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Drug Formulary

Your Account > QUESTIONS BROKERS ASK US

Questions Brokers Ask Us

  
Coverage/Benefits
Cobra
HIPAA
Products
Pharmacy
Enrollment and Renewals
Eligibility
Provider Network
Premiums/Rates and Quotes
Notification of Changes
Claims
Broker Eligibility/Commissions


Coverage/Benefits

Will your plan send out detailed benefits information to employees?
Yes. Each subscriber will receive a Summary of Benefits and Certificate of Coverage upon initial enrollment with Oxford or when a change is made to their Oxford benefits during a renewal period.

What is a pre-existing condition and how can it impact coverage?
A pre-existing condition is a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to the enrollment date, or for New Jersey individual plan Members, a condition for which an ordinarily prudent person would have sought medical advice, care or treatment during that time period.

For certain lines of business in certain states, benefits and/or coverage may be limited or excluded based on the identification of a pre-existing condition.

Do you issue policies to minors?
Yes. Oxford issues policies to minors, but only under certain conditions. A parent or guardian would need to provide their signature and accept responsibility for the policy.

When does coverage begin?
Coverage begins on the policy activation date at 12:01 AM.

What type of wellness or health promotion programs do you offer to your Members?
Oxford offers various wellness and disease management health programs that are geared toward preventive and condition-specific care.


Cobra

Does COBRA coverage count as creditable coverage?
Yes. COBRA coverage counts as creditable coverage.


HIPAA

Who is affected by the Health Insurance Portability and Accountability Act (HIPAA)?
HIPAA affects HMOs, insurance companies, providers and clearinghouses, as well as business associates of these entities. Members and customer groups are also affected.

How are credits for pre-existing condition waiting periods applied under HIPAA?

A policyholder will receive credit for prior creditable coverage as long as any gap in coverage is for no more than:

  1. 63 days for New York individual plans, New York small groups, Pennsylvania small groups, and Delaware small groups;
  2. 90 days for New Jersey small groups; and
  3. 31 days for New Jersey individual plans.

The prior creditable coverage time periods are 12 months for all group and plan types listed above except for New Jersey small groups, which have a six-month coverage time period.

How will the latest HIPAA requirements regarding security, privacy, etc. affect the products your plan offers?
HIPAA does not directly affect the products Oxford offers, but rather the policies and procedures utilized by Oxford.

What qualifies as creditable coverage?
Any health coverage that is similar to the coverage the Member will receive on an Oxford policy qualifies as creditable coverage. See the second question under the HIPAA section for the required time periods.

How does an employer-imposed waiting (elimination/probationary) period affect a break in coverage?
Members are not held responsible for an employer-imposed waiting (elimination/probationary) period. Coverage is counted from the date of hire, not the Member's effective date of coverage.

How does a new employer or insurance carrier know that an employee had prior group coverage?
Every Member should receive a HIPAA Certificate upon termination of coverage. The HIPAA Certificate will provide the Member's dates of coverage under that carrier.

How does HIPAA legislation affect individual coverage?
HIPAA legislation is the same for both commercial and individual plan coverage.


Products

What products and services do you offer?
Oxford offers a wide variety of commercial and Medicare Advantage products and services.
Click here to view a listing of our products and services.


Pharmacy

Does a group or a subscriber within a group have to take prescription drug coverage?
Depending on the line of business, pharmacy coverage may or may not be available to the group. However, a subscriber within a group that has pharmacy coverage cannot decline the pharmacy coverage.


Enrollment and Renewals

What documentation is necessary for enrolling a group?
To review the necessary documentation needed for enrolling or renewing a group, please view our Selling Oxford section located on Your Account page.

Does renewal paperwork require signatures from the broker and/or the group if there are no changes other than the renewal rates?
No. Provided the group's existing plan design is still available, Oxford will automatically renew a group without signatures from the group or broker if there are no requested changes.

How are effective dates (or enrollment deadlines) assigned to groups?
Groups may choose the 1st or the 15th of the month as their effective date (this date also serves as their enrollment deadline). Enrollment packets must be received on or before the chosen effective date.

Exception: New Jersey groups may choose any day of the month as their effective date (this date also serves as their enrollment deadline). Enrollment packets must be received on or before the chosen effective date.

Can a group upgrade their medical and/or dental policy at a time, other than on the renewal date, if the group has grown?
Depending on the line of business and conditions of the growth, a group may be able to make upgrades to the policy at a time other than the renewal period.

Can a group downgrade to a different product at a time, other than renewal date?
A group cannot downgrade to a different product during the first year of their contract. However, after the group's first renewal, a group may downgrade to a different product once per 12-month period.

How do I submit enrollment files to the plan?
Based on certain rules and conditions, enrollment files may be submitted electronically on an Oxford form or via e-mail.

Can I e-mail enrollment files to the plan?
Based on certain rules and conditions, enrollment files may be submitted via e-mail.

When will I receive the renewal information for a group enrolled with your plan?
Oxford mails renewal information 60 days prior to the group's renewal date.


Eligibility

What is the average turnaround time required to determine a group's or a subscriber's underwriting or eligibility status?
On average, group and subscriber applications are reviewed within four business days to determine underwriting or eligibility status.


Provider Network

Describe your provider network.
Our network of commercial and Oxford Medicare AdvantageSM providers includes over 50,000 providers and 220 hospitals in Connecticut, New Jersey and New York.* Our Freedom Plan DirectSM in Delaware and Pennsylvania and our Individual plans in Delaware utilize the MultiPlan network of providers. The Oxford USASM plan utilizes the First Health® Network of providers. Specific information about Oxford's providers is available online through our
Doctor Search tool. You can also order a provider roster online.

* As of 6/30/02. This data represents all participating providers except ancillary providers. Dental and complementary and alternative medicine providers are included. Providers who are multiply boarded are counted multiple times.

How often are your printed and online provider rosters updated?
Our printed rosters are updated twice a year. Our online Doctor Search tool is updated weekly.


Premiums/Rates and Quotes

Is payment required at the time of application?
Yes. Oxford is a pre-paid plan. Therefore, each group application must include a binder check, which is equal to one month's premium.

How do I obtain a small group (2 to 50 employees) quote?
Depending on the line of business, small group quotes may be obtained on our web site, through an Oxford sales representative, or through Group Services upon renewal time.

How do I obtain a large group quote?
Large group quotes must be obtained from Oxford's Sales Department.

What percentage of the premium does the employer have to contribute?
Minimum employer contributions are mandated by each state.


Notification of Changes

Who must be notified of a change of address or other administrative changes?
Administrative changes should be mailed to:
    Oxford Health Plans,
    Attn: Group Enrollment,
    P.O. Box 7085
    Bridgeport, CT 06601-7085,
or e-mailed to
groupservices@oxfordhealth.com by an authorized listed contact of the group.

How do I change the waiting (elimination/probationary) period on a group's policy?
A group's waiting (elimination/probationary) period can only be changed when the group renews. A written request should be returned with the renewal or submitted separately.

Exception: New Jersey small groups can change their waiting period at any time.

What is the maximum waiting (elimination/probationary) period a group can impose?
The maximum waiting (elimination/probationary) period varies based on the product selected and group's line of business.


Claims

How are claims handled for employees with more than one health insurance plan?
A coordination of benefits may take place between the health insurance carriers based on the claim submitted, the coverage provided, and the primary carrier.


Broker Eligibility /Commissions

How do I become a broker for your company?
All brokers must be licensed by the state in which they will do business and appointed by Oxford to sell Oxford products. Brokers should contact our Commissions Department for more information or necessary forms and contracts.
    Oxford Health Plans, Inc.
    Attn: Broker Commissions & Licensing Department
    48 Monroe Turnpike
    Trumbull, CT 06611
    888-666-6844

How and when will I receive commission payments?
All monthly commission statements are mailed by the 15th day of the month following the month in which the premium is received.

Can I have my commission deposited directly to my bank account?
No. Oxford does not currently offer direct deposit for commissions.


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