pace university oxford health plans benefit presentation
Post on 21-Dec-2015
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TRANSCRIPT
Pace UniversityOxford Health Plans
Benefit Presentation
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Benefits Overview There are many benefits to being an Oxford Member An overview of common characteristics of Oxford’s primary
products as well as the key procedures for accessing medical care:
Network
Service
What is a Primary Care Physician?
In-Network and Out-of-Network Coverage
Precertification Requirements
Emergency and Urgent Care Coverage
Pharmacy Coverage
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Network Overview
Freedom Network
87,637 providers in Oxford’s service area (New York, New Jersey, and Connecticut)
99% Board certified or recently board eligible, one of the best available measures of physician quality.
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Network Overview
Choice Plus Network
500,000 physicians Nationwide
4200 hospitals
250,000 physicians and 1500 hospitals added nationally in the last 5 years
National scope, local presence
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What is a Primary Care Physician?
Primary Care Physician (PCP)An Oxford participating physician who acts as the Member’s personal physician, providing routine exams and other basic medical care
The PCP is responsible for:
Knowing the Member’s medical history Maintaining the Member’s medical records Providing routine exams and basic medical care
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What is the difference between In-network & Out-of-network Coverage?
In-network coverageThe services provided by Oxford participating providers or providers participating with one of Oxford’s affiliated networks such as Freedom and United Healthcare Choice Plus Network
In order to obtain services at the in-network level of cost share, a Member must use a provider that participates one of the above networks.
• Emergency and urgent care may also be covered on an in-network basis
Out-of-network coverageA Member can seek care from providers who do not participate in his/her Oxford network
Covered services obtained from non-participating providers will be subject to a higher level of cost share than those services obtained from Oxford participating providers. Not all services are covered on an out-of-network basis
• A Member should check his/her Summary of Benefits and Certificate of Coverage in order to determine the specific coverage available to him/her
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Preventive Care
No charge or co-payment in network for routine preventive care, including:
• Annual physicals
• Well-baby care
• Children’s immunizations
• For women: Two preventive care visits a year to the OB/GYN
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Freedom EPO PlanOption #1 (No claim forms)
In Network Benefits
$20 co-pay for Office Visits to PCP/Ob-Gyn
$20 co-pay to see a Specialist;
No charge for hospital
$75 Emergency Room co-pay
Rx - $15/25/50, Mail Order 2x
Out of Network Benefits
Do Not Apply
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Freedom Direct 90/70 Plan Option #2
In Network Benefits
Annual Single Deductible: $250Annual Family Deductible: $500
$20 co-pay for Office Visits to PCP$20 co-pay to see a SpecialistDeductible and 10% Coinsurance for Hospital$75 Emergency Room co-pay$15/25/50 Rx, Mail Order 2xOut-of-pocket maximum for the calendar year:
• $750 Single out-of-pocket maximum
• $1,500 Family out-of-pocket maximum
Out of Network Benefits
Annual Single Deductible: $500Annual Family Deductible: $1000
Coinsurance: 70% Oxford responsibility, 30% Member responsibility All charges subject to usual, customary, and reasonable (UCR) rates (80% of HIAA
Out-of-pocket maximum for the calendar year:
• $2,000 Single out-of-pocket maximum
• $4,000 Family out-of-pocket maximum
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Freedom Access 100/70 Plan Option #3
In Network Benefits
$10 co-pay for Office Visits to PCP/Ob-Gyn
$15 co-pay to see a Specialist;
No charge for hospital
$75 Emergency Room co-pay
$15/25/50 Rx, Mail Order 2x
Out of Network Benefits
Annual Single Deductible: $300Annual Family Deductible: $600
Coinsurance: 70% Oxford responsibility, 30% Member responsibility All charges subject to usual, customary, and reasonable (UCR) rates (80% of HIAA
Out-of-pocket maximum for the calendar year:
• $1,800 Single out-of-pocket maximum
• $3,600 Family out-of-pocket maximum
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When is Precertification Required?
All planned Inpatient Hospitalizations and Professional Services and all outpatient procedures performed at:
• Hospital outpatient departments
• Ambulatory surgical facilities
• Freestanding facilities Major Diagnostic Tests, precertification
will be required for:
• CT scans
• Magnetic Resonance Imaging (MRI)
• Magnetic Resonance Angiography (MRA)
• Positron Emission Tomography (PET) scans
• Nuclear medicine studies
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Who is Responsible for Obtaining Precertification?
In-network covered servicesA Member’s participating provider must obtain the necessary precertification directly from Oxford
Out-of-network covered servicesWhen a Member seeks care out-of-network (s)he will be responsible for obtaining any necessary precertification
Members who do not receive precertification for services received out-of-network will be obligated to pay for all charges, or may be subject to a reduction in coverage, depending on their plan
Self Referrals and Pre-Authorizations are not the same.
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In accordance with your health plan coverage, Oxford covers only medically necessary physical/occupational therapy and chiropractic services
Physical/Occupational Therapy• Outpatient physical therapy and occupational therapy
services that are received from in-network (participating) providers are covered based on your Oxford plan (these may require precertification through OrthoNet)
Chiropractic Services• Oxford participating chiropractors are required to pre-
approve all chiropractic visits through TRIAD for most commercial Members (this requirement only applies to Members whose plans require precertification)
Physical Therapy, Occupational Therapy, and Chiropractic Services Covered
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How Emergencies & Urgent Care are Covered
What to do in case of an emergency Go straight to the emergency room, you are covered 24 hours a day,
7 days a week, Worldwide.
You will be responsible for the $75 emergency room co-payment
• Co-payment is waived if admitted to hospital through the Emergency Room.
• If the ER visit results in a hospital admission, the Member must notify Oxford’s Customer Service Department within 48 hours of the admission.
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Pharmacy Coverage
Oxford contracts with a pharmacy benefit manager, Medco Health, to help administer Oxford’s retail and mail-order pharmacy servicesWorking with Medco Health helps Oxford to
Better manage prescription drug costs
Provide Members with comprehensive clinical programs and industry-leading customer service
Offer mail-order prescription drug coverage, 2 Rx co-pays for 90 day supply.
When Members visit a participating pharmacy for covered prescriptions, they will be responsible only for co-pay of $15, $25 or $50, for tier 1, tier 2, and tier 3 drugs respectively
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Value Added Benefits
•Quitnet •STOTT PILATES
•General Vision Services •Weight Watchers
•Chelsea Piers •Yoga Journal
Healthy Bonus ®
A preventive program offering Members access to discounts and special offers on health-related products and services
Offers include weight loss, nutrition, wellness and important health issues such as pediatric nutrition and condition management (diabetes and asthma)
Gym Reimbursement Members and spouses are eligible for up to $200/$100 reimbursement
of the membership fee Must complete a minimum of 50 visits per six-month period
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GENERAL VISION SERVICES:
Members who have used their vision benefits within the last 24 months are not eligible. Qualified Members are entitled to the following vision services at no cost:
Eyewear: Complete eye examination Choice of frames in assorted styles, sizes, and colors, with a retail
value of up to $150 Quality plastic lenses Cosmetic tinting and prescription sunglass lenses.
Contact Lenses: If Members prefer contact lenses, standard, soft, daily-wear or
extended-wear spherical contact lenses are available. Members will receive a complete eye examination, a year of follow-up
visits, and one pair of contact lenses. For standard disposable contact lenses, a 6-month supply will be
provided.
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Vision Plan
VISION CARE:
EXAMINATION: Oxford covers one routine eye examination per Member per 12 month period. There is a maximum payment of $50 per examination.
HARDWARE: Oxford provides coverage for corrective eye glass lenses and frames up to a maximum amount payable of $70 per Member once every 24 month period.
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Cancer Resource Services (CRS), a United Resource Network
A national network of premier cancer centers. Although CRS specializes in uncommon and complex cancers, eligible Members may access CRS for any type of cancer.
If you have been diagnosed with cancer and are interested in receiving care from a
CRS participating facility, you must be registered with Cancer Resource Services in advance of your treatment. Members may call 1-866-936-6002 to register. Registration will ensure that services performed at Centers such as Memorial Sloan Kettering will be treated as in-network.
Please remember that all other Oxford plan provisions and pre-certification rules
remain in place and must be followed, as per your Certificate of Coverage. For general information, Members may contact CRS or visit www.urncrs.com
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Oxford’s Member Service 800-444-6222
Member Service Associates
8 AM to 6 PM, Monday through Friday
Oxford Express®
www.oxfordhealth.com
Available 24 hours a day, seven days a week
Oxford On-Call® 800-201-4911Team of experienced Registered Nurses,
24/7
Healthcare guidance over the phone, based on your specific symptoms
Medical ManagementMedical professionals led by doctors and registered nurses 8 AM to 6 PM, Monday through Friday
Available to discuss surgical procedures, emergency care, and hospitalizations
Precertification for diagnostic procedures at CareCore National at 877-773-2884 (877-PREAUTH)
Pharmacy Customer Service from Medco Health Solutions at 800-905-0201 or log onto www.medcohealth.com
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Check Benefits Online
Visit www.oxfordhealth.com and log into Your Account page
Click on the “Check” tab and highlight “Benefits” from the drop-down menu
Enter the employee’s Oxford Member ID# or Social Security # and click Enter
The employee’s Summary of Benefits will be displayed
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