Oxford Health Plans Underwritten by United HealthCare

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1 Oxford Health Plans Underwritten by United HealthCare Benefits Guide for New York County Medical Society Members Members continue to have important decisions to make about the type of plan that best meets their needs and how much to pay for it. NYCMS provides many medical plan options for members and their employees through United Healthcare s Oxford Products. Questions? NYCMS.Insurance@marsh.com If you practice as a sole proprietor, you can save significantly on your premium during the special limited open enrollment opportunity to join the Society s program. The open enrollment period ends April 1st of each year. Things to consider: Enroll in a qualified High Deductible Health Plan and open a Health Savings Account. Consider the significant savings this option provides. In 2013, with individual only coverage you are eligible to contribute up to $3,250 to your HSA, or $6,450 with family coverage, on a tax deductible* basis. Members between the ages of 55 and 64 are eligible to add an additional $1,000 per year. If you or your employees utilize in-network benefits only, consider an EPO (Exclusive Provider Option) or HMO plan design. Both choices are available through the NYCMS program. If you have questions or need help in receiving program benefit summaries and rates, please call Marsh/Seabury & Smith Insurance Program Management at or NYCMS.Insurance@marsh.com. Marsh serves NYCMS members who participate in the sponsored health insurance program. We can assist you with the information you need to make the critical choices on the road ahead. Eligibility/Renewability Society Members May Apply For Oxford Coverage If: You are an employer group of one or more; You are actively engaged in the duties of your profession at least 20 hours per week; You work in New York State. Sole proprietors may enroll during annual open enrollment periods each April. Dependents Are Eligible To Apply, Provided They Are A Member s: Lawful spouse; Registered domestic partner; or Unmarried, dependent children under age 26. Young Adult Option: Young adults through the age of 29 who do not have access to employer sponsored health insurance may continue their coverage through a parent s health coverage once they reach the maximum age of dependency. This allows an eligible dependent to purchase his or her parent s group coverage as an individual subscriber. To be eligible, the dependent child must be under age 30, not married, not insured or eligible for coverage as an employee or member under any employer sponsored plan and not be covered under Medicare. Permanent, Full-Time Employees Are Eligible To Apply If: You are actively employed at least 20 hours per week; You work in New York State; You work for a Society member. * Marsh and NYCMS do not provide tax, investment or legal advice. Please consult with your professional advisors for guidance on these issues.

2 Member/Employee Coverage Will Terminate When: You are no longer working at least 20 hours per week; The period for which coverage has been paid ends; You are no longer a Society member; You no longer work in New York; You are no longer working full-time for a Society member. Dependent Coverage Will Terminate When: A person no longer qualifies as a dependent; The period for which coverage has been paid ends; Your coverage as a Society member ceases. General Facts Coordination Of Benefits The benefits of this plan will be coordinated with the benefits of any other group health plan to which the individual is entitled. Medicare is the primary coverage and Oxford Health Plans is secondary for employees with Medicare in firms with fewer than 20 employees. Preexisting Conditions (applies only to groups with less than 50 employees) A preexisting condition is a disease or a physical condition for which: a) a member sought treatment, diagnosis or medical advice within six months immediately prior to becoming covered; or b) treatment, diagnosis or medical advice was actually recommended or received within six months immediately prior to becoming covered. However, credit will be given if you are covered by a qualified plan of coverage prior to enrolling in this program as required by law. Medically Necessary The benefits of this program shall be provided only to the extent that services are determined to be medically necessary. Oxford defines medically necessary as those services or supplies provided by a hospital, skilled nursing facility, physician or other provider, required to identify or treat your illness or injury that is determined by Oxford to be: a) consistent with the symptoms or diagnosis and treatment of your condition; b) appropriate with regard to standards of good medical practice; c) not solely for your convenience or that of any provider; and d) the most appropriate supply or level of service that can safely be provided. For inpatient services, it further means that your condition cannot safely be diagnosed or treated on an outpatient basis. If You Use A Non-Network Provider: If a member chooses to receive treatment from a non-participating provider, the claim reimbursement check may be sent directly to the member, rather than to the non-participating provider. In such cases, the following process will be followed: 1. The non-participating provider will be instructed to bill the covered member for services rendered. 2. The reimbursement check the member receives from Oxford will represent the benefit amount payable for the service and will be attached to an Explanation of Benefits (EOB). 3. The member is responsible for making payment to the non-participating provider for the full amount of the check mailed to them, in addition to any applicable copayment, deductible, coinsurance or other cost share allowances, according to their benefit plan

3 How To Apply Please complete each question on the application and return to Marsh. Groups Of 50 Or More Special rules apply. Please contact us for details and information. Questions? Marsh is your advocate. If you have any questions or need more information on this sponsored program, please call a Client Advisor at Sponsored by: Underwritten by: (3/13) Seabury & Smith, Inc d/b/a in CA Seabury & Smith Insurance Program Management CA Ins. Lic. # AR Ins. Lic. # South Figueroa Street, Los Angeles, CA NYCMS.Insurance@marsh.com About Our Role and Compensation The New York County Medical Society has selected Oxford Health Plans for this insurance program. Alternative insurance products may be available in the insurance market place. Marsh/Seabury & Smith Insurance Program Management is providing this single insurer option on behalf of the New York County Medical Society. In accordance with industry custom, we are compensated through commissions that are calculated as a percentage of the insurance premiums charged by insurers. We may also receive additional monetary and nonmonetary compensation from insurers, or from other insurance intermediaries, which may be contingent upon volume, profitability or other factors. This compensation may include payment from insurers for marketing related expenses or investments in technology. Our compensation may vary depending on the type of insurance purchased and the insurer selected. We will provide you additional information about our compensation and information about alternative quotes, upon your request. You may obtain this information by referring to and entering the security code E or call us at for specific details. Oxford Special Services Sensible Spending Guidance The Common Sense Guide to Your Health Plan gives tips to better enable the member to make decisions about their healthcare dollars. 24-Hour Nurse Line Oxford On-Call, a 24/7 phone service staffed by registered nurses to provide healthcare guidance. Keeping You as Healthy as We Can Well-care coverage, exam reminders, Complementary & Alternative Medicine (CAM) Program and Healthy Mind Healthy Body Member magazine. Additional Savings for You Healthy Bonus discount program with special values for vision care, weight loss, nutrition, fitness, and spa services, among others. Care Management Active Partner Education and Outreach for members with chronic conditions, such as diabetes and asthma. Your Benefits The MyOxford customized web site allows members to view benefit information, make changes to personal information and select a new PCP. Decision Support Tools Get more information about health conditions and hospital ratings prior to procedure with Subimo Healthcare Advisor TM. Use our doctor search tool to find physicians that meet your needs. Health Information Daily health news, quizzes and calculators, medical encyclopedia, disease management support and symptom guides, and KidsHealth enewsletter for parents. Pharmacy Refill or renew prescriptions, locate pharmacies in the area, learn about the differences between prescription and over-the-counter drugs, and research treatment options for health conditions. Alternative Care Find out about complementary and alternative medicine options through our online encyclopedia. Try the ConsumerLab.com drug interaction checker

4 April 1, 2013 Monthly Rates NYCMS Small Group Monthly Rates Employer Groups of 2 50 Members and Employees. Effective April 1, 2013 Lowest HDHP EPO 5000 HDHP EPO 2850 Liberty HMO HDHP B HDHP A Metro EPO 25/50 Metro EPO 20/40 Option 6 Metro 4 Metro 5 POS Option 3 Highest POS Option 2 Manhattan, Bronx, Suffolk, Staten Island, Westchester Single $ $ $ $ $ $ $ $ $ $ $1, $1, Parent & Child(ren) $ $ $1, $ $1, $1, $1, $1, $1, $1, $2, $2, Couple $ $1, $1, $1, $1, $1, $1, $1, $1, $2, $2, $2, Family $1, $1, $1, $1, $2, $2, $2, $2, $2, $2, $3, $3, Brooklyn, Queens, Nassau Single $ $ $ $ $ $ $ $ $ $ $1, $1, Parent & Child(ren) $ $ $1, $1, $1, $1, $1, $1, $1, $1, $2, $2, Couple $ $1, $1, $1, $1, $1, $1, $1, $1, $2, $2, $2, Family $1, $1, $1, $1, $2, $2, $2, $2, $2, $3, $3, $3, Rockland Single $ $ $ $ $ $ $ $ $ $ $1, $1, Parent & Child(ren) $ $ $1, $ $1, $1, $1, $1, $1, $1, $2, $2, Couple $ $ $1, $1, $1, $1, $1, $1, $1, $2, $2, $2, Family $1, $1, $1, $1, $1, $2, $2, $2, $2, $2, $3, $3, Dutchess, Orange, Putnam Single $ $ $ $ $ $ $ $ $ $ $ $1, Parent & Child(ren) $ $ $1, $ $ $1, $1, $1, $1, $1, $1, $1, Couple $ $ $1, $ $1, $1, $1, $1, $1, $1, $1, $2, Family $ $1, $1, $1, $1, $1, $1, $1, $2, $2, $3, $3, For more information, please contact Marsh at Premiums must be paid by the first of each month or your plan will be terminated by Oxford. Deductibles are per Calendar Year, and restart each January 1st. This information is a brief highlight of the benefits, please refer to the Evidence of Coverage booklet for complete details. Rates are based upon employer ZIP code and are subject to increase 4/1/2014 regardless of effective date (4/13) d/b/a in CA Seabury & Smith Insurance Program Management Seabury & Smith, Inc CA Ins. Lic. # AR Ins. Lic. # S. Figueroa St., Los Angeles, CA NYCMS.Insurance@marsh.com

5 New York County Medical Society (NY 2193) Mail to: Marsh, attn: Association Dept., 777 South Figueroa Street, Los Angeles, CA 90017, along with a check made payable to Marsh for the first month s premium. S m a l l G r o u p

6 Name of Company: April 1st (Month / Day=1st / Year) 20 All Full-Time 30 2

7 Name of Company: 2.5x copayment

8 Name of Company: * 1. Full legal name of firm: Seabury & Smith Insurance Program Management CA Ins. Lic. # AR Ins. Lic # Address for firm: Marsh attn: Association Department 777 South Figueroa Street Los Angeles, CA Telephone/Fax Number Fax: NYCMS.Insurance@marsh.com 4. Broker ID Code: BC9522

9 Name of Company: (2/13) d/b/a in CA Seabury & Smith Insurance Program Management CA Ins. Lic. # AR Ins. Lic. # Seabury & Smith, Inc South Figueroa Street, Los Angeles, CA About Our Role and Compensation The New York County Medical Society has selected Oxford Health Plans for this insurance program. Alternative insurance products may be available in the insurance market place. Marsh/Seabury & Smith Insurance Program Management is providing this single insurer option on behalf of the New York County Medical Society. In accordance with industry custom, we are compensated through commissions that are calculated as a percentage of the insurance premiums charged by insurers. We may also receive additional monetary and nonmonetary compensation from insurers, or from other insurance intermediaries, which may be contingent upon volume, profitability or other factors. This compensation may include payment from insurers for marketing related expenses or investments in technology. Our compensation may vary depending on the type of insurance purchased and the insurer selected. We will provide you additional information about our compensation and information about alternative quotes, upon your request. You may obtain this information by referring to and entering the security code E or call us at for specific details.

10 New York Member Enrollment Form OHI MAILING ADDRESS: Marsh, P. O. attn: Box Association 7085, Bridgeport Department, CT South Figueroa Street, Los Angeles, CA A. Group Information (To be completed by the employer) Please print neatly using black or blue ballpoint pen ALL DATES MUST BE: MM/ DD/YYYY Group Number NY 2193 Group Name Plan CSP Billing Group Date of Hire Effective Date Occupation On Leave of Absence Retired COBRA/Young COBRA/SC Qualifying Adult/SC Qualifying Event Event Date Employer Signature Date Event Must Union work Employee min. 20 hrs/week Disabled B. Applicant Details (To be completed by the employee) Employee/Subscriber Spouse Child Child Social Security Number: Last Name: First Name, Middle Initial: Date of Birth: (MM/DD/YYYY) Gender and Disability Status: (Check appropriate boxes.) M F / Disabled M F / Disabled M F / Disabled M F / Disabled Primary Care Physician (PCP) ID Number: PCP Name: (If an existing patient of PCP, check Yes.) Yes Yes Yes Yes Under age 26 Young Adult Check all that apply: Domestic Partner Under Full-time age Student 26 Young Adult Full-time Student Prior Carrier Carrier: (List coverage prior to this.) Policy Number: Same for all From Date Thru date:: C. Coordination of Benefits Employee/Subscriber Spouse Child Child Medicare Coverage Pharmacy Check appropriate box and list effective date: Policy Number: Same for all Carrier: Policy Holder: Effective Date: Group Number: Medical Same for all Policy Number: Carrier: Policy Holder: Effective Date: Part A Part B Part D BIN: PCN: Part A Part B Part D Part A Part B Part D Part A Part B Part D BIN: PCN: BIN: PCN: BIN: PCN: I understand that my enrollments and benefits are in accordance with those described in the Oxford Health Insurance Certificate. I understand that, in order to receive in-network benefits, I and any enrolled dependents must seek care through our Oxford affiliated primary care physician or through an Oxford-affiliated specialist physician with an authorized referral from the primary care physician if required. I further understand that if I do not adhere to these requirements, I will be eligible only for out-of-network health insurance coverage under the terms of the Certificate. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. I authorize any health provider or insurer to furnish Oxford any records concerning me or any enrolled member of my family for whom information is requested. Employee s Address (Apt #) City State Zip Employee s Signature (1/13) d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA NYCMS.Insurance@marsh.com Seabury & Smith, Inc CA Ins. Lic. # AR Ins. Lic. # OHINY MEF LS REV 6 Date