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The Important: Legal Notice Regarding Changes to Your Oxford* Small Group Health Coverage to Take Effect at Your Next Renewal in 2016.

The following coverage changes are required and will be implemented at your next renewal in 2016 for the offerings referenced in this renewal package.

The benefit changes include:

• Delivery of Covered Services Using Telehealth: If the member’s network provider offers covered services using telehealth, the service will be subject to the same terms and conditions that would apply if the same service was delivered in person. These include medical necessity, quality assurance and other terms and conditions of the Certificate.
• General Provisions: Members must start any lawsuit against us within two (2) years from the date the claim was required to be filed. The prior language allowed one additional year to bring the action.
• Infertility Treatment: The COC has been updated to clarify that gender reassignment procedures are not excluded from coverage. When requested as part of an infertility treatment, these procedures will be reviewed for medical necessity.
• Mail Service Member Select: A new pharmacy program will take effect for maintenance prescription drugs. After the first two prescription orders, maintenance prescription drugs must be obtained through mail order pharmacy or the member must opt-out of this program. Members will receive a letter explaining the program change before it becomes effective. Upon notification, the member will need to either enroll their maintenance medications in the mail order pharmacy program or disenroll from the program. If no action is taken and the member continues to use a retail pharmacy, the member must pay 100% of the drug cost.

• Medications for Use in the Office and Outpatient Facility: The COC was updated to clarify that this benefit also covers medications and injectable drugs when they are administered in an office setting. Please remember for benefits to be available, administration in an outpatient facility setting must be medically necessary.

• Members Eligible for Medicare Coverage – The exclusions and limitations have been updated to clarify that we reduce claim payments for members who are eligible for Medicare. Once eligible, benefits will be reduced by the amount Medicare would have paid for covered services unless otherwise required by law. This reduction will be taken even if a member fails to enroll in Medicare or does not pay his or her Medicare premium. Benefits for Covered Services will not be reduced if we are required to pay first under federal law or if the member is not eligible for premium-free Medicare Part A.

• Mental Health, Neurobiological Disorders, Substance Use Disorders (aka ‘mental health parity’): When using services for outpatient mental health, substance use disorders, neurobiological disorders, or autism spectrum disorders, member claims will process as a standard office visit or as partial hospitalization or intensive outpatient treatment. There are different co-pays or co-insurance for each.

• Pediatric Vision and Pediatric Dental: The benefits were updated to extend coverage for members who turn 19 through the end of the month in which the member turns 19.

• Plans Requiring Referrals: All referrals must now be submitted electronically. In addition, if your plan requires referrals and has Out-of-Network benefits, the COC clarifies that care from participating providers will be treated as being out-of-network when it is received without being provided, arranged or authorized in advance by your primary care physician (PCP) and, when required, approved by us.

• Prescription Drug Coverage:

  • Smoking Cessation: The COC has been updated to clarify that over the counter smoking cessation drugs are covered when prescribed by a physician.

  • Formulary Exception Process: If a Prescription Drug is not on our Formulary, a member may request a Formulary exception for a clinically-appropriate Prescription Drug. The process for requesting an exception has been updated to provide additional information about how to submit a request and the information that needs to be submitted to the member’s physician. Members should review this information before requesting an exception.

  • Step Therapy: Step therapy is a process which may require a member to try an alternate prescription drug before we cover the cost of the requested drug. The COC clarifies that the process may require a member to try more than one type of prescription drug before benefits are available for the requested Medically Necessary drug.

  • Specialty Prescription Drugs: The COC has been updated to explain that these drugs may be limited to a 30-day supply when obtained at a retail or mail order pharmacy. After renewal, members may call the number on their ID card for more information on supply limits for specialty Prescription Drugs.

• Prosthetics: The COC continues to cover the cost of only one (1) external prosthetic device, per limb, per lifetime. The COC previously covered repair and replacement for children only. The COC now covers the cost of medically necessary repairs or replacement for both adults and children. It does not provide benefits for costs covered under warranty or if the repair or replacement is the result of misuse or abuse by the member.

• Referrals and Out-of-Network Services: As we explained last year, new state law expanded and enhanced member rights related to referrals and out-of network services. This year’s certificate clarifies some requirements including how the member can obtain the form required to initiate review of a surprise bill.

• Standard Cost-Sharing: Please see the “Plan Design” grid under the “Other Changes to Your Current Health Insurance Policy” of your renewal package for certain changes to cost-share amounts that may have been made to your plan. Additional information about member cost-share and benefit changes is contained in your Summary of Benefits and Coverage (SBC).

• Utilization Review and External Appeal: The medical necessity review processes have been updated. The main changes include clarifications about the Formulary Exception process (discussed above under prescription drug benefits) and updates to the review of the court ordered mental health and/or substance use disorder services before services are provided.

• Wellness Benefit: The Certificate of Coverage (COC) has been updated with a new wellness program that gives members access to a health and wellness tool intended to engage our members. This change will be effective upon renewal, beginning with January 1, 2016 effective dates. Members should check their COC for more information. Additional information regarding the wellness program is available on the employer portal of Oxfordhealth.com under the “Manage Your Health” section of the “Tools and Resources”.

* Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.

Employee Health and Benefits