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Oxford Plans at a Glance

Quick Start Enrollment Tips Reporting Changes to Group Information

Member Enrollment and Eligibility Charts Group Termination Protocol

Oxford as the Secondary Health Medical Leave of Absence Insurance Carrier

Verifying Enrollment of New Subscribers Contract Renewal

Health Insurance Portability and Accountability Act (HIPPA)

At a glance

Enrollment Contact Information

Do you have enrollment questions? • Please contact your Account Manager or

call Client Services at 1-888-654-0065. • E-mail: groupservices@oxfordhealth.com

Response time is generally within 24 hours

For online enrollment and to download enrollment forms • Go to www.oxfordhealth.com • Log on to the Employer section • Click on the Tools and Resources tab.

Forms can be found under Practical Resources.

• Make real-time changes by using our online enrollment transactions under the Transactions tab.

Send Enrollment Forms to:

Oxford Enrollment Department P.O. Box 7085 Bridgeport, CT 06601-7085

Send New Group Submissions to:

Oxford New Group Submissions Department 14 Central Park Drive Hooksett, NH 03106

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Quick Start Enrollment TipsWhether you are a new group or a renewing group, we would like to thank you for choosing us. We know that, regardless of your status, there can be some confusion when it comes to understanding health benefits and enrollment.

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 plan.

To make your job easier, download, order, and/or use the following materials and tools from our web site at www.oxfordhealth.com.

• Rosters of Participating Physicians and Providers

• 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 your active Contract Specific Package(s) (CSP), where applicable:

New groups: call Client Services at 1-888-201-4216

Current groups: look on your billing statement

• Employees must complete all Employee and Dependent Information sections

Questionnaires will be mailed within 31 days to members who do not adequately complete the coordination of benefits section of the enrollment form.

• 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, we 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.

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This is a sample of the New York Member Enrollment Form-OHI used for New York large employer groups. To view and download this and all other enrollment forms, log on to the Employer page at www.oxfordhealth.com and click on the Tools and Resources tab. Forms can be found under Practical Resources.

Materials

A roster of Participating Physicians and Providers

BA Bulletin

Gym Reimbursement brochure

Pharmacy Q&A

Spanish/English Q&A

Healthy Bonus® brochure

Member brochure

Replacement ID cards

Forms

Member Enrollment

Dental Enrollment

Addition/Termination/Change

Student Verification/Parent Affidavit

Need Additional Enrollment Materials?

Just log on to the employer site at www.oxfordhealth.com or contact Client Services to either download or order any of the following materials (please allow 5 days for delivery): www

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Where to Send Enrollment Forms

All enrollment forms must be sent directly to:

Oxford Enrollment Department P.O. Box 7085 Bridgeport, CT 06601-7085

IMPORTANT NOTE: Do not send enrollment forms to Client Services or your 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, call Client Services at 1-888-654-0065

• Certificates of Coverage will be mailed to each subscriber. However, spouses and dependents will not receive a copy unless they request one.

Member Enrollment and Eligibility Charts

Electronic Data Interchange (EDI) – eligibilitydatafile@oxhp.com

If your company has the ability to pull employee and dependent demographics extracts from your current HR database, and format into a specific text file layout (provided by us), extracting these electronic files and submitting them directly to our Enrollment Department will be more efficient than paper/report submission. It’s fast, easy and efficient. Electronic submission allows us to immediately compare our data against your data, noting any discrepancies, which results in increased accuracy of group membership. You will also receive consistent feedback from our Enrollment Department regarding eligibility and file issues.

Need help getting started? We have a team of EDI specialists that can assist you with the transition from paper to electronic file submission. We provide a specified file layout and coordinate regular submissions of your eligibility data. For answers to your questions about electronic file submission, contact the EDI team at eligibilitydatafile@oxhp.com.

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What You Need to Know About Enrollment and 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 an easy-to-read Large Group Member Eligibility Requirements chart for New York, New Jersey and Connecticut.

You’ll find information about:

• Enrolling employees, their spouses and dependents

• Changing existing member information

• Health Insurance Portability and Accountability Act (HIPAA)

• Termination

EnrollmentLarge Group Member Eligibility Requirements for: New York, New Jersey, and Connecticut

Who is an eligible employee?

Three easy ways to enroll

When enrollment forms must be submitted

Pre-existing conditions

Retirees

Who is eligible as a spouse?

When a spouse can be enrolled

Three easy ways to enroll a member’s spouse

When enrollment and ATC forms must be submitted

Any full-time employee meeting the eligibility requirements of the group can enroll as a member:• 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).

• Online: Go to www.oxfordhealth.com and click on “Employers” • Forms: New York Member Enrollment Form (OHI or OHP) Connecticut Member Enrollment Form (OHI or OHP) New Jersey Large Member Enrollment/Change Request Form • EDI: Groups with 100+ employees should contact an Account Manager for more

information.

Enrollment forms must be:• Signed by the employer and employee within 31 days of the effective date• Received by us within 31 days of the effective date

Does not apply for large groups

Coverage for retirees must be specified in the contract

• Legal spouse, including civil union spouse for CT and NJ;• Domestic partner (rider required only for New Jersey members age 62 or over

and New York members)

Spouse may be added to an existing policy effective for:• Open Enrollment• Date of marriage or civil union• Date of U.S. immigration • Date of HIPAA event (see HIPAA section)• Date of domestic partnership

• Online: www.oxfordhealth.com • Forms: NY and CT: Addition/Termination/Change Form (ATC) NJ: New Jersey Large Group Member Enrollment/Change Request Form• EDI: Groups with 100+ employees should contact an Account Manager for more

information.

Enrollment and ATC forms must be: • Signed by the employer and employee within 31 days of the

requested effective date;• Received by us within 31 days of the requested effective date.

ENROllMENT: EMPlOYEE/SubSCRIbER

SPOuSE

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Enrollment

Who is eligibleas a dependent?

When a dependentcan be enrolled

Student verification

Student medical leave

Important enrollment time frames

Newborn

Adoption

• 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, regardless of age, incapable of self-sustaining employment who is disabled with proof of disability (as defined in their Certificate of Coverage). The disabling condition must have arisen prior to attaining the age when dependent coverage would otherwise terminate.

Dependent may be added to an existing policy effective for:• Open enrollment• Date of birth• Date of adoption or permanent placement in the home• Date of HIPAA event (See HIPAA section)

Required for all dependents over age 19, but under the maximum age limit of the group. Every fall semester thereafter, verification will be requested.

Acceptable Proof of Verification:• A completed Student Parent Affidavit Form• Verbal confirmation of the semester and the school name and phone number

In the event a student is unable to attend school on a full-time basis, they may continue to be covered for up to 12 months, provided the attending physician gives a written explanation of the medical reason for the leave.

This provision does not require us to continue coverage beyond the age at which coverage should otherwise terminate.

The premium charged during this coverage will remain the same as when the student was enrolled in school.

Failure to provide verification by the deadline will result in termination effective December 31 of the current year. Note: The deadline to provide verification will change every year.

CT/NJ: Automatically provided for children of the subscriber or the subscriber’s spouse for the first 31 days. No premium is required. Refer to the Certificate of Coverage to determine if a form is required to continue coverage beyond the first 31 days or if the child’s information can be given to Client Service verbally.

NY: Refer to the Certificate of Coverage to determine if a form is required for enrollment or if the child’s information can be given to Client Services verbally.

Refer to the Certificate of Coverage for specific details for enrolling an adopted child.

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Enrollment

Three easy waysto enroll a dependent

When enrollment and ATC forms must be submitted

Who is eligible

When an over-age dependent can enroll

How to enroll

When forms must be submitted

• Online: www.oxfordhealth.com • Forms: NY and CT: Addition/Termination/Change Form (ATC) NJ: New Jersey Large Group Member Enrollment ChangeNote: Documents supporting an adoption will be required at the time of enrolment.• EDI Groups with 100+ employees should contact an Account Manager for more

information.

Enrollment and ATC forms and New Jersey Large Group Member Enrollment/Change Request Form must be: • Signed by the employer and employee within 31 days of the requested

effective date;• Received by us within 31 days of the effective date.

An employee’s child who:• Has reached the limiting age, but is less than 30 years of age• Is not married• Has no dependents of his or her own• Is either a resident of New Jersey or enrolled as a full-time student at an

accredited school; and• Is not covered under any other group or individual health benefits plan, group

health plan, church plan or health benefits plan and is not entitled to Medicare

• The date the over-age dependent meets the limiting age• The date the subscriber enrolls• The date the dependent meets the eligibility requirements• At the group’s open enrollment

Form: Temporary HINT Form or New Jersey Member Enrollment/Change Request Form

When using the New Jersey Member Enrollment/Change Request Form, the dependent must complete the information required of a subscriber (including an address) and must sign the form along with the employee.

• Must be signed by the employer, employee and over-age dependent• Must be received within 31 days of the requested effective date.

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DEPENDENT (CONT.)

OVER-AGE DEPENDENTS (NEW jERSEY ONlY)

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Enrollment CHANGES TO ExISTING MEMbER INFORMATION

Types of changes to inform us about

Method of requesting change

Special enrollment period

How to enroll during HIPAA special enrollment period

We must be notified in the event of any of the following changes. Some changes can be requested by the member, while other changes require the employer to make the request. Note: many changes may be made using www.oxfordhealth.com.

Members must notify us of the following changes: • Name • Address and ZIP code • Primary Care Physician or OB/GYN • Student status • Disability or handicapped status • Coordination of Benefit (changes to other carrier information)

Benefits Administrators must notify us of the following changes: • Change in family status (e.g., newborn, loss of dependent status, etc.) • Divorce • Death • Retirement • COBRA/state continuation

Within 31 days of the change:Online: www.oxfordhealth.com Forms: NY and CT: Addition/Termination/Change Form NJ: New Jersey Large Group Member Enrollment/Change Request Form

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 exhausted2. Change in family status: • Marriage • Birth of child/adoption or placement of child in home

• Online: Go to www.oxfordhealth.com and click on “Employers”• Forms: If subscriber is electing coverage: NY and CT: Member Enrollment Form NJ: NJ Large Group Member Enrollment/Change Request Form If adding spouse and/or dependent to existing policy: NY and CT: Addition/Termination/Change Form (ATC) NJ: NJ Large Group Member Enrollment/Change Request Form• EDI: Groups with 100+ employees should contact an Account Manager for more

informationNote: The following supporting documents are required at the time of enrollment: HIPAA certificate: if enrolling for loss of coverage Adoption document: if enrolling due to an adoption

HEAlTH INSuRANCE PORTAbIlITY AND ACCOuNTAbIlITY ACT (HIPAA)

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Enrollment

When enrollment and ATC forms must be submitted

When an employee should be disenrolled

How to report employee termination or disenrollment

When to notify us of termination or disenrollment

Dates of termination

When should a spouse/dependent be terminated/ disenrolled?

Enrollment and ATC forms must be: • Signed by the employer and employee within 31 days of the requested effective date• Received by us within 31 days of the requested effective date

If an employee resigns, is terminated, or becomes ineligible for health benefits according to the group’s policies or the provisions of coverage

Online: Go to www.oxfordhealth.com and click on “Employers”• Forms: NY and CT: Addition/Termination/Change Form NJ: New Jersey Large Group Member Enrollment/Change Request Form• EDI: Groups with 100+ employees should contact and Account Manager for

more information.

ATC Form must be:• Signed by the employer within 31 days of the requested date of termination• Received by us, 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.

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 a spouse and/or dependent should be terminated for any of the following reasons:• Divorce/cessation of domestic partner relationship• Reaching the age limit set by group• Loss of full-time student status (this includes failing to submit completed

student verification documentation)• Loss of dependent status due to marriage

HEAlTH INSuRANCE PORTAbIlITY AND ACCOuNTAbIlITY ACT (HIPAA) CONT.

TERMINATION

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Oxford as the Secondary Health Insurance CarrierWhen Oxford is the secondary carrier for a member, all claims for health care services must be evaluated by the primary insurer before benefits will be considered. This includes all claims that are covered by:

•Another health insurance company;

•Auto insurance; and/or

•Workers’ Compensation insurance

Verifying Enrollment of New Subscribers

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.

When to Verify Enrollment – As Soon as You Receive Your Invoice

Please be sure to carefully review the Invoice Details section of your billing statement and immediately notify Client Services of any omissions or changes, to avoid denial of coverage at a later date. Please note: We do not enroll individuals more than 31 days from their eligibility date.

See the Billing section to view a sample Invoice Detail.

Spouse 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.

What to Do if Your Invoice Details Section is Not Accurate

•Contact Client Services at 1-888-654-0065 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 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.

You can also verify employee

enrollment at www.oxfordhealth.com

after logging on to “Your Account”

with your user name and password.

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EnrollmentReporting Changes to Group Information

Changes to Group Information You Should Report

•Group name

•Address

•Tax identification number

•Benefits administrator (BA) contact

How to Report Changes

To report changes to our Enrollment Department:

•Employer groups may submit a request in writing on your company’s letterhead, signed by an officer of your company, making sure to include your group number.

•You can report these changes at www.oxfordhealth.com any time.

Group Termination Protocol

How to Request Group Termination

Requests for voluntary termination must be submitted using:

•Completed Group Termination Form (available from the employer section of www.oxfordhealth.com)

Or

•Letter on company letterhead, including:

• Group name • Group number • Requested termination date • Signature of an officer of the company

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.

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EnrollmentMedical Leave of Absence

How Our Medical Leave Policy Works

We 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 us.

We reserve the right to determine:

•Whether the leave-of-absence policy is reasonable; and

•Whether the employee is entitled to such a leave.

For us to consider an employee entitled to a medical leave of absence:

•There must be a reasonable expectation by us that the employee will recover from the injury or illness;

•There must be a reasonable expectation by us 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.

How Long will an Employee on Medical Leave be Covered by us?

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 we determine, in our 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.

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, call Client Services at 1-888-654-0065.

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Contract Renewal

When Additional Employees Enroll at Renewal Time

• If you need additional member enrollment materials, contact your Account Manager or log on to the Employer section of www.oxfordhealth.com.

• If an employee did not elect coverage in the previous contract year, the employee 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 Account Executive or broker/consultant.

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RENEWAL NOTICE(Your broker/con-sultant is sent your renewal 60 days prior to your renewal date)

Call your broker, consultant or Account Executive.

NOTIFY US 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)

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 or your broker renew as-is.

Notes:

•If submitting by mail, changes should be submitted up to the 15th of the month prior to the renewal date.

•Your renewal period is the only time during the year that we will accept changes to your plan. Renewals and changes are contingent upon your account with us being current.

•It is your responsibility to notify us 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.

Actions You Can Take

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Health Insurance Portability and Accountability Act (HIPAA)

Notice to Members Regarding 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.

We reserve 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 we make 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 Client Services Department, or visit our web site at www.oxfordhealth.com.

Q. How do we use or disclose your PHI?

A. We may use or disclose your PHI, without your consent or authorization, under the following circumstances: •Treatment: We may disclose your PHI to a health care 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 health care agency, etc.

• Payment: We may use or disclose your PHI to pay claims submitted by a health care 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.

• Health Care 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 preventive 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 you become a member, the 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.

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• 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 our 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 our 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. Do we ever need an authorization to use or disclose your PHI?

A. Yes. Except for the purposes described above, we cannot use or disclose your PHI without a signed authorization from you. If you provide such an authorization to us, 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.

Q. Can you inspect or receive copies of any PHI in our possession?

A. Yes. You have the right to inspect or receive copies of your PHI with certain exceptions. You must make a request to us in writing. We reserve the right to charge a reasonable fee for the cost of producing and mailing the PHI. Request forms are available on our web site or by calling the number listed at the end of this Notice.

Q. Can you find out if we disclosed your PHI to a third party?

A. Yes. You have the right to receive an accounting of all occasions when we disclosed your PHI for any purpose other than treatment, payment, health care 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 us 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?

A. Yes. You have the right to request that we place additional restrictions on the use or disclosure of your 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 we use alternate means to confidentially communicate with you about your PHI or communicate with you at an alternate location?

A. You must inform us, 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.

Q. Do you have the right to request that we 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. We 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 dis-agreement 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 we 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 our 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:

Office of the SecretaryDepartment of Health and Human Services200 Independence Avenue, S.W.Washington, D.C. 20201 Telephone: 1-877-696-6775

We support 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 Custome Service at the toll-free number on your ID card, or call 1-800-444-6222. You can also contact us by mail at:

HIPAA Member Rights Unit Oxford48 Monroe TurnpikeTrumbull, 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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Privacy Notice Concerning Financial InformationAt 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 we collect in the course of conducting its business. Our policy applies to both current and former customers and members.

The Information We Collect

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 or others; and

• Information we receive from consumer reporting agencies concerning large group customers.

The Information We Disclose

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.

Security Practices

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.

This notice is being provided on behalf of the following Oxford affiliates:

Oxford Health Plans, llCOxford Health Plans (CT), Inc.Oxford Health Plans (Nj), Inc.Oxford Health Plans (NY), Inc.Oxford Health Insurance, Inc.Oxford benefit Management, Inc.

• If you would like a copy of these Notices in Spanish, Chinese, or Korean please call Customer Service at the number on the back of your member ID card.

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Overview of Our Policy Regarding the Release of Confidential Member Information

Confidential Member InformationWhen it comes to personal medical records, we strongly believe that we must safeguard all medical information about our members. We 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.

We treat medical records with the utmost respect and confidentiality. Access to medical records is limited to per-sons who need to see them, such as Medical Management staff responsible for reviewing and authorizing treat-ment. 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 InformationIn order for a Client Services Associate to release confidential medical information regarding a member’s claims, we require that the member complete and sign the HIPAA Member Authorization Form. This authorization form pro-vides us 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.

• 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 call Client Services at 1-888-654-0065 or download it from the employer home page at www.oxfordhealth.com.

Prior to submitting the authorization form to us, please call Client Services to obtain the proper mailing address or fax number for submitting the authorization form. Once we receive the completed authorization form, employee claim information will be made available over the phone by a Client Services Associate. Due to privacy concerns, BAs and brokers cannot access employee claims information through our web site; however, members can view their own claim information online through our member web site at www.oxfordhealth.com. Members can also contact our Customer Service Department to discuss their own claims.

Member Information that does not Require a Signed, Written AuthorizationAs 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.

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HIPAA Member Authorization FormExcept as otherwise permitted or required by applicable federal and state laws and regulations, we must obtain an authorization before using or disclosing protected health information (“PHI”). Upon receipt of a valid authoriza-tion for its use and/or disclosure of PHI, we will make such use and/or disclosure in a manner consistent with such authorization.

To: Oxford 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 we are 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):

______________________________________________________________________________________________

______________________________________________________________________________________________

Does the person(s), class of persons, or entity named above that we are authorized to make the use or disclosure to also have the authority to file an appeal and/or grievance on behalf of the member?

(check one) p Yes p No

Expiration:

This authorization will expire:

p Remain in place until____________. (Date)

p On occurrence of the following event (which must relate to the member or to the purpose of the use and/or dis-closure being authorized):

_____________________________________________________________________________________

_____________________________________________________________________________________

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HIPAA Member Authorization Form (cont.)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 revoca-tion. I also understand that any revocation of this authorization will not result in my disenrollment from Oxford or denial of my eligibility for benefits.

HIPAA Member Rights unit Oxford 48 Monroe Turnpike Trumbull, CT 06611

Note the following:

• As a 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 us 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 may 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:

I have read and understand the contents of this document and am hereby providing my agreement to the terms of this Authorization.

Signature:*

Print Name:

Date:

* 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.