent fails to meet the

dependent eligibility requirements• For cause, if a Member:

• Fails to pay required premium • Performs an act or practice that constitutes

fraud or made an intentional misrepresentation of a material fact

• No longer resides, lives or works in the service area

Member must provide written notice of termination


HIPAA

Renew

als

Renewals

renewals

63

idea Management SystemSM

Review your groups that are in their annualrenewal cycle, create optional plan designsand submit the request for changes toOxford at www.oxfordhealth.com. See page 10 for more details.

Contract Renewal

Prior to the group’s policy anniversary, Oxford will send groups and their broker/consultant (if applicable) a letter to remind the group of their renewal date.

At this point, changes can be made to the group’s policy, including, but not limited to:

• Adding, dropping, or changing riders

• Changing waiting periods and eligibility requirements (subject to state laws); and/or

• Increasing or decreasing deductibles and coinsurance levels

The renewal period is the only time during the year that Oxford will accept changes to thegroup’s plan. Renewals and changes are contingent upon the group’s account with Oxfordbeing current.

Oxford Renewal Process• Renewal letters created and distributed to brokers (60-75 days prior to renewal)

• Renewal letters created and distributed to groups (45-60 days prior to renewal)

• Oxford systems are updated with the group’s renewal decision, either no changes (“as is”) or with requested benefit changes (15-45 days prior to renewal)

• Bills are generated with applicable rates (0-15 days prior to renewal)

OOxford xford Health alth PlaPlans®

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Claim

s

Claims

claims

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Claim SubmissionWhen Members receive care on an in-network basis, there are usually no claim forms tocomplete. They simply show their Oxford ID cards and pay any applicable cost shares.

There are, however, cases when Oxford Members may be required to complete claimforms in order to receive reimbursement, such as:

• When Members have out-of-network coverage and/or obtain care on an out-of-network basis

• When Oxford is the secondary insurance carrier• When Members receive laboratory services from a non-participating laboratory

To submit an out-of-network claim:• The Member must complete an Insurance Claim Form, and• Send the claim form and the original provider invoice to:

Oxford Health PlansClaims DepartmentP.O. Box 7082Bridgeport, CT 06601-7082

Claim Filing Deadlines• Filing deadlines are based on the claim’s date of service. It is not based

on the date that the claim was mailed or received by Oxford.• Commercial Members and participating providers have 180 days to submit a claim

to Oxford per their certificate/agreement.Clean claims are processed within 30 business days.

• A clean claim does not require any additional information in order to be processed and includes ALL of the following:

• Patient name and Oxford Member ID# • Oxford Provider ID#• Provider information, including federal tax ID number (FTIN) • Date of service • Place of service • Diagnosis code • Procedure code • Individual charge for each service • Provider signature

If you have any questions regarding a particular claim submission, please contact GroupServices or your Oxford sales representative.

Members can check claims online at www.oxfordhealth.com or by calling Oxford’sCustomer Service at 800-444-6222.

For a hearing impaired interpreter, call Oxford's TTY/TDD line at 1-800-201-4875; MedicareMembers may call our TTY/TDD line at 1-800-201-4874. Please call 1-800-303-6719 forassistance in Chinese, 1-888-201-4746 for assistance in Korean, 1-800-449-4390 para ayuda en espanol, and for assistance in other languages call the number on your Member ID card.

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Misc. Item

s

Miscellaneous Items

miscellaneous items

67

Brokers Acting on Behalf of Benefits AdministratorsIn order for brokers to continue to assist benefits administrators with the day-to-dayadministrative functions associated with their employees, brokers can now act on behalf ofthe benefits administrator.

What does this mean?With written consent from the benefits administrator, brokers will have authorization tocomplete the following transactions:

• New group applications • Member Enrollment Forms and other necessary enrollment documents• Renewals

How can you get started?• The benefits administrator must complete the “Consent Form –

Authorization for broker to Act as Benefits Administrator” (located on thewww.oxfordhealth.com broker site) and return it to the broker

• The broker is encouraged to call Group Services to review the process prior to sending in the completed form

• Please allow four to six business days for Oxford to update their files to recognize that the broker can now act on behalf of the benefits administrator. Sendthe “Consent Form – Authorization for Broker to Act as Benefits Administrator” to:

Oxford Health PlansP.O. Box 7085Bridgeport, CT 06601-7085

Please note: Once a broker has obtained the consent form and submits it to Oxford, theymay contact Group Services to receive a user name and password to administer onlinetransactions on behalf of their group. Unfortunately, a single user name/password for brokers across all groups is not currently possible. Brokers must get a unique user name andpassword for each group they have consent to administer and wish to administer online.

To obtain a copy of the “Consent Form – Authorization for Broker to Act asBenefits Administrator”, log on to www.oxfordhealth.com, click on “Forms andOther Materials”, and click on “Consent Form – Authorization for Broker to Act as Benefits Administrator.”

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Oxford’s Confidentiality Policy In order for Group Services to release confidential medical information regarding aMember’s claims, Oxford requires that the Member complete and sign the MemberAuthorization Form. The completed authorization form provides Oxford with a signed,written release from the Member (or from a legal guardian/power of attorney, withappropriate documentation) authorizing us to release the confidential information to thebenefits administrator (BA) or broker.

The following explains what information regarding a Member’s claim can and cannot bereleased to a broker without the Member’s signed, written authorization:

Authorization Form NOT required for: • Claims payment date • Check number • Claim status (paid, denied, currently in process)• Denial code if it does not indicate diagnosis • BA only: Social Security number

Authorization Form required for:• Diagnosis codes • Provider names • CPT codes • Explanation of Benefits• Broker only: Social Security number

(Broker should obtain this from the BA)

To obtain a copy of the Member Authorization Form, log on towww.oxfordhealth.com, click on ‘Forms and Other Materials’, and click on “Member Authorization Form”

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Oxford is pleased to acknowledge that we are HIPAA compliant with both the Privacy provision as of 4/14/03 as well as the Transactions and Code Sets provision as of10/16/03. Policies and Procedures have been developed to ensure that Member information is protected and safeguarded according to the law. Oxford is currently receiv-ing electronic HIPAA format and content compliant transactions as required by thefederal regulation in efforts to standardize the electronic submission of data between covered entities.

Members can contact Oxford directly via phone or mail to obtain a copy of the PrivacyNotice outlining their individual rights.

COBRA

70

COBRA

State Continuation

Qualifying Events:

Federal law requires employers with group health plans to providecontinuation coverage to former covered employees and their cov-ered dependents in certain instances. Groups exempt from COBRA:• Companies with fewer than 20 employees on a typical business

day during the preceding calendar year• State and local government plans• Church plans• Federal government employees

State laws require employers with group health plans withfewer than 20 employees on a typical business day during the preceding calendar year to provide continuation of coverage• NY and CT State Continuation provisions are similar to COBRA• NJ State Continuation provisions differs from COBRA• Delaware and Pennsylvania do not offer State Continuation;

all groups (regardless of size) are subject to the provisions of COBRA

COBRA, NY State Continuation, CT State Continuation:• Events that qualify the covered employee and his/her

covered dependent(s) for 18 months of coverage:• Voluntary termination of employment;• Involuntary termination of employment (excluding gross

misconduct); or• Reduction in hours of employment (strike, layoff,

full-time to part-time, leave of absence) that no longerqualifies the employee for health coverage

• Events that qualify the covered spouse or covered dependentchild(ren) for 36 months of coverage:

• Death of the employee;• Divorce or legal separation from the employee; or• Dependent child(ren) exceeding the dependent cut-off age

NJ State Continuation:• Events that qualify the subscriber for 12 months of coverage:

• Termination of employment (other than for gross misconduct), or

• Reduction in hours of employment (strike, layoff or leaveof absence)

• Events that entitle the spouse and dependents to make anelection for 180 days of coverage:

• Death of the covered employee

Consolidated Omnibus Budget Reconciliation Act(COBRA) Continuation of CoverageImportant Note: This section of the Oxford Broker Resource Guide provides a briefoverview of continuation coverage requirements. It is not intended to be a completeguide to continuation law and requirements. Employer groups should consult with legalcounsel regarding their specific obligations with respect to continuation coverage.

COBRA

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COBRAAdministrativeRequirements

Methods of Enrollment

Disability Extension

Termination

• COBRA administration is complex. The law specifies noticerequirements, model notice forms, and time frames for providing notice of COBRA rights, election of COBRA coverage, and payment of COBRA premium

• Generally, employers need to notify any eligible employee ofCOBRA rights within 14 days of the qualifying event

• Covered employees and their covered dependent(s) have 60days from the qualifying event date or from the date theyreceive a COBRA notice from the employer, whichever islater, to elect to continue coverage

• Employers must immediately send Oxford anAddition/Termination/Change Form (ATC) to terminate the covered employee and/or covered dependent(s) from active coverage, whether or not the covered individual haselected COBRA

• A Member Enrollment Form (MEF) must be completed whencovered spouses or covered dependent(s) are electing tocontinue coverage independently

• Disabled individuals (NJ State Continuation excluded) mayqualify for an extension that extends the otherwise applicable 18-month coverage period to 29 months

• Disability extension will only apply if a qualified beneficiary:• Is determined, under the Social Security Act, to have

been disabled prior to or within the first 60 days of continuation coverage; and

• Applies for the disability extension within 60 days of thedate of the determination of disability by the SocialSecurity Administration (SSA) and before the end of the18-month continuation period

• Coverage will terminate:• On the last day of the continuation coverage period;• If any premium payment is not made within the

grace period; or• If the employer ceases to provide group health

coverage to employees

• A qualified beneficiary is no longer eligible:• When the qualified beneficiary becomes covered under

another group health plan, which does not limit orexclude a pre-existing condition; or

• If the qualified beneficiary is entitled to Medicare afterthe date of election.

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Rate Quote for Large/Executive AccountsIn addition to plan details, the following items may be needed to obtain a large grouprate quote:

Material requirements:• Census • Current carrier benefit summary• Out-of-area form • Employer contribution• Age/Sex • Large claims• Current and prior area • COBRA information• Current enrollment breakdown • Retiree information• Current rates • Original/renewal effective dates• Renewal rates • Current carrier bill

Additional material required for experience rated submissions:• Claims experience• Average/monthly enrollment• Large claim information (detailed)

If you have any questions, please contact your Oxford sales representative.

Termination and DisenrollmentIf an employee resigns, is terminated, or becomes ineligible for health benefits per the group’s policies or the provisions of your Oxford coverage, anAddition/Termination/Change Form (ATC) must be signed by the benefits administrator within 31 days.

Addition/Termination/Change Forms should be sent to:

Oxford Health PlansAttn: Enrollment DepartmentP.O. Box 7085Bridgeport, CT 06601-7085

COBRA (continued)

RequestingTermination

• A Benefits Administrator can complete anAddition/Termination/Change Form (ATC); or

• The qualified beneficiary can submit a letter requesting thatCOBRA/State Continuation coverage be terminated The letter should contain the following and be sent to:

• Member name Oxford Health Plans• Member ID Commercial Enrollment Dept.• Group ID P.O. Box 7085• Exact date of termination Bridgeport, CT 06601-7085

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Group ConversionsLocation ConversionsLocation conversions occur when an employer group moves their office location. Planbenefits and pricing can vary based on an employer group’s county location. Contact yourOxford sales representatives to determine if benefits and rates are affected when anemployer group changes location.

Large to Small ConversionsLarge to small group conversions occur when an employer no longer qualifies for largegroup coverage due to the fact that they no longer have over 50 employees. Uponrenewal, if an employer group falls below 50 employees, contact your Oxford sales representatives to verify that the group no longer qualifies for large group coverage andto obtain a small group quote.

Small to Large ConversionsSmall to large group conversions occur when an employer no longer qualifies for smallgroup coverage due to the fact that they have over 50 employees. Upon renewal, if anemployer group has over 50 employees, contact your Oxford sales representatives to findout what information is required to determine if the employer group qualifies to receive alarge group quote from Oxford.

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Tax FormsBelow is a list of accepted tax forms to verify a group’s eligibility for group healthcarecoverage in New York.

Official Group Filing in New York and Required Documentation

New CorporationArticles of Incorporation and W4 for each employee

Existing Corporation NYS-45 (indicating all eligible employees)

New Partnership Partnership Agreement and W4 for each employee

Existing Partnership K1 for each partner and NYS-45(indicating all eligible non-partner employees)

NYSHIPP Approved OrganizationNYSHIPP Certificate

New Proprietorship W4 for each employee

Existing Proprietorship Schedule C and NYS-45 (indicating all eligible employees)

New Subchapter S CorporationCT6 and W4 for each employee

Existing Subchapter S Corporation1120S or K1 and NYS-45 (indicating all eligible employees)

New Limited Liability CorporationArticles of Incorporation and W4 for each employee

Existing Limited Liability CorporationNYS-45 (indicating all eligible employees)

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Below is a list of accepted tax forms to verify a group’s eligibility for group healthcarecoverage in Connecticut.

Official Group Filing in Connecticut and Required Documentation

New Corporation1. UC-5A (Quarterly Wage and Tax Report), 941 or UC2B with copy of current pay stubs

for all active employees or electronic payroll report (ADP)

2. Federal and State of CT documents confirming registration of the business with copiesof current pay stubs for all active eligible employees or electronic payroll report (ADP)

Existing CorporationCopy of current year form 1120 or 1120S with current pay stubs for all active eligible employees or electronic payroll report (ADP)

Partnership or LLCCopy of current year 1065 and K-1s with current pay stubs for all other active eligible employees or electronic payroll report (ADP)

Existing ProprietorshipCopy of current year Schedule C

Non-profit OrganizationCopy of UC1NP form with current pay stubs for all active eligible employees or electronicpayroll report (ADP)

“S” CorporationCopy of current year form 1120 or 1120S with copies of current pay stubs for all active eligible employees or electronic payroll report (ADP)

Please note: Tax forms are not required for New Jersey group enrollment.

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