EXTENDED BENEFITS FOR TOTAL DISABILITY

Transcription

1 ADMINISTRATIVE POLICY EXTENDED BENEFITS FOR TOTAL DISABILITY Plicy Number: ADMINISTRATIVE 49.8 T2 Effective Date: January, 205 Table f Cntents APPLICABLE LINES OF BUSINESS/PRODUCTS PURPOSE... DEFINITIONS... POLICY... REFERENCES... POLICY HISTORY/REVISION INFORMATION... Page Related Plicies: Nne 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 enrllees. 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's plan f benefits 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 s plan f benefits r Certificate f Cverage, the plan f benefits r Certificate f Cverage will gvern. APPLICABLE LINES OF BUSINESS/PRODUCTS This plicy applies t Oxfrd Cmmercial plan membership excluding: New Jersey Individual Plans Self-Funded Plans PURPOSE This plicy utlines the guidelines fr extended benefits fr ttal disability accrdance with applicable state laws and Oxfrd's Certificates f Cverage. 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. Ttally Disabled: 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. Extended Benefits fr Ttal Disability: Administrative Plicy (Effective 0/0/205) , Oxfrd Health Plans, LLC

2 POLICY I. State-by-State Overview f Extended Benefits Requirements A. New Yrk Plans:. Large and Small Grup Cntracts (OHP based prducts and OHP/OHI based prducts): Extended benefits cverage will prvided fr a perid f ttal disability fr: A Hspital stay cmmencing, r surgery perfrmed, within 3 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 2 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. 2. Individual Cntracts: 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 2 mnths frm the plicy terminatin date. B. Cnnecticut Plans:. All Grup Cntracts: 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 2 mnths frm the plicy terminatin date. C. New Jersey Plans:. Extended Benefits: All Large and Small Grup Cntracts: when grup cverage under the grup Agreement is terminated, the extended benefits prvisin applies. Large Grup Cntracts (OHI based prducts): 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. Extended Benefits fr Ttal Disability: Administrative Plicy (Effective 0/0/205) , Oxfrd Health Plans, LLC 2

3 Fr the NJ prducts referenced abve 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 2 mnths frm the plicy terminatin date. 2. A Ttally Disabled Emplyee's Right t Cntinue Grup Health Benefits: In additin, emplyees f New Jersey grup plans have a special right called: "A ttally disabled Emplyee's Right t Cntinue Grup Health Benefits": All New Jersey Grup Cntracts: 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 3 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: i. Emplyee: a. Fails t timely pay premiums. b. 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. ii. Emplyer's grup cverage terminates, prvided that: a. 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; b. 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. c. The prir grup plicy shall cntinue t prvide benefits t the extent f its accrued liability. iii. 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 Extended Benefits fr Ttal Disability: Administrative Plicy (Effective 0/0/205) , Oxfrd Health Plans, LLC 3

4 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 the ttal disability prvisin sectin and elects t cntinue cverage under either 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. II. Extended Benefits Cverage Infrmatin 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. III. Terminatin f Extended Benefits: 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. IV. Limits n Extended Benefits: 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 fr Ttal Disability: Administrative Plicy (Effective 0/0/205) , Oxfrd Health Plans, LLC 4

5 REFERENCES. Member Certificates f Cverage. 2. NYCRR NYCRR N.J.S.A. 7B: N.J.A.C. : N.J.A.C. 8: N.J.S.A. 7B: C.G.S.A. 38a CT ADC 38a POLICY HISTORY/REVISION INFORMATION Date 0/0/205 Actin/Descriptin Rerganized plicy cntent Updated definitin f extended benefits Revised plicy guidelines: Updated state-by-state verview f extended benefits requirements: Fr New Yrk, Cnnecticut and New Jersey Plans: Added language t indicate extended benefits prvisin applies; - 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 2 mnths frm the plicy terminatin date Fr New Yrk Plans: Added language t clarify extended benefits cverage will prvided fr a perid f ttal disability fr a hspital stay cmmencing, r surgery perfrmed, within 3 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 Added Extended Benefits Cverage Infrmatin t indicate: 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 Extended Benefits fr Ttal Disability: Administrative Plicy (Effective 0/0/205) , Oxfrd Health Plans, LLC 5

6 Date Actin/Descriptin 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 A Ttally Disabled Emplyee's Right t Cntinue Grup Health Benefits sectin f the plicy Archived previus plicy versin ADMINISTRATIVE 49.7 T2 Extended Benefits fr Ttal Disability: Administrative Plicy (Effective 0/0/205) , Oxfrd Health Plans, LLC 6