EXTENDED BENEFITS FOR TOTAL DISABILITY & SUCCEEDING CARRIER FOR INPATIENT ADMISSIONS

Transcription

1 UnitedHealthcare Oxfrd Administrative Plicy EXTENDED BENEFITS FOR TOTAL DISABILITY & SUCCEEDING CARRIER FOR INPATIENT ADMISSIONS Plicy Number: ADMINISTRATIVE T2 Effective Date: December 1, 2017 Table f Cntents Page INSTRUCTIONS FOR USE... 1 APPLICABLE LINES OF BUSINESS/PRODUCTS... 1 PURPOSE... 1 DEFINITIONS... 1 POLICY... 2 REFERENCES... 6 POLICY HISTORY/REVISION INFORMATION... 6 Related Plicy Newbrns INSTRUCTIONS FOR USE The services described in Oxfrd plicies are subject t the terms, cnditins and limitatins f the member's cntract r certificate. Unless therwise stated, Oxfrd plicies d nt apply t Medicare Advantage members. Oxfrd reserves the right, in its sle discretin, t mdify plicies as necessary withut prir written ntice unless therwise required by Oxfrd's administrative prcedures r applicable state law. The term Oxfrd includes Oxfrd Health Plans, LLC and all f its subsidiaries as apprpriate fr these plicies. Certain plicies may nt be applicable t Self-Funded members and certain insured prducts. Refer t the member specific benefit plan dcument r Certificate f Cverage t determine whether cverage is prvided r if there are any exclusins r benefit limitatins applicable t any f these plicies. If there is a difference between any plicy and the member specific benefit plan dcument r Certificate f Cverage, the member specific benefit plan dcument r Certificate f Cverage will gvern. APPLICABLE LINES OF BUSINESS/PRODUCTS This plicy applies t Oxfrd Cmmercial plan membership excluding Self-Funded Plans. Nte: While Self-Funded Grups are nt required t adpt the guidelines utlined within this plicy, they may elect the same r similar guidelines. Check the member specific benefit plan dcument and any federal r state mandates, if applicable. PURPOSE This plicy utlines the guidelines fr: Extended Benefits fr ttal disability When a Member changes carriers while cnfined in an inpatient facility (acute care hspital, substance abuse r mental health facility, physical rehabilitatin r skilled nursing facility) DEFINITIONS Extended Benefits: A prvisin that allws medical cverage t cntinue past the terminatin date f the plicy fr cvered emplyees r their cvered dependents wh are Ttally Disabled as f the plicy terminatin date. Inpatient Stay: Perid f time during which a Member is cnfined in a cvered inpatient facility (e.g., acute care hspital, substance abuse r mental health facility, physical rehabilitatin r skilled nursing facility). Prir Carrier: The carrier that prvided cverage n the date the Member was admitted. Succeeding Carrier: The carrier that begins cverage fr a new Member and such Member is in an inpatient facility n the date cverage becmes effective fr that Member. Extended Benefits fr Ttal Disability & Succeeding Carrier Fr Inpatient Admissins Page 1 f 7

2 Ttally Disabled (Excluding New Jersey Small Plans): A subscriber wh is prevented because f injury r disease frm perfrming their regular r custmary ccupatinal duties and is nt engaged in any wrk r ther gainful activity fr pay r prfit. Pregnancy alne des nt warrant privileges under the ttal disability definitin. This definitin als prvides fr a cvered dependent, defined as the subscriber's lawful spuse r any unmarried child as described in the Certificate fr New Yrk individual cntracts, wh is prevented because f injury r disease frm engaging in substantially all the nrmal activities f a persn f like age and sex wh is in gd health. Ttally Disabled (New Jersey Small Plans): Except as therwise specified in the Plicy, that an Emplyee wh, due t illness r injury, cannt perfrm any duty f his r her ccupatin r any ccupatin fr which he r she is, r may be, suited by educatin, training and experience, and is nt, in fact, engaged in any ccupatin fr wage r prfit. A Dependent is Ttally Disabled if he r she cannt engage in the nrmal activities f a persn in gd health and f like age and sex. The Emplyee r Dependent must be under the care f a Practitiner. POLICY New Yrk Plans Large and Small Grup Cntracts (OHP Based Prducts and OHP/OHI Based Prducts) Individual Cntracts Cnnecticut Plans All Grup Cntracts New Jersey Plans All Large and Small Grup Cntracts State-by-State Overview f Extended Benefits Requirements Extended Benefits cverage will prvided fr a perid f ttal disability fr: A Hspital stay cmmencing, r surgery perfrmed, within 31 days frm the date cverage ends. The Hspital stay r surgery must be fr the treatment f the injury, sickness, r pregnancy causing the ttal disability. Up t 12 mnths frm the date cverage ends fr Cvered services t treat the injury, sickness, r pregnancy that caused the ttal disability, unless these services are cvered under anther grup health plan. Extended Benefits apply: Only t the specific medical cnditin which caused the ttal disability (i.e., cvered services are limited t thse that relate t treatment fr the particular injury r sickness that caused the ttal disability) Only t the specific Member wh is Ttally Disabled at the time f the plicy terminatin; Only as lng as the Member remains Ttally Disabled. When individual cverage is terminated, the Extended Benefits applies as fllws: Only t the specific medical cnditin which caused the ttal disability (i.e., cvered services are limited t thse that relate t treatment fr the particular injury r sickness that caused the ttal disability); Only t the specific Member wh is Ttally Disabled at the time f the plicy terminatin; Only as lng as the Member remains Ttally Disabled; T a maximum perid f 12 mnths frm the plicy terminatin date. When grup cverage under the grup agreement is terminated, the Extended Benefits prvisin applies as fllws: Only t the specific medical cnditin which caused the ttal disability (i.e., cvered services are limited t thse that relate t treatment fr the particular injury r sickness that caused the ttal disability); Only t the specific Member wh is Ttally Disabled at the time f the plicy terminatin; Only as lng as the Member remains Ttally Disabled; T a maximum perid f 12 mnths frm the plicy terminatin date. When grup cverage under the grup Agreement is terminated, the Extended Benefits prvisin applies. The Extended Benefits prvisin applies as fllws: Only t the specific medical cnditin which caused the ttal disability(i.e., cvered services are limited t thse that relate t treatment fr the particular injury r sickness that caused the ttal disability); Only t the specific Member wh is Ttally Disabled at the time f the plicy terminatin; Only as lng as the Member remains Ttally Disabled; T a maximum perid f 12 mnths frm the plicy terminatin date. Extended Benefits fr Ttal Disability & Succeeding Carrier Fr Inpatient Admissins Page 2 f 7

3 New Jersey Plans Large Grup Cntracts (OHI Based Prducts) State-by-State Overview f Extended Benefits Requirements When grup cverage under the grup Agreement is terminated, if a Member elects Extended Benefits, he/she must ntify Oxfrd f this electin, in writing, within 30 days f his/her lss f cverage. The Extended Benefits prvisin applies as fllws: Only t the specific medical cnditin which caused the ttal disability(i.e., cvered services are limited t thse that relate t treatment fr the particular injury r sickness that caused the ttal disability); Only t the specific Member wh is Ttally Disabled at the time f the plicy terminatin; Only as lng as the Member remains Ttally Disabled; T a maximum perid f 12 mnths frm the plicy terminatin date. All New Jersey Grup Cntracts A Ttally Disabled New Jersey Emplyee's Right t Cntinue Grup Health Benefits In additin t the abve Extended Benefits, emplyees f New Jersey grup plans have a special right called: "A Ttally Disabled Emplyee's Right t Cntinue Grup Health Benefits": Where an emplyee's grup cverage terminates because the emplyee's active emplyment r membership in an eligible class ends due t ttal disability, the emplyee will be entitled t elect t cntinue his r her grup health cverage subject t the fllwing: Emplyee must have been insured by the grup plicy fr at least three mnths immediately prir t the date his r her grup health benefits ended. Cverage includes dental, visin and prescriptin drugs, if such benefits are prvided under the grup plicy. Cverage may include (at the emplyee's ptin) eligible cvered dependents, subject t all f the grup plicy's terms and cnditins. Benefits are nt limited t the disabling cnditin. Cverage is available fr any emplyee r eligible cvered dependent wh is cvered by r eligible fr Medicare, subject t any nn-duplicatin f benefits in the grup plicy. Emplyee is respnsible fr prviding written ntice t the emplyer that he r she has elected this benefit, tgether with the first mnth's premium payment, within 31 days f terminatin f cverage. Emplyee is respnsible fr paying the applicable premium directly t the grup. If the emplyer fails, after the timely receipt f premium payment by the emplyee, t pay Oxfrd n behalf f the emplyee thereby causing the emplyee's cverage t end, then the emplyer will be liable fr the emplyee's benefits, t the same extent as, and in place f, Oxfrd. Cverage may cntinue until the: Emplyee: Fails t timely pay premiums. Becmes emplyed and eligible fr ther grup cverage, r in the case f cvered dependent, the date such dependent becmes emplyed and eligible fr grup cverage. Emplyer's grup cverage terminates, prvided that: The emplyee has the right t be cvered under any new grup plicy fr the balance f the perid that he r she wuld have remained cvered under the prir grup plicy; The minimum level f benefits t be prvided by the ther grup plicy shall be the applicable level f benefits f the prir grup plicy, reduced by any benefits payable under that prir grup plicy; and accrued liability. The prir grup plicy shall cntinue t prvide benefits t the extent f its accrued liability. With respect t a cvered dependent, if the cvered dependent n lnger meets the eligibility requirements. *This sectin sets frth special rights fr Ttally Disabled emplyees f New Jersey plans; it is nt an "Extended Benefits" prvisin, althugh emplyees wh qualify fr and elect this cverage must still satisfy the definitin f Ttally Disabled. If a cvered emplyee elects t cntinue his r her grup health cverage under Extended Benefits fr Ttal Disability & Succeeding Carrier Fr Inpatient Admissins Page 3 f 7

4 A Ttally Disabled New Jersey Emplyee's Right t Cntinue Grup Health Benefits All New Jersey Grup the ttal disability prvisin sectin and elects t cntinue cverage under either Cntracts (cntinued) COBRA r State Cntinuatin, the cntinuatins: Start at the same time; Run cncurrently; and End independently n their wn terms. While cvered under mre than ne cntinuatin prvisin, the emplyee and his r her cvered dependents will nt be: Entitled t duplicate benefits; and Subject t the premium requirements f mre than ne sectin at the same time. Extended Benefits Determinatin f Disability, Limitatins & Terminatin f Cverage Determinatin f Ttal Disability An Oxfrd Medical Directr must determine if the Member is Ttally Disabled based upn the Member's medical and/r claims recrds. If the Member is determined t be Ttally Disabled, the Medical Directr will specify the ttal disability diagnsis. The Member must be under the regular care f a practitiner fr the particular illness r cnditin that caused the ttal disability. All services rendered during the Extended Benefits perid are subject t Oxfrd's standard plicy terms and cnditins (e.g., utilizatin review, pre-certificatin requirements, Member cst share, referrals, where applicable). The Member and/r new insurance carrier will be respnsible fr services unrelated t the ttal disability and Oxfrd will nt be respnsible fr any claims fr services rendered after the Extended Benefits perid ends. Cntinuatin f cverage under either COBRA r State Cntinuatin is nt available if Extended Benefits have been elected r exhausted. In additin, cnversin cverage is nt available nce Extended Benefits have been elected r exhausted. There is n premium payment due frm the Member r grup. Exceptin: Special rights fr emplyees f New Jersey plans. Refer t the A Ttally Disabled Emplyee's Right t Cntinue Grup Health Benefits sectin f the plicy. Limitatins Terminatin f Cverage Oxfrd will nt pay Extended Benefits: Fr any Member wh is nt Ttally Disabled n the date his r her insurance/cverage terminates; Fr any newbrn as the result f a pregnancy fr which benefits are being extended; Beynd the extent t which we wuld have paid benefits under the Certificate if cverage had nt ended. Extended Benefits will end n the earliest f the fllwing: The date the Member is n lnger Ttally Disabled, as determined by an Oxfrd Medical Directr. The date the cntractual benefit limit has been reached. Twelve mnths frm the date cverage under the Extended Benefits prvisin began. All States Member Eligibility Succeeding Carrier Fr Inpatient Admissin Member Eligibility and Applicability All f the states wherein Oxfrd is licensed t d business require carriers t prvide Extended Benefits. It applies t large and small grup prducts. Exceptins: It des nt apply t: Self-Funded plans (sme f these plans may elect t prvide this benefit). New Yrk individual prducts (including Healthy New Yrk) In rder t be eligible: A Member must lse his r her cverage while they were Ttally Disabled (either the Agreement ended r their cverage ended); r An emplyee/subscriber must lse cverage due t their Ttal Disability (New Jersey Small Grups). The emplyee must be cvered fr at least three mnths prir t the date cverage ends. Extended Benefits fr Ttal Disability & Succeeding Carrier Fr Inpatient Admissins Page 4 f 7

5 Succeeding Carrier Fr Inpatient Admissin When is Oxfrd Required t Prvide Cverage? Oxfrd is the Prir Carrier If an Oxfrd Member is in an inpatient facility (Ttally Disabled) at the time his r her cverage with us terminates, the remainder f the Inpatient Stay is Oxfrd's respnsibility unless: The Member was cvered under an Oxfrd New Yrk insurance prduct (Classic, Access, Direct, Metr) and there is a Succeeding Carrier. (i.e., Members cannt elect t stay with the Prir Carrier in this instance); Nte: The abve des nt apply t New Yrk HMO r individual market prducts. The Member elects cverage under the Succeeding Carrier; r The Member was cvered under ne f ur Self-Funded plans that des nt cntain an Extended Benefits prvisin. Oxfrd is the Succeeding Carrier Oxfrd is the Prir Carrier and there is N Succeeding Carrier Oxfrd is Bth the Prir Carrier and the Succeeding Carrier If a Member is in an inpatient facility (Ttally Disabled) at the time his/her cverage with Oxfrd begins, the remainder f the Inpatient Stay is the respnsibility f the Prir Carrier unless: In New Yrk, the Prir Carrier is an insurer (nt an HMO). Insurance cmpanies are nt required t prvide Extended Benefits if the Member is cvered under a Succeeding Carrier. Please nte, this als means that Members cannt elect t stay with the Prir Carrier in this instance; r The Member has elected t be cvered under the Succeeding Carrier. The Member was cvered under a Self-Funded plan that des nt have an Extended Benefits prvisin. Oxfrd is still respnsible fr prviding Extended Benefits except when the Member was cvered under ne f ur New Yrk insurance prducts r a Self- Funded plan withut an Extended Benefits prvisin. Oxfrd will fllw the same rules as utlined herein. Even thugh the carrier remains the same, the "plans" are actually different. Therefre, different benefit levels may apply. Succeeding Carrier fr Inpatient Admissin Cverage Limitatins and Terminatin f Cverage Extent f Cverage All Prducts fr NY, CT and NJ Large Grup Cverage is limited t Cvered Services that are used t treat the disabling cnditin. N premium is required. Only the Ttally Disabled Member is cvered under this prvisin. NJ Small Prvisin Cverage is the same as the grup cverage. The Subscriber must elect this cverage and must pay the entire premium. Dependents can be added t the Extended Cverage. Terminatin f Cverage New Yrk Insurance Prducts NJ Large Grups NJ Small Prvisin All Other Prducts fr NY and All CT Prducts Cverage ends n the date as f which: The Member is n lnger defined as Ttally Disabled; The benefit being used has been exhausted; 12 mnths have elapsed frm the date n which the Extended Benefits began. The Member is eligible fr cverage under anther grup plicy r Medicare where allwed by federal law (grups with fewer than 100 emplyees). Cverage ends n the date as f which: The Member is n lnger defined as Ttally Disabled; The benefit being used has been exhausted; 12 mnths have elapsed frm the date n which the Extended Benefits began. The Member becmes eligible fr cverage under Medicare where allwed by federal law (grups with under 100). Cverage ends n the date as f which: The subscriber ceases t pay the premium; Cverage fr the subscriber's class f emplyees ends; The subscriber becmes emplyed and eligible fr r is therwise cvered under anther grup health plan; r Fr a dependent, the subscriber n lnger meets the applicable eligibility requirements. Cverage ends n the date as f which: The Member is n lnger defined as Ttally Disabled; The benefit being used has been exhausted; 12 mnths have elapsed frm the date n which the Extended Benefits began. Extended Benefits fr Ttal Disability & Succeeding Carrier Fr Inpatient Admissins Page 5 f 7

6 REFERENCES 11 NYCRR NYCRR C.G.S.A. 38a Cntinuatin f benefits under grup health plicies. C.G.S.A. 38a-546. CT ADC 38a Department f Health and Human Services and the Health Care Financing Administratin; Prgram Memrandum: Insurance Cmmissiners and Insurance Issues Transmittal N N.J.A.C. 11: N.J.A.C. 11: Replacement carrier cverage. N.J.A.C. 8: N.J.S.A. 17B:26-3. N.J.S.A. 17B: N.Y. Cmp. Cdes R. & Regs. Tit Rules relating t cntent f frms fr individual insurance. (Regulatin 62). POLICY HISTORY/REVISION INFORMATION Date 12/01/2017 Actin/Descriptin Changed plicy title; previusly titled Extended Benefits fr Ttal Disability (Including Succeeding Carrier fr Inpatient Admissins) Updated list f applicable lines f business/prducts; Remved instructin t cnsult with the individual grup benefit administratr r the member specific benefit plan dcument fr additinal infrmatin Added instructin t check the member specific benefit plan dcument and any federal r state mandates, if applicable Revised plicy purpse statement; replaced language indicating: This plicy utlines guidelines fr Extended Benefits fr ttal disability accrdance with applicable state laws and Oxfrd's Certificates f Cverage with this plicy utlines guidelines fr Extended Benefits fr ttal disability This plicy utlines guidelines fr when a member changes carriers while cnfined in an inpatient facility (acute care hspital, substance abuse r mental health facility, physical rehabilitatin r skilled nursing facility), therefre meeting the definitin f Ttally Disabled; this may ccur as a result f a change in the member's emplyer grup r emplyment status with this plicy utlines guidelines fr when a member changes carriers while cnfined in an inpatient facility (acute care hspital, substance abuse r mental health facility, physical rehabilitatin r skilled nursing facility) Rerganized and revised plicy guidelines: Extended Benefits Determinatin f Disability, Limitatins & Terminatin f Cverage Added cntent previusly addressed in the Prcedures and Respnsibilities sectin f the plicy (n change t guidelines) Succeeding Carrier fr Inpatient Admissin Member Eligibility and Applicatin Added language t indicate New Yrk individual prducts (including Healthy New Yrk) are nt required t prvide Extended Benefits Remved language indicating New Yrk individual prducts, including Healthy New Yrk, are required t prvide Extended Benefits Succeeding Carrier fr Inpatient Admissin When is Oxfrd Required t Prvide Cverage? Updated language pertaining t extended cverage when Oxfrd is the primary carrier t clarify the nted guidelines d nt apply t New Yrk HMO r individual market prducts Updated supprting infrmatin t reflect the mst current references Extended Benefits fr Ttal Disability & Succeeding Carrier Fr Inpatient Admissins Page 6 f 7

7 Date Actin/Descriptin Archived previus plicy versin ADMINISTRATIVE T2 Extended Benefits fr Ttal Disability & Succeeding Carrier Fr Inpatient Admissins Page 7 f 7