enrollment
Plans at a Glance
at Oxford
a glance
Quick Start Enrollment Tips
Reporting Changes to Group Information
Member Enrollment & Eligibility Charts
Group Termination Protocol
Oxford as the Secondary Health
Insurance Carrier
Medical Leave of Absence
Verifying Enrollment of New Subscribers
Contract Renewal
Pre-existing Condition Clause
Health Insurance Portability & Accountability
(HIPAA)
Enrollment Contact Information
■
Do you have enrollment questions?
■
www
■
Please contact Oxford Group Services
at 1-888-201-4216, Monday through
Friday, 8:00 AM to 5:00 PM or
Send Enrollment Forms to:
Oxford Health Plans
Enrollment Department
P.O. Box 7085
Bridgeport, CT 06601-7085
E-mail: [email protected].
Turnaround time is generally 24 hours
For Online Enrollment and to download
enrollment forms
■
Go to www.oxfordhealth.com
■
Log onto the Employer section
■
Click on the ‘Tools and Resources’ tab.
Forms can be found under Practical
Resources.
Make real-time changes by using
Oxford’s online enrollment transactions
under the ‘Transactions’ tab. www
www
Send New Group Submissions to:
Oxford Health Plans
14 Central Park Drive
Hooksett, NH 03106
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Quick Start Enrollment Tips
Whether you are a new group or a renewing group, we would like to thank you for choosing Oxford. We know
that, regardless of your status, there can be some confusion when it comes to understanding health benefits and
enrollment.
This is a sample of the NY Member Enrollment Form-OHI used for Oxford New York small employer groups.
To view and download this and all other Oxford enrollment forms, log on to the Employer page at www
www.oxfordhealth.com and click on the ‘Tools and Resources’ tab. Forms can be found under Practical Resources.
At Oxford, we’ve helped hundreds of companies and thousands of employees understand the benefits we
provide. In our experience, good communication is vital in any situation. But we also understand how busy you
are, so we have provided suggestions for getting everyone comfortable with their Oxford plan.
www
To make your job easier, download, order, and/or use the following materials and tools from our web
site at www.oxfordhealth.com.
Oxford Rosters of Participating Physicians and Providers
Oxford enrollment forms
■ Doctor Search tool
■
■
General Enrollment Instructions
Here’s a general “Who, What, When, Where, and How” for enrolling eligible employees and
their dependents.
How to Complete A Member Enrollment Form
■
Employers must complete the top section of the enrollment form.
• To find out your Group Number and all your active Contract Specific Package(s) (CSP),
where applicable:
New groups: contact Group Services at 1-888-201-4216
Current groups: look on your billing statement
■
Employees must complete all Employee and Dependent Information
• Coordination of Benefits questionnaires will be mailed within 31 days to Members who don’t
adequately complete the “other carrier” question on the enrollment form. See “Coordination of
Benefits” under the Claims section for more details.
• Incomplete or altered forms will not be processed — which may result in a denial of enrollment and
lack of coverage. Because enrollment forms are legal documents, Oxford cannot accept forms that
are altered in any way, including:
■
• Erased
• Whited out
• Crossed out
• Written over
Completed enrollment forms must be signed by both the employer and the employee.
Need Additional Enrollment Materials?
www
Just log on to the employer site at www.oxfordhealth.com or contact Group Services to either
download or order any of the following Oxford materials:
Materials
Pharmacy Q&A Materials
Forms
An Oxford Roster of Participating
Physicians and Providers
Spanish/English Q&A
Member Enrollment Forms
Healthy Bonus® brochure
Dental Enrollment Forms
BA Bulletin
Member Brochure
Gym Reimbursement brochure
Replacement ID Cards
Addition/Termination/
Change Forms
Student Verification/Parent
Affidavit Form
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Where to Send Enrollment Forms
Small Group Member Eligibility Requirements By State:
New York Small Group
All Oxford enrollment forms must be sent directly to:
Oxford Health Plans
Enrollment Department
P.O. Box 7085
Bridgeport, CT 06601-7085
ENROLLMENT: EMPLOYEE/SUBSCRIBER
Who is an eligible
employee?
Any full-time employee working 20+ hours per week can enroll as an Oxford
Member. 20+ is the state minimum, a group may choose to increase this number
for enrollment eligibility.
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)
Two easy ways to enroll
www •Online: Go to www.oxfordhealth.com and click on “Employers”
• Member Enrollment and Physician Selection Form with Health Coverage History Form
(HCHF.)
Note: If prior carrier information is listed directly on MEF, an HCHF is
not required
When enrollment forms
must be submitted
Enrollment forms must be:
• Signed by the employer and employee within 31 days of the
requested effective date
• Received by Oxford within 31 days of the requested effective date
Pre-existing conditions
Applicable if Member had less than 12 months of continuous
coverage or a gap in coverage greater than 63 days
See “Pre-existing Condition Clause” in the Enrollment section.
Retirees
Coverage for retirees must be specified in the contract
IMPORTANT NOTE: Do not send Oxford enrollment forms to Group Services or your
Oxford Account Manager.
Always keep copies of submitted forms for your files.
What Happens Next
■
ID Cards for new hires, new enrollees, newly added spouses, and/or dependents will be mailed directly
to the Member’s home.
• If the employee does not receive an ID card, contact Group Services at 1-888-201-4216
■
Certificates of Coverage will be mailed to each subscriber. However, spouses and dependents will not
receive a copy unless they request one.
Member Enrollment & Eligibility Charts
What You Need to Know About Enrollment & Disenrollment in Your State
Eligibility requirements and enrollment instructions vary by state laws and by the size of your group and can be
confusing. That’s why we’ve created easy-to-read enrollment and eligibility charts. Just look up the one that
matches your group:
■
Small Group Member Eligibility Requirements by State:
• New York (2-50 full time employees)
• New Jersey (2-50 full time employees)
• Connecticut (1-50 full time employees)
• Healthy New York (50 or fewer eligible employees)
SPOUSE
Who is eligible as a
spouse?
When a spouse can
be enrolled
You’ll find information about:
■
Enrolling employees, their spouses and dependents
■
Changing existing Member information
■
Health Insurance Portability and Accountability Act (HIPAA)
■
Termination
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Legal spouse, domestic partner
Spouse may be enrolled for the following effective dates:
• Same time as subscriber/employee
• 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 definition as specified by the group.
How to enroll a
Member’s spouse
www • Online: www.oxfordhealth.com
• Addition/Termination/Change Form (ATC) with Health Coverage History Form
(HCHF)
• HIPAA Certificate (only if enrolled for loss of coverage)
When Enrollment and
ATC forms must be
submitted
Enrollment and ATC forms must be:
• Signed by the employer and employee within 31 days of the effective date
• Received at Oxford within 31 days of the effective date
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SPOUSE CONT.
Pre-existing conditions
DEPENDENT (CONT.)
Applicable if Member had less than 12 months of continuous coverage or a gap
in coverage greater than 63 days. For more information, see the Pre-existing
Condition portion of the Enrollment section.
Two easy ways to enroll
a dependent?
www • Online: www.oxfordhealth.com
• Addition/Termination/Change Form (ATC) with
– Health Coverage History Form (HCHF) (not required for newborn)
– HIPAA Certificate (only if enrolled for loss of coverage)
Adoption: The subscriber must also submit a copy of legal adoption papers.
Who is eligible
as a dependent?
• 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), provided the child is a full-time student
(see Student Verification)
• Any child who is disabled and can provide proof of disability, regardless of age.
When enrollment and
ATC forms must be
submitted
Enrollment and ATC forms must be:
• Signed by the employee and employer within 31 days of the
requested effective date
• Received at Oxford within 31 days of the requested effective date
Pre-existing conditions
When a dependent can
be enrolled
Dependent may be enrolled for the following effective dates:
• Same time as subscriber/Open enrollment/Date of birth/Date of HIPAA event
Applicable if Member had less than 12 months of continuous coverage or a gap
in coverage greater than 63 days
See “Pre-existing Condition Clause” in the Enrollment section.
Student verification
Required for all dependents over age 19, but under the maximum age limit of
the group. Every fall semester thereafter, the student will be required to submit
a valid fall verification.
DEPENDENT
CHANGES TO EXISTING MEMBER INFORMATION
Types of changes to
inform Oxford about
Acceptable Proof of Verification
• Oxford Student Verification Parent Affidavit Form or letter from Registrar’s office
• Verification on school letterhead
• The Student Verification Parent Affidavit Form must:
- Be completed and signed by the covered parent on the Oxford insurance policy
- Confirm full-time status in an accredited educational institution
- Be submitted at time of enrollment to confirm eligibility
Note- The student’s Member ID or Social Security number must appear on any
student verification information
It is the Member’s responsibility to notify Oxford of any personal or family status
changes that affect eligibility for services and benefits, as defined in your
Certificate of Coverage.
Changes that must be reported to Oxford include, but are not limited to:
• Social Security numbers for newborn children
• Termination or addition of any other group health insurance
• Changes in:
– Name
– Mailing address and Zip code
– Primary care physician or OB/GYN
– Student status
– Disability or handicapped status
– Medicare status
– COBRA (See the Continuation Coverage section.)
– Family status
– Retirement*
– Death*
– Divorce*
* The group may report these types of changes to Oxford in lieu of the Member.
Please note that some of these changes may require the group’s approval in order
to terminate and/or add a Member and to elect COBRA.
Unacceptable Proof of Verification
• Unpaid bill/Acceptance letter from an educational institution/Preregistration
forms from an educational institution/Class schedule
Student Medical Leave
A full-time student as described may continue coverage under the plan for up to
12 months while on medical leave and not attending classes. To be eligible for
such coverage, a student’s attending physician must certify, in writing, the medical reason why the leave from school is medically necessary. The letter from the
physician must be sent to us. The student’s attending physician must be licensed
to practice in the state of New York. However, this provision does not require us
to continue coverage beyond the age at which coverage would otherwise
terminate (the full-time student limiting ages as shown in the Summary of
Benefits). The premium charged for this coverage will remain the same as
when the student was enrolled in school.
Important enrollment
time frames
Dependents that fail to provide valid verification by November 14 will be
terminated effective December 31 of that year. (Note: The deadline to provide
Fall verification will change every year).
Newborns & Adoption
A newborn of the subscriber or subscriber’s spouse will be covered from the
date of birth only if the Subscriber completes and submits an Addition/
Termination/Change form specifically adding the newborn child as well as
submits any applicable premium to the group within 31 days following the birth.
This provision applies to newly born adopted children if the Subscriber takes
physical custody of the child upon its release from the hospital and files a petition
pursuant to the section 115-c of the domestic relations law within 30 days of birth,
and provided no notice of revocation has been filed and consent for the adoption
has not been revoked.
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Any change that needs to be made to the Member’s personal information (i.e.,
address, name, date of birth, etc.)
Methods of
requesting change
• ATC Form (received within 31 days of the change)
www • Online: www.oxfordhealth.com
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Special enrollment
Members may be added to the plan off-cycle for the effective date of any of the
periods
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
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HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) CONT.
Special enrollment
periods (cont.)
2. Change in family status:
• Marriage
• Birth of child/adoption or placement of child in home
How to enroll during
HIPAA special
enrollment period
• Online: www.oxfordhealth.com
• 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)
– HCHF Form (not required for newborn enrollment)
– HIPAA Certificate (only if enrolled for loss of coverage)
When Enrollment, ATC,
and HCHF forms must
be submitted
Enrollment, ATC, and HCHF forms must be:
• Signed by the employer and employee within 31 days of the
requested effective date
• Received at Oxford within 31 days of the requested effective date
Small Group Member Eligibility Requirements By State:
New Jersey Small Group
ENROLLMENT: EMPLOYEE/SUBSCRIBER
Who is an eligible
employee?
Any full-time employee working 25+ hours per week can enroll 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.
• An employee with a HIPAA Certificate can enroll on the date of the HIPAA
event (see HIPAA Section)
• Late enrollees can enroll more than 30 days after first becoming eligible, but
are subject to the Policy’s pre-existing conditions section. The date of coverage
is the date that Oxford receives the enrollment form. Late enrollees will not
be retroactively covered. (Note there are certain circumstances in which an
eligible employee or dependent will not be considered a late enrollee, and
therefore, will not be subject to pre-existing condition limitations. See your
Policy for more information.) Members can also enroll for a future effective
date as long as Oxford receives all enrollment materials prior to the requested
effective date.
Two easy ways to enroll
www • Online: Go to www.oxfordhealth.com and click on “Employers”
• NJ Small Member Enrollment/Change Request Form
When enrollment forms
must be submitted
Enrollment forms must be:
• Signed by the employee only within 31 days of the requested effective date
• Received at Oxford within 31 days of the requested effective date
Pre-existing conditions
• 2 to 5 life group: Pre-existing conditions will apply if the Member has less than
180 days of coverage or a gap in coverage greater than 90 days prior to the
effective date of coverage
• 6+ life group: Pre-existing conditions do not apply
• Late enrollees are subject to the Policy’s pre-existing conditions limitation section, except for certain circumstances. See your Policy for more information.
See “Pre-existing Condition Clause” in the Enrollment section.
Late enrollee
If an eligible employee, spouse, or dependent does not enroll within 30 days of a
change in status, they may enroll anytime; however, they may only be effective
for one of the following 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 requested effective date
• If request to enroll is received after the requested effective date, Member will
be enrolled for the date the request was received at Oxford
1099 employees
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 access to this form required by the
State of New Jersey)
TERMINATION
When an employee
should be disenrolled
If employee resigns, is terminated, or becomes ineligible for health benefits per
the group’s policies or the provisions of the Oxford coverage
How to report employee
termination/disenroll
www • Online: www.oxfordhealth.com
• ATC Form
When to notify Oxford of
termination/disenroll
ATC Form must be:
• Signed by the employer within 31 days of the requested date of termination.
• Received at Oxford, within 31 days of the requested date of termination. If an
ATC Form is received more than 31 days after an employee or dependent is
terminated, you will be responsible for the premium payments for a certain
period following the termination.
Dates of termination
When should
a spouse/dependent
be terminated?
Please refer to your Group Enrollment Agreement (GEA) to determine your group’s
termination policy.
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 day of the month in which the Member
terminated employment
2. Termination Date — coverage will be terminated for the same date
employment was terminated
Coverage for spouse and/or dependent should be terminated for any of the
following reasons:
• 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
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ENROLLMENT: EMPLOYEE/SUBSCRIBER CONT.
Retirees
DEPENDENT CONT.
Coverage for retirees must be specified in the contract
SPOUSE
Who is eligible as a
spouse?
Two easy ways to enroll a
Member’s spouse
When enrollment and
ATC forms must be
submitted
New Jersey Small Member Enrollment /Change Request Form must be:
• Signed by the employer and employee within 31 days of the
requested effective date
• Received at Oxford within 31 days of the requested effective date
Pre-existing conditions
Who is eligible
as a dependent?
When a dependent
can be enrolled
Student verification
Note: The student’s Member ID Social Security number must appear on
any student verification information.
Important enrollment
time frames
Dependents that fail to provide valid verification by November 14 will be
terminated effective December 31 of that year or other such date set forth in
the Group Enrollment Agreement. (Note: The deadline to provide Fall verification
will change every year.)
Newborn
Coverage is automatically provided for children of the subscriber or the
subscriber’s spouse for the first 31 days from date of birth; for coverage to
continue beyond the first 31 days, a request to enroll the newborn must be
received within 31 days of the birth.
No premium is required for the first 31 days. If an additional premium is
required, Oxford may make coverage beyond the first 31 days contingent upon
notification and payment of any applicable premium. Also, if such a child is
not properly enrolled, coverage will terminate, but Oxford must still pay for
treatment received in that first 31-day period.
• For 2 – 5 life groups pre-existing conditions will apply if:
- Member has less than 180 days of coverage or a gap in coverage greater
than 90 days prior to effective date of coverage
- Late enrollee
• 6+ life group: pre-existing conditions do not apply
• See “Pre-existing Condition Clause” in the Enrollment section.
DEPENDENT
• 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), provided the child is a full-time student
(see Student Verification)
• Regardless of age, any child who is disabled and can provide proof of disability
Dependent may be enrolled for the following effective dates:
• Same time as subscriber/employee
• Open enrollment
• Date of birth
• Date of HIPAA event (See HIPAA section)
• Late enrollee
Required for all dependents over age 19, but under the maximum age limit of
the group.
Acceptable Proof of Verification
• The Student Verification Parent Affidavit Form must:
– Be completed and signed by the covered parent on the Oxford
insurance policy
– Confirm full-time status in an accredited educational institution
– Be submitted at time of enrollment to confirm eligibility
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Every fall semester thereafter, the student will be required to submit a
valid fall verification.
Unacceptable Proof of Verification
• Unpaid bill
• Acceptance letter from an educational institution
• Preregistration forms from an educational institution
• Class schedule
• Legal spouse or same sex Domestic Partner
Spouse may be enrolled for the following effective dates:
• Same time as subscriber/employee
• Open enrollment
• Date of marriage
• Date of U.S. immigration on passport
• Date of HIPAA event (See HIPAA Section)
• Late enrollee
• Domestic Partner- date they meet the definition as specified by the group.
www • Online (only if adding to an existing policy): www.oxfordhealth.com
• New Jersey Small Member Enrollment /Change Request Form with HIPAA
Certificate (only if enrolled for loss of coverage)
When a spouse
can be enrolled
Student verification
(cont.)
Adoption
All adopted children under the age of 18 are eligible for coverage from the date
of acceptance or permanent placement in the home. Dependents who are being
enrolled pursuant to a court order must enroll within 30 days of the date of the
court order. No evidence of good health is required.
Two easy ways to enroll
a dependent
www • Online (only if adding to an existing policy): www.oxfordhelath.com
• New Jersey Small Member Enrollment/Change Request Form with HIPAA Certificate
(only if enrolled for loss of coverage)
Adoption: The subscriber must also submit a copy of legal adoption papers
When enrollment and
ATC forms must be
submitted
Enrollment and New Jersey Small Member Enrollment/Change Request Form must be:
• Signed by the employer and employee within 31 days of the
requested effective date
• Received at Oxford within 31 days of the requested effective date
Pre-existing conditions
• 2 – 5 life groups pre-existing conditions will apply if:
- Member has less than 180 days of coverage or a gap in coverage greater
than 90 days prior to effective date of coverage
- Late enrollee
• 6+ life groups pre-existing conditions do not apply
• See “Pre-existing Condition Clause” in the Enrollment section.
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CHANGES TO EXISTING MEMBER INFORMATION
Types of changes to
inform Oxford about
When an employee
should be disenrolled
If employee resigns, is terminated, or becomes ineligible for health benefits per
the group’s policies or the provisions of the Oxford coverage
It is the Member’s responsibility to notify Oxford of any personal or family status
changes that affect eligibility for services and benefits, as defined in your
Certificate of Coverage.
How to report employee
termination/disenroll
www • Online: www.oxfordhealth.com
• New Jersey Small Member Enrollment/Change Request Form
When to notify Oxford of
termination/disenroll
ATC Form must be:
• Signed by the employer
• Received at Oxford, within 31 days of the requested date of termination. If a
New Jersey Small Member Enrollment/Change Request Form is received more than 31
days after an employee or dependent is terminated, you will be responsible for
the premium payments for a certain period following the termination.
Dates of termination
Please refer to your policy or contract to determine your group’s termination
policy.
Employees coverage ends on the first of the following:
1. Date employee ceases to be a full-time employee for any reason
2. Date an employee stops being an eligible employee
3. Date policy ends or is discontinued for a class of employees to which the
employee belongs.
4. Last day of the period for which required payments are made for the employee.
When should
a spouse/dependent
be terminated?
Coverage for spouse and/or dependent should be terminated for any of the
following reasons:
• 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
Changes that must be reported to Oxford include, but are not limited to:
• Social Security numbers for newborn children
• Termination or addition of any other group health insurance
• Changes in:
– Name
– Mailing address and Zip Code
– Primary care physician or OB/GYN
– Student status
– Disability or handicapped status
– Medicare status
– COBRA (See Continuation Coverage section)
– Family status
– Retirement*
– Death*
– Divorce*
* The group may report these types of changes to Oxford in lieu of the Member.
Please note that some of these changes may require the group’s approval in
order to terminate and/or add a Member and to elect COBRA.
Methods of requesting
change
TERMINATION
Any change that needs to be made to the Member’s personal information (i.e.
address, name, date of birth, etc.)
• New Jersey Small Member Enrollment /Change Request Form (received within 31 days
of the change)
www • Online: www.oxfordhealth.com
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Special enrollment period
Members may be added to the plan off-cycle within 90 days of any of the following:
1. Loss of coverage — under another health plan for any of the following reasons:
• Divorce/separation or termination of domestic partnership
• Death of the employee’s spouse
• Termination/reduction in hours
• Termination of group coverage/change in contribution
• COBRA or continuation has been exhausted (must enroll within 30 days)
2. Change in family status. Enrollment must be within 30 days of event of:
• Marriage
• Birth of child/adoption or placement of child in home
How to enroll during
HIPAA special enrollment
period
• If subscriber is electing coverage:
– New Jersey Small Member Enrollment/Change Request Form
– HIPAA Certificate (only if enrolled for loss of coverage)
Methods of enrollment
• If adding spouse and/or dependent to existing policy:
– New Jersey small Member Enrollment/Change Request Form
– HIPAA Certificate (only if enrolled for loss of coverage)
When enrollment and
ATC forms must be
submitted
Enrollment and New Jersey Small Member Enrollment/Change Request Form must be:
• Signed by the employer and employee within 31 days of the
requested effective date
• Received at Oxford within 31 days of the requested effective date
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Small Group Member Eligibility Requirements By State:
Connecticut Small Group
DEPENDENT (CONT.)
When a dependent
can be enrolled
Dependent may be enrolled for the following effective dates:
• Same time as subscriber
• Open enrollment
• Date of birth
• Date of HIPAA event
Student verification
Required for all dependents over age 19, but under the maximum age limit of
the group.
ENROLLMENT: EMPLOYEE/SUBSCRIBER
Who is an eligible
employee?
Any full-time employee working 30+ hours per week, unless noted otherwise in the
group’s contract, can enroll 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; or
• An employee with a HIPAA Certificate can enroll on the date of the HIPAA event
(see HIPAA Section)
Two easy ways to enroll
www • Online: Go to www.oxfordhealth.com and click on “Employers”
• Member Enrollment and Physician Selection Form (MEF) with
CT Family Health Statement (FHS)
When enrollment forms
must be submitted
Enrollment forms must be:
• Signed by the employer and employee within 31 days of the requested effective date
• Received at Oxford within 31 days of the requested effective date
Pre-existing conditions
Does not apply
Retirees
Coverage for retirees must be specified in the contract
Acceptable Proof of Verification
• Oxford Student Verification Parent Affidavit Form or letter from Registrar’s office
• Verification on school letterhead
• The Student Verification Parent Affidavit Form must:
- Be completed and signed by the covered parent on the Oxford insurance policy
- Confirm full-time status in an accredited educational institution
- Be submitted at time of enrollment to confirm eligibility
Note: The student’s Member ID or Social Security number must appear on any
student verification information
Unacceptable Proof of Verification
• Unpaid bill/Acceptance letter from an educational institution/Preregistration
forms from an educational institution/Class schedule
Important enrollment
time frames
SPOUSE
Who is eligible as a
spouse?
When a spouse can
be enrolled
Two easy ways to enroll a
Member’s spouse
• Legal spouse only
Spouse may be enrolled for the following effective dates:
• Same time as subscriber/employee
• Open enrollment
• Date of marriage
• Date of U.S. immigration on passport
• Date of HIPAA event (see HIPAA Section)
• Online: www.oxfordhealth.com
• Addition/Termination/Change Form (ATC) with:
– CT Family Health Statement (FHS) and
– HIPAA Certificate (only if enrolled for loss of coverage)
When enrollment
and ATC forms must
be submitted
Enrollment and ATC Forms must be:
• Signed by the employer and employee within 31 days of the requested effective date
• Received at Oxford within 31 days of the requested effective date
Pre-existing conditions
Does not apply
Newborn
Dependents that fail to provide valid verification by November 14 will be
terminated effective December 31 of that year. (Note: The deadline to provide
fall verification will change every year).
Coverage is automatically provided for children of the subscriber or the
subscriber’s spouse for the first 31 days from date of birth; for coverage to
continue beyond the first 31 days, a request to enroll the newborn must be
received within 31 days of the birth.
No premium is required for the first 31 days. If an additional premium is
required, Oxford may make coverage beyond the first 31 days contingent upon
notification and payment of any applicable premium. Also, if such a child is not
properly enrolled, coverage will terminate, but Oxford must still pay for covered
services received in that first 31-day period.
Adoption
All adopted children under the age of 18 are eligible for coverage from the date
of acceptance or permanent placement in the home. Dependents who are being
enrolled pursuant to a court order must enroll within 60 days of the date of the
court order. No evidence of good health is required.
DEPENDENT
Who is eligible
as a dependent?
• 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), provided the child is a full-time student
(see Student Verification)
• Any child who is disabled and can provide proof of disability, irrespective of age.
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DEPENDENT (CONT.)
Two easy ways to enroll
a dependent
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) CONT.
www
• 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 for loss of coverage)
Adoption: The subscriber must also submit a copy of legal adoption papers.
When enrollment and
ATC forms must be
submitted
Enrollment and ATC forms must be:
• Signed by the employer and employee within 31 days of the
requested effective date
• Received at Oxford within 31 days of the requested effective date
Pre-existing conditions
Does not apply
CHANGES TO EXISTING MEMBER INFORMATION
Types of changes to
inform Oxford about
Any change that needs to be made to the Member’s personal information (i.e.,
address, name, date of birth, etc.)
It is the Member’s responsibility to notify Oxford of any personal or family status
changes that affect eligibility for services and benefits, as defined in your
Certificate of Coverage.
Changes that must be reported to Oxford include, but are not limited to:
• Social Security numbers for newborn children
• Termination or addition of any other group health insurance
• Changes in:
• Name
• Mailing address and Zip code
• Primary care physician or OB/GYN
• Student status
• Disability or handicapped status
• Medicare status
• COBRA (See the Continuation Coverage section)
• Family status
• Retirement*
• Death*
• Divorce*
* The group may report these types of changes to Oxford in lieu of the Member.
Please note that some of these changes may require the group’s approval in
order to terminate and/or add a Member and to elect COBRA.
Methods of enrollment
• ATC Form (received within 31 days of the change)
www • Online: www.oxfordhealth.com
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Special enrollment
periods
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 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 child/adoption or placement of child in home
24
How to enroll during
HIPAA special enrollment
period
Two easy ways to enroll
www • Online: www.oxfordhealth.com
• If subscriber is electing coverage:
– Member Enrollment Form (MEF)
– CT 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 FHS Form (not required for newborn enrollment)
– HIPAA Certificate (if enrolled for loss of coverage)
When enrollment forms
must be submitted
Enrollment forms must be:
• Signed by the employer and employee within 31 days of the requested
effective date
• Received at Oxford within 31 days of the requested effective date
TERMINATION
When an employee
should be disenrolled
If employee resigns, is terminated, or becomes ineligible for health benefits per the
group’s policies or the provisions of the Oxford coverage
How to report employee
termination/disenroll
www • Online: www.oxfordhealth.com
• ATC Form
When to notify Oxford of
termination/disenroll
ATC Form must be:
• Signed by the employer
• Received at Oxford, within 31 days of the requested date of termination. If an
ATC Form is received more than 31 days after an employee or dependent is
terminated, you will be responsible for the premium payments for a certain
period following the termination.
Dates of termination
Please refer to your Group Enrollment Agreement (GEA) to determine your group’s
termination policy.
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 day of the month in which the Member
terminated employment
2. Date — coverage will be terminated for the same date employment was
terminated
When should
a spouse/dependent
be terminated?
Coverage for spouse and/or dependent should be terminated for any of the
following reasons:
• 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
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Small Group Member Eligibility Requirements By State:
Healthy NY
ENROLLMENT: EMPLOYEE/SUBSCRIBER
Overview
State-mandated HMO product designed to encourage small employers to offer
health insurance coverage to their employees and to also make coverage
available to uninsured employees whose employers do not provide group
health insurance
Who is eligible
• Small Groups (2-50 eligible lives)
Eligibility requirements
In order to participate in the Healthy NY program for small employers, the business must meet the following eligibility:
• The business must be located within New York State
• The small employer must have 50 or fewer eligible employees
• 30% of the employees must earn wages of $33,000* of less
• The small employer must not have provided group health insurance coverage
to their employees within the last 12 months. A small employer is considered to
have provided health insurance if the employer has both arranged for and contributed more than $50 (or $75 if the business if located in the Bronx, Kings,
Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, and
Westchester counties) per employee per month toward health insurance.
If an eligible employer opts to enroll their business in Healthy NY they must
assure that:
• 50% of the eligible employees will participate in the program and at least one
participant earns annual wages of $33,000* or less.
• The employer will contribute at least 50% of the premium
• The employer will offer Healthy NY to all employees who are working 20 or
more hours per week and earning $33,000* or less.
* These employers may be eligible for alternative small business
insurance programs.
ENROLLMENT: EMPLOYEE/SUBSCRIBER (CONT.)
How to enroll
• Contact Oxford’s Inside Consumer Sales and Marketing Department at
1-800-216-0778 for an enrollment packet
Effective dates
• The first of every month
Pre-existing conditions
• Applicable if Member had less than 12 months of continuous coverage or a
gap in coverage greater than 63 days
SPOUSE
Who is eligible
as a spouse?
• Legal spouse
• Domestic partner riders available
Method of enrollment
• Addition/Termination/Change Form (ATC) (with HIPAA Certificate if enrolled for
loss of coverage)
Pre-existing conditions
• Applicable if Member had less than 12 months of continuous coverage or a
gap in coverage greater than 63 days
DEPENDENT
Who is eligible
as a dependent?
• 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), provided the child is a full-time student (see Student
Verification)
• Any child who is disabled and can provide proof of disability, regardless of age.
When a dependent can
be enrolled
• Same time as subscriber
• Date of birth
• Date of HIPAA event
• Open enrollment
Newborn
Coverage is provided only if the child is enrolled within 30 days of birth and any
applicable premium is submitted to the group within 31 days following the birth.
Adoption
Same provision for newborns applies to newly born adopted children.
Student verification
Verification of student status is required for all dependents between the ages
of 19 and 23 and the Student Verification Parent Affidavit Form must:
• Be completed and signed by the covered parent on the Oxford insurance
policy
• Confirm full-time status in an accredited educational institution
• Be submitted at time of enrollment to confirm eligibility
Every fall semester thereafter, the student will be required to submit a
valid fall verification.
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DEPENDENT (CONT.)
Student verification
(cont.)
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Unacceptable Proof of Verification
• Unpaid bill
• Acceptance letter from an educational institution
• Pre-registration forms from an educational institution
• Class schedule
Special enrollment
periods
Note: The student’s Member ID or Social Security number must appear on any
student verification information.
Important enrollment
time frames
Dependents that fail to provide valid verification by November 14 will be
terminated effective December 31 of that year. (Note: The deadline to provide
fall verification will change every year).
How to enroll
a dependent
• Addition/Termination/Change Form (ATC) with HIPAA Certificate (only if
enrolled for loss of coverage)
Adoption: The subscriber must also submit a copy of legal adoption papers.
Pre-existing condition
• Applicable if Member had less than 12 months of continuous coverage or a
gap in coverage greater than 63 days
TERMINATION
When a Member
is disenrolled
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
How to report Member
termination/disenroll
• Member must provide written notice of termination
CHANGES TO EXISTING MEMBER INFORMATION
Any change that needs to be made to the Member’s personal information (i.e.,
Types of changes to
address, name, date of birth, etc.)
inform Oxford about
It is the Member’s responsibility to notify Oxford of any personal or family status
changes that affect eligibility for services and benefits, as defined in your
Certificate of Coverage.
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 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
Changes that must be reported to Oxford include, but are not limited to:
• Social Security numbers for newborn children
• Termination or addition of any other group health insurance
• Changes in:
– Name
– Mailing address and Zip code
– Primary care physician or OB/GYN
– Student status
– Disability or handicapped status
– Medicare status
– COBRA (See the Continuation Coverage section)
– Family status
– Retirement*
– Death*
– Divorce*
* The group may report these types of changes to Oxford in lieu of the Member.
Please note that some of these changes may require the group’s approval in
order to terminate and/or add a Member and to elect COBRA.
Methods of requesting
change
• ATC Form received within 31 days of the change
www • Online: www.oxfordhealth.com
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Oxford as the Secondary Health Insurance Carrier
Pre-existing Condition Clause
When Oxford is the secondary carrier for a Member, all claims for healthcare services must be evaluated by the
primary insurer before Oxford benefits will be considered. This includes all claims that are covered by:
What is a Pre-existing Condition?
■
Another health insurance company;
■
Auto insurance; and/or
■
Worker’s Compensation insurance
A pre-existing condition is a physical or mental condition for which medical advice, diagnosis, care, or
treatment was recommended or received within the prior 6 months of joining Oxford. During the pre-existing
period, Oxford may opt not to cover or pay for treatment of a medical condition based on the fact that the
condition was present prior to a Member's enrollment date with Oxford.
Please refer to the Coordination of Benefits (COB) section for more details.
Oxford currently applies pre-existing condition limitations to New Jersey and New York small group plans, and
individual plans.
Verifying Enrollment of New Subscribers
Exceptions:
Oxford does not impose pre-existing conditions on the following:
Where to Find Newly Enrolled Employee Information on
Your Statement
■
All newly enrolled employees (subscribers) will appear on the Invoice Details section of your monthly
billing statement.
Pregnancies;
■
Newborns enrolled within 31 days of birth; and
■
Adopted children or children placed for adoption who are under age 18 and enrolled within
days of the event.
When to Verify Enrollment – As Soon as You Receive Your Invoice
Additionally, genetically inherited medical conditions cannot be treated as pre-existing conditions.
Please be sure to carefully review the Invoice Details section of your Oxford billing statement and immediately
notify Oxford of any omissions or changes to avoid denial of
coverage at a later date. Please note: Oxford does not enroll
individuals more than 31 days from their eligibility date.
You can also verify employee
Oxford waives this limitation for a covered person’s pre-existing condition if the condition was payable under
another plan that insured the covered person right before the covered person’s coverage under Oxford’s
policy started.
See the Billing section, to view a sample Invoice Detail.
enrollment at www.oxfordhealth.com
When Does a Pre-existing Condition Limitation Apply?
after logging on to “Your Account”
Spouses and/or dependents are not listed individually. Check
the “# of Members” column to see the number of Members
associated with each subscriber’s name and ID number.
with your User Name and Password.
What to Do if Your Invoice Details Section is Not Accurate
■
Contact Group Services at 1-888-201-4216 to report any inconsistencies
■
Submit corrections on an Addition/Termination/Change Form (ATC) or enrollment form for new subscribers.
These forms must be received within 31 days of the event necessitating the change.
Please note: Corrections written on the billing statement will not be accepted.
All subsequent Oxford statements should be reviewed to ensure accuracy and corrected in the manner
described above.
For more information, please see the Invoice Details portion of the Billing section.
New York Small Group
New Jersey Small Group
www
Q: What is a pre-existing condition?
A pre-existing condition is a physical or mental condition for which the Member sought medical
advice, received a diagnosis, or received recommended care or treatment within the six months prior
to their effective date with Oxford.
Q: How much prior coverage must a Member have in order for a pre-existing condition to be covered?
Members must have 12 months of prior coverage
that was similar to their Oxford coverage.
Members must have six months of prior coverage
that was similar to their Oxford coverage.
Q: What is an acceptable lapse in coverage between the prior coverage and the Oxford coverage?
A 63-day lapse is allowed between the prior
coverage and the Oxford coverage.
A 90-day lapse is allowed between the prior
coverage and the Oxford coverage.
Oxford will credit Members for new-hire waiting periods, when applicable.
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New York Small Group
New Jersey Small Group
Q: How long would a Member be subject to pre-existing condition?
Oxford can deny coverage for a
pre-existing condition for the first
12 months after the Member’s
effective date.
NA
Reporting Changes
to Group
Information
Oxford can deny coverage for a
pre-existing condition for the first
six months (180 days) after the
Member’s effective date.
■
All Oxford employer groups may submit your request in writing on your company’s letterhead, signed by an
officer of your company, making sure to include your group number.
■
If you have less than 50 covered employees, complete a Small Group Contact/Address/Name Change Form
(New Jersey groups need to fill out a New Jersey Small Member Enrollment/Change Request Form) available by
logging on to the employer home section of www.oxfordhealth.com, www or by calling Oxford Group Services
at 1-888-201-4216.
Or
Prior coverage credit is granted
Prior coverage credit is granted on
on a month-to-month basis based a month-to-month basis based on
on the following criteria:
the following criteria:
■ That prior coverage was similar to ■ That prior coverage was similar
Oxford; and
to Oxford; and
■
Group Termination Protocol
How to Request Group Termination
All requests for voluntary termination must be submitted to Oxford by submitting a:
Q: How is credit for prior coverage determined?
There was a lapse of 63 days or
less between coverage.
To report any of the changes on the preceeding page to Oxford’s Enrollment Department:
For New Jersey small groups with
late enrollees only: Oxford can
deny coverage for a pre-existing
condition for the first 18 months
after the Member’s effective date.
A late enrollee is a Member who
did not apply for coverage within
30 days of becoming eligible for
coverage under Oxford.
■
How to Report Changes
■
Completed Group Termination Form (available from the employer section of www.oxfordhealth.com)
■
Letter on company letterhead, including:
Or
• Group name
• Group number
• Requested termination date
• Signature of an officer of the company
There was a lapse of 90 days or
less between coverage.
Reporting Changes to Group Information
No requests will be honored from the broker or writing agent unless the authorized benefits administrator has
completed, signed, and returned an Authorization for Broker to Act as Benefits Administrator Form.
Please refer to your Group Enrollment Agreement (GEA) for details on terminating your group’s policy.
Changes to Group Information You Should Report
■
Group name
■
Address
■
Tax identification number
■
Benefits administrator (BA) contact
Medical Leave of Absence
How Oxford’s Medical Leave Policy Works
You can report these changes to Group Services at any time.
Oxford will allow an employee who leaves work for an extended period due to accident or illness to remain
covered as an active employee if the company grants the employee a medical leave of absence that is consistent
with the company’s written leave-of-absence policy. Note that this written leave-of-absence policy must have been
established by your company and reviewed and approved by Oxford.
Oxford reserves the right to determine:
32
■
Whether the leave-of-absence policy is reasonable; and
■
Whether the employee is entitled to such a leave.
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For Oxford to consider an employee entitled to a medical leave of absence:
■
There must be a reasonable expectation by Oxford that the employee will recover from the injury or illness;
■
There must be a reasonable expectation by Oxford that the employee will return to work on a full-time
basis; and
■
The employer must maintain the employee status of the individual in all respects, except for payroll status.
Contract Renewal
ACTIONS YOU CAN TAKE
Call your broker or Group Services
at 1-888-201-4216.
How Long will an Employee on Medical Leave be Covered by Oxford?
Please note that in the absence of a reasonable, established medical leave policy (other than a state or federally
mandated medical leave policy), 60 days is the maximum period for which an employee will be covered. If
Oxford determines, in its sole discretion, that the employee has actually been terminated, or if it is clear that
the employee will not be returning to work within 60 days, coverage will end at the time that such a
determination is made.
RENEWAL NOTICE
(sent to small groups
60 days prior to your
renewal date)
Employees who take leave pursuant to the Federal Family and Medical Leave Act (FMLA) or an equivalent state
law may retain coverage on the same basis as active employees. Please refer to your Certificate of Coverage for
details. If necessary, contact Group Services at 1-888-201-4216.
NOTIFY OXFORD OR YOUR BROKER
WITH CHANGES TO YOUR PLAN
(i.e., add, drop or change riders,
change waiting periods, increase or
decrease deductible and coinsurance
levels, change copayments)
Log on to 'Your Account' page at
www.oxfordhealth.com and click on
the IDEA icon (available 60 days prior
to your renewal) to renew online.
Don't do anything, and your plan will
renew as is with new rates.
RENEWAL CONTRACT
Confirmation of your renewal
plan design will be sent to you.
Your signature is required if you
submit the renewal, either as-is
or with changes, by mail or fax
to Group Enrollment.
No signature is required if you,
your broker or Group Service
renews as-is or with changes
performed in IDEA.
Notes:
■
New York, New Jersey and Connecticut groups can submit changes up to the day prior to the renewal date
when using IDEA. If submitting by mail, changes should be submitted up to the 15th prior to the renewal date.
■
Your renewal period is the only time during the year that Oxford will accept changes to your plan.
Renewals and changes are contingent upon your account with Oxford being current.
■
It is your responsibility to notify Oxford of any changes to your plan. No revisions will be processed after the
renewal date. If we do not hear from you by the deadline stated on your renewal letter, the current plan
design will renew as is, and your bill will reflect the new rates as indicated in the renewal letter.
■
All premiums due for coverage periods before the renewal date must be paid in order to renew with us.
When Additional Employees Enroll at Renewal Time
■
If you need additional Member enrollment materials, contact Group Services at 1-888-201-4216 or log on to the
Employer section of www.oxfordhealth.com. www
■
If an employee did not elect coverage in the previous contract year, he or she may now elect coverage during
open enrollment as long as he or she has met the appropriate waiting period.
To help ensure a smooth transition into the new contract year, we urge you to work closely with your Oxford
sales representative or broker/consultant.
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Health Insurance Portability & Accountability Act (HIPAA)
Notice to Oxford Health Plans Members Regarding Oxford’s
Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can access
this information. Please review it carefully.
Oxford Health Plans, LLC (“Oxford”) is committed to maintaining the privacy and confidentiality of your
protected health information (PHI). PHI is information about you that is used or disclosed by Oxford to
administer your insurance coverage and to pay for the medical treatment you receive. It includes demographic
information, such as your name, address, telephone number and Social Security number, and any medical
information obtained from you or from providers who submit claims to Oxford related to your medical care.
We are required by applicable federal and state laws to maintain the privacy of your PHI. This document serves
as the required Notice of Oxford’s privacy practices, our legal duties, and your rights concerning your PHI.
Oxford is required to abide by the terms of this Notice unless and until it is amended. This Notice took effect
April 14, 2003, and will remain in effect until such time that it is amended or replaced.
Oxford reserves the right to change our privacy practices and the terms of this Notice at any time, provided that
applicable law permits such changes. We reserve the right to make the changes in our privacy practices and the new
terms of our Notice effective for all PHI that we maintain, including information we created or received prior to any
such changes. When Oxford makes a significant change in our privacy practices, we will revise this Notice and send
the revised Notice to our health plan subscribers.
For additional copies of this Notice, please call our Customer Service Department at the toll-free number on your Oxford ID
card, or visit our web site at www.oxfordhealth.com.
Q. How does Oxford use or disclose your PHI?
A. Oxford may use or disclose your PHI, without your consent or authorization, under the following
■
Required by Law: We may use or disclose your PHI when we are required to do so by law. For example,
upon request, we would disclose PHI to the U.S. Department of Health and Human Services so that this
agency can verify Oxford compliance with federal privacy laws.
■
Health Oversight Activities: We may disclose your PHI to health oversight organizations and agencies as
part of accreditation surveys, investigations related to our eligibility for government programs,
regulatory audits, and for licensure and disciplinary actions.
■
Workers’ Compensation: We may disclose your PHI to comply with laws relating to workers’
compensation or other similar programs that provide benefits for work-related injuries or illnesses.
■
Public Health and Safety: We may disclose your PHI to the extent necessary to avert an imminent threat to
your safety or the health or safety of others. We may disclose your PHI to appropriate
authorities if we have reasonable belief that you might be a victim of abuse, neglect, domestic violence,
or other crimes.
■
Judicial and Administrative: We may disclose your PHI in response to a court or administrative order,
subpoena, discovery request, or other lawful process.
■
Sale of Business: We may disclose PHI upon sale of all or part of Oxford’s business to another party.
■
Law Enforcement: We may disclose limited information to law enforcement officials concerning the PHI
of a suspect, fugitive, material witness, crime victim or missing person. Under certain
circumstances, we may disclose the PHI of an inmate or other person in lawful custody of a law
enforcement official or correctional institution.
■
Military and National Security: Under certain circumstances, we may disclose the PHI of armed forces
personnel to military authorities. We may disclose PHI to authorized federal officials when required for
national security or intelligence activities.
■
To Family and Friends: If, in the event of a medical emergency, you are unable to provide any required
authorization, we may disclose PHI to a family member, friend or other person to the extent necessary to
ensure appropriate medical treatment or to facilitate payment for that treatment.
Q. Does Oxford ever need an authorization to use or disclose your PHI?
circumstances:
■
■
Treatment: We may disclose your PHI to a healthcare provider who requests it in order to provide you with
necessary medical treatment, such as emergency care, X-rays or lab work. A provider might be a doctor, a
hospital, a home healthcare agency, etc.
A. Yes. Except for the purposes described above, Oxford cannot use or disclose your PHI without a signed
Payment: We may use or disclose your PHI to pay claims submitted by a healthcare provider for
treatment provided to you. For example, we may ask a hospital emergency department for details about
the treatment you received so that we can accurately pay the hospital for your care.
Q. Can you inspect or receive copies of any PHI in Oxford’s possession?
■
Healthcare Operations: We may use or disclose your PHI to manage our business. Examples include using
it to determine appropriate premiums, to conduct quality improvement activities, to contact you regarding
benefits or services that might be of interest to you, and to provide you with preventative health advisories.
■
Plan Sponsor: We may disclose limited PHI to your health plan sponsor, benefits administrator, or group
health plan in order to perform plan administrative functions, such as activities related to billing and renewals.
■
Underwriting: We may receive your PHI for underwriting, premium rating or other activities relating to
the creation, renewal or replacement of a contract of health insurance or health benefits. Once an Oxford
Member, use and disclosure of your PHI is governed by this Notice.
■
Marketing: We may use your PHI to contact you with information about health-related benefits and
services, treatment alternatives, or appointment reminders.
■
Research; Death; Organ Donation: In limited circumstances, we may use or disclose your PHI for research
purposes or to a coroner, medical examiner, funeral director or an organ procurement center.
36
authorization from you. If you provide such an authorization to Oxford, you may revoke it at any time.
Your revocation will not affect any use or disclosure of PHI made while the authorization was in place.
A. Yes. You have the right to inspect or receive copies of your PHI with certain exceptions. You must make a
request to Oxford in writing. Oxford reserves the right to charge a reasonable fee for the cost of producing
and mailing the PHI. Request forms are available on the Oxford web site or by calling the number listed at
the end of this Notice.
Q. Can you find out if Oxford disclosed your PHI to a third party?
A. Yes. You have the right to receive an accounting of all occasions when Oxford disclosed your PHI for any
purpose other than treatment, payment, healthcare operations and certain other instances. Beginning with
disclosures made on or after April 14, 2003, we will maintain a record of disclosures for six (6) years. A
request for an accounting must be submitted to Oxford in writing. We reserve the right to charge you a
reasonable fee for the cost of producing and mailing the information if you request this accounting more
than once in a 12-month period. Please note, that Connecticut and New Jersey Members will automatically
get an abridged accounting whenever they make a request to inspect or receive copies of their PHI.
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Q. Can you restrict the use or disclosure of your PHI by Oxford?
Privacy Notice Concerning Financial Information
A. Yes. You have the right to request that Oxford place additional restrictions on the use or disclosure of your
At Oxford Health Plans, LLC ("Oxford"), protecting the privacy of the personal information we have about our
customers and Members is of paramount importance, and we take this responsibility very seriously. This
information must be and is maintained in a manner that protects the privacy rights of those individuals. This
notice describes our policy regarding the confidentiality and disclosure of customer and Member personal
financial information that Oxford collects in the course of conducting its business. Our policy applies to both
current and former customers and Members.
PHI. We are not required by law to agree to these restrictions. However, if we do agree to the restrictions, we
will abide by them except in the event of an emergency.
Q. Can you request that Oxford use alternate means to confidentially communicate with you about your PHI or
communicate with you at an alternate location?
A. You must inform Oxford, in writing, that confidential communication by alternate means or to an alternate
location is required to avoid potential harm to yourself or others. We must accommodate your request if it is
reasonable, specifies the alternate communication means or location, and does not interfere with the collection
of premiums, the payment of claims, or the administration of your health insurance coverage.
The Information Oxford Collects
We collect non-public, personal financial information about you from the following sources:
■
Information we receive from you on applications or other forms (such as name, address, Social Security
number and date of birth.)
■
Information about your transactions with us, our affiliates (companies controlled or owned by Oxford), or
others; and
■
Information we receive from consumer reporting agencies concerning large group customers.
Q. Do you have the right to request that Oxford correct, amend, or delete your PHI?
A. Yes. You must make your request in writing, and it must explain why the PHI should be corrected, amended,
or deleted. Oxford may deny your request if we did not create the PHI in question or for certain other
reasons. If we deny your request, we will provide you with a written explanation. You may respond with a
statement of disagreement to be added to the information you sought to change. If we accept your request to
correct, amend, or delete the PHI, we will make reasonable efforts to inform others of the changes and to
include the changes in any future disclosures of that information.
Complaints
To express concern about a decision Oxford made about access to your PHI, to report a concern that we violated
your privacy rights, or to express a complaint about any aspect of Oxford’s privacy practices, please contact the
HIPAA Member Rights Unit at the address below. You may also submit a written complaint to the Secretary of the
U.S. Department of Health and Human Services at the following address:
The Information Oxford Discloses
We do not disclose any non-public, personal financial information about our current and former customers and
members to anyone except as permitted by law. For example, we may disclose information to affiliates and other
third parties to service or process an insurance transaction; or provide information to insurance regulators or
law enforcement authorities upon request.
Oxford Security Practices
Office of the Secretary
Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
We emphasize the importance of confidentiality through employee training, the implementation of procedures
designed to protect the security of our records, and our privacy policy. We restrict access to the personal
financial information of our customers and members to those employees who need to know that information to
perform their job responsibilities. We maintain physical, electronic, and procedural safeguards that comply with
federal and state regulations to guard your non-public, personal financial information.
Telephone: 1-877-696-6775
This notice is being provided on behalf of the following Oxford affiliates:
Oxford Health Plans, LLC
Oxford Health Plans (CT), Inc.
Oxford Health Plans (NJ), Inc.
Oxford Health Plans (NY), Inc.
Oxford Health Insurance, Inc.
Investors Guaranty Life Insurance Company
Oxford Benefit Management, Inc.
Oxford supports your right to protect the privacy of your PHI and will not retaliate against you for filing a
complaint with any government regulatory body or with us.
If you received this Notice on our web site or by electronic mail (e-mail), you are entitled to receive a written
copy of the Notice as well. To request a written copy of the Notice, please call our Customer Service Department
at the toll-free number on your Oxford ID card, or call 1-800-444-6222. You can also contact us by mail at:
HIPAA Member Rights Unit
Oxford Health Plans
48 Monroe Turnpike
Trumbull, CT 06611
All written communications related to this Notice and your rights under HIPAA should be mailed to the HIPAA
Member Rights Unit at the address above.
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If you would like a copy of these Notices in Spanish, please contact Oxford Customer Service at the
number on the back of your Oxford Member ID card.
■
If you would like a copy of these Notices in Chinese, please contact Oxford Customer Service at the
number on the back of your Oxford Member ID card.
■
If you would like a copy of these Notices in Korean, please contact Oxford Customer Service at the
number on the back of your Oxford Member ID card.
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enrollment
enrollment
Overview of Oxford’s Policy Regarding the Release of
Confidential Member Information
Confidential Member Information
When it comes to personal medical records, Oxford strongly believes that it must safeguard all medical
information about its Members. Oxford will disclose confidential medical information only if authorized by a
Member or when required by law. Confidential medical information is considered to be any Member-specific
information gathered as part of the patient care process, including, but not limited to, information on services
received, referrals/provider names, results of services, diagnoses/CPT codes, treatment, copies of Explanation of
Benefits (EOBs), and appointment information.
At Oxford, medical records are treated with utmost respect and confidentiality. Access to medical records is
limited to persons who need to see them, such as Oxford Medical Management staff responsible for reviewing
and authorizing treatment. Oxford employees with access to medical information are trained in the standards
and protocols that come with this responsibility and are monitored to ensure that they are in compliance with
confidentiality policies and procedures.
How to Request Confidential Member Information
In order for an Oxford Group Service Associate to release confidential medical information regarding a
Member’s claims, Oxford requires that the Member complete and sign the HIPAA Member Authorization Form.
This authorization form provides Oxford with:
■
A signed, written release from the Member in question (or from a legal guardian/power of attorney, with
appropriate documentation), authorizing us to release the confidential information to the benefits administrator or broker.
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In addition, the authorization form has a box to check to authorize the Member’s BA or broker to file an
initial appeal or grievance on the Member’s behalf concerning any claim issue covered by the
authorization form. Please note: If the employee (i.e., Member) has already filed an initial appeal, the BA
or broker cannot file another appeal for that Member regarding the same issue.
To obtain a copy of the HIPAA Member Authorization Form on the following page contact Oxford Group Services at
1-888-201-4216 or download it from the Employer home page at www.oxfordhealth.com.
HIPAA Member Authorization Form
Except as otherwise permitted or required by applicable federal and state laws and regulations, Oxford Health
Plans must obtain an authorization before using or disclosing protected health information (“PHI”).
Upon receipt of a valid authorization for its use and/or disclosure of PHI, Oxford will make such use and/or
disclosure in a manner consistent with such authorization.
To: Oxford Health Plans
Attn: Correspondence
P.O. Box 7081
Bridgeport, CT 06601-7081
Member Name: ____________________________________________________________________________________
Member ID Number: ______________________________________________ Telephone: _____________________
Address:
________________________________________________________________________________________
______________________________________________________________________________________________
Description of PHI: A description of the PHI to be used or disclosed:
______________________________________________________________________________________________
______________________________________________________________________________________________
Persons Authorized to Use or Disclose: The person(s), class of persons, or entity to whom Oxford is authorized
to make the use or disclosure:
______________________________________________________________________________________________
______________________________________________________________________________________________
Description of each Purpose to Use or Disclose: A description of each purpose of use or disclosure
(the statement “at the request of the Member” is sufficient):
______________________________________________________________________________________________
______________________________________________________________________________________________
Prior to submitting the authorization form to Oxford, please contact Oxford Group Services to obtain the
proper mailing address or fax number for submitting the authorization form. Once Oxford receives the completed authorization form, employee claim information will be made available over the phone by a Group
Service Associate. Due to privacy concerns, BAs and brokers cannot access employee claims information through
our web site; however, Oxford Members can view their own claim information online through our Member web
site at www.oxfordhealth.com. Members can also contact Oxford’s Customer Service Department to discuss their
own claims.
Does the person(s), class of persons, or entity named above that Oxford is authorized to make the use or disclosure to also have the authority to file an appeal and/or grievance on behalf of the Member?
Member Information that does not Require a Signed, Written Authorization
❐ Remain in place until____________. (Date)
(check one) ❐ Yes
❐ No
Expiration:
This authorization will expire:
As your group’s BA, the following information regarding a Member’s claim can be requested without the
Member’s signed, written authorization: claims payment date, check number, and claim status (i.e., paid, denied,
currently in process). Any further information would require that the authorization form be submitted,
as noted above.
❐ On occurrence of the following event (which must relate to the Member or to the purpose of the use and/or
disclosure being authorized):
____________________________________________________________________________________
____________________________________________________________________________________
40
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enrollment
HIPAA Member Authorization Form (cont.)
coverage policy
and
Revocation:
I understand that I may revoke this authorization at any time by giving written notice of my revocation to the
HIPAA Member Rights Unit at the address provided below. I understand that any revocation of this authorization
will not affect any action Oxford took in reliance on this authorization before Oxford received my written notice
of revocation. I also understand that any revocation of this authorization will not result in my disenrollment
from Oxford or denial of my eligibility for benefits.
at a glance
HIPAA Member Rights Unit
Oxford Health Plans
48 Monroe Turnpike
Trumbull, CT 06611
Note the following:
• As an Oxford Member, your decision to sign this Authorization is voluntary and said decision will not impact
treatment, payment, enrollment or eligibility for benefits under your Oxford coverage plan.
• If you instruct Oxford to release all of your PHI, please be aware that such release may include information
relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human
immunodeficiency virus (HIV). It many also include information relating to alcohol or drug abuse, genetic
testing, psychiatric care and behavioral or mental health services and treatment.
• The PHI disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no
longer protected by federal and state laws and regulations.
Signature:
What is a Primary Care Physician (PCP)?
Pharmacy Coverage
What is the Difference Between
In-Network & Out-of-Network Coverage?
How Emergencies &
Urgent Care are Covered
How Oxford’s Referral Policy Works
Oxford Plans at a Glance
When is Precertification Required?
Oxford Coverage/Policy Contact
Information
■
• 1-800-905-0201
Do you have benefits questions? (Please have your
group number ready)
■
Please call Oxford Group Services at
1-888-201-4216, Monday to Friday, 8:00 AM
to 5:00 PM or
■
E-mail: [email protected]. In general,
we will respond within 24 hours. www
I have read and understand the contents of this document and am hereby providing my agreement to the terms
of this Authorization.
Signature:*
• www.medcohealth.com
■
■
Date:
Oxford Members can call our Customer Service
department at 1-800-444-6222,
Monday to Friday, 8:00 AM to 6:00 PM
Since the benefits for each plan vary somewhat, be
sure you read your group’s Summary of Benefits and
Certificate of Coverage carefully — they are your
definitive source for information about your
group’s coverage.
Do you need to confirm a referral?
* If a personal representative of an Oxford Member signs this Authorization, please provide a
description and any available documentation of the authority to act in this capacity.
www
■
www.oxfordhealth.com
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Oxford Express® 1-800-444-6222, 24 hours a day/
7 days a week
Other helpful reference information:
■
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www
Oxford On-Call®: 1-800-201-4911, 24 hours a day/
7 days a week (Available only to Members in
Connecticut, New Jersey, and New York.)
There are many benefits to being an Oxford
Member — and many different Oxford plans to
choose from. We created this overview of the
common characteristics of Oxford’s primary
products, as well as the key procedures for
accessing medical care.
Do you need to direct an employee with Oxford
benefit questions?
Print Name:
Pharmacy Customer Service from Medco Health
Solutions:
Precertification for diagnostic procedures at
CareCore National: 1-877-773-2884
(1-877-PREAUTH)
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