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Q & A Select/PPO Plans

Q: How do I choose or change my doctor?
A: Simply choose your doctor from the listing of primary care physicians (PCPs) in Oxford's Roster of Participating Physicians and Providers or search for a doctor on our web site, oxfordhealth.com. Women can also select an OB/GYN to provide additional preventive care. If you have children, you may select an Oxford pediatrician as their PCP. You may change your PCP at anytime by using our web site or by calling Member Services at the number on the back of your Member ID card.

Q: What if I want to see a doctor who's out-of-network?
A: Visits to out-of-network physicians will be subject to deductible, coinsurance payments, and Usual, Customary and Reasonable (UCR) charges limitations. You also need to submit claim forms. However, if you have the HMO Select Plan, you are responsible for all out-of-network costs, since HMO Select Members do not have out-of-network benefits. When visiting an in-network physician, Members are only subject to a copayment for most covered services.

Q: If I need to see a specialist, will I need a referral?
A: Oxford gives you open access to thousands of board-certified or recently board-eligible participating specialists when seeking care in-network. You do not need a referral to see a participating specialist to be eligible for in-network coverage. If you see an out-of-network specialist, you are responsible for paying any deductibles, coinsurance, and are subject to UCR charges limitations. However, if you have the HMO Select Plan, you are responsible for all out-of-network costs, since HMO Select Members do not have out-of-network benefits.

Q: What if I need to be admitted to the hospital?
A: All inpatient hospital stays require precertification. If you are admitted to the hospital as a result of an emergency room visit or by your PCP or Oxford specialist, you do not need to fill out any claim forms or satisfy any deductible, and your hospital expenses will generally be completely covered (some plans require a copayment or deductible and coinsurance). If admitted to an out-of-network hospital, you are responsible for obtaining precertification, paying any deductibles, coinsurance and are subject to Usual, Customary and Reasonable (UCR) charges limitations. However, if you have the HMO Select Plan, you are responsible for all out-of-network costs, since HMO Select Members do not have out-of-network benefits.

Q: What standard benefits are included in my Oxford coverage at no charge?
A: Because Oxford wants to help you make healthier decisions, we offer a wide range of preventive programs and benefits. These range from wellness programs to reminders for routine care. All plans feature one physical with your PCP every 12 months at no charge. Members should check their Summary of Benefits for details on other benefits that are available at no charge.

Q: How are my children covered under my plan? What benefits do they receive at no charge?
A: If enrolled, your children are covered as dependents under your plan. Your children receive the same standard benefits that any other Oxford Member would, as well as childhood immunizations, adolescent well-care, routine pediatric care through age 19, and in-network preventive dental care through age 11.

Q: Are prescription drugs covered?
A: Oxford offers various prescription drug benefit programs to help defray the rising costs of prescription drugs. Check your Summary of Benefits or contact your Benefits Administrator for details about the plan for which you may be eligible.

Q: Do I need to submit claim forms?
A: Members do not need to submit claim forms for in-network services. You must submit claim forms for out-of-network services in order to receive payment, subject to deductible, coinsurance and Usual, Customary and Reasonable (UCR) charges limitations. However, if you have the HMO Select Plan, you are responsible for all out-of-network costs, since HMO Select Members do not have out-of-network benefits.

Q: Do I have to pay a deductible or coinsurance?
A: If you visit an in-network provider for a covered service, you are generally responsible only for a copayment. Check your Summary of Benefits for more information. If you visit an out-of-network provider, you are responsible for any applicable deductible, coinsurance and are subject to Usual, Customary and Reasonable (UCR) charges limitations. However, if you have the HMO Select Plan, you are responsible for all out-of-network costs, since HMO Select Members do not have out-of-network benefits.

Q: When can I enroll with Oxford? What if I get married or have a child?
A: If you are not a newly-eligible employee, you may only enroll during your company's annual Open Enrollment period. Oxford Members may add dependents to their plan in the event of the birth (or adoption) of a child or marriage. Contact your Benefits Administrator for more information.

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