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enrollmentOxford Plans at a Glance

Quick Start Enrollment Tips Reporting Changes to Group Information

Member Enrollment & Eligibility Charts Group Termination Protocol

Oxford as the Secondary Health Medical Leave of AbsenceInsurance Carrier

Verifying Enrollment of New Subscribers Contract Renewal

Pre-existing Condition Clause Health Insurance Portability & Accountability (HIPAA)

at a glance

Enrollment Contact InformationDo you have enrollment questions?

■ Please contact your Oxford AccountManager or call Group Services at 1-888-654-0065.

■ E-mail: groupservices@oxfordhealth.com.Turnaround time is generally 24 hours

For Online Enrollment and to downloadenrollment forms

■ Go to www.oxfordhealth.com

■ Log on to the Employer section

■ Click on the “Tools and Resources” tab.Forms can be found under PracticalResources.

■ Make real-time changes by usingOxford’s online enrollment transactionsunder the “Transactions” tab.

Send Enrollment Forms to:

Oxford Health PlansEnrollment DepartmentP.O. Box 7085Bridgeport, CT 06601-7085

Send New Group Submissions to:

Oxford Health Plans14 Central Park DriveHooksett, NH 03106

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Quick Start Enrollment Tips

Whether you are a new group or a renewing group, we would like to thank you for choosing Oxford. We knowthat, regardless of your status, there can be some confusion when it comes to understanding health benefits andenrollment.

At Oxford, 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 youare, so we have provided suggestions for getting everyone comfortable with their Oxford plan.

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

■ Oxford Rosters of Participating Physicians and Providers■ Oxford enrollment forms■ Doctor Search tool

General Enrollment InstructionsHere’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 all your active Contract Specific Package(s) (CSP), where applicable:

New groups: contact Group Services at 1-888-201-4216

Current groups: look on your billing statement

■ Employees must complete all Employee and Dependent Information

• Coordination of Benefits questionnaires will be mailed within 31 days to Members who don’t adequately complete the “other carrier” question on the enrollment form. See “Coordination ofBenefits” under the Claims section for more details.

• Incomplete or altered forms will not be processed, which may result in a denial of enrollment andlack of coverage. Because enrollment forms are legal documents, Oxford cannot accept forms thatare 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 Oxford New York large employergroups. To view and download this and all other Oxford enrollment forms, log on to the Employer page atwww.oxfordhealth.com and click on the “Tools and Resources” tab. Forms can be found under Practical Resources.

Materials

An Oxford Roster of ParticipatingPhysicians and Providers

BA Bulletin

Gym Reimbursement brochure

Pharmacy Q&A Materials

Spanish/English Q&A

Healthy Bonus® brochure

Member Brochure

Replacement ID Cards

Forms

Member Enrollment Forms

Dental Enrollment Forms

Addition/Termination/Change Forms

Student Verification/Parent Affidavit Form

Need Additional Enrollment Materials?Just log on to the employer site at www.oxfordhealth.com or contact Group Services to either download or order any of the following Oxford materials (please allow 5 days for delivery):

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Where to Send Enrollment FormsAll Oxford enrollment forms must be sent directly to:

Oxford Health PlansEnrollment DepartmentP.O. Box 7085Bridgeport, CT 06601-7085

IMPORTANT NOTE: Do not send Oxford enrollment forms to Group Services or your Oxford 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, contact Group Services at 1-888-201-4216

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

Member Enrollment & Eligibility Charts

Electronic Data Interchange (EDI) – eligibilitydatafile@oxhp.comIf your company has the ability to pull employee and dependent demographics extracts from your current HRdatabase, and format into a specific text file layout (provided by Oxford), extracting these electronic files andsubmitting them directly to Oxford's Enrollment Department will be more efficient than paper/report submis-sion. It's fast, easy and efficient. Electronic submission allows Oxford to immediately compare our data againstyour data, noting any discrepancies, which results in increased accuracy of group membership. You will alsoreceive consistent feedback from Oxford's Enrollment Department regarding eligibility and file issues.

Need help getting started? Oxford has a team of EDI specialists that can assist you with the transition frompaper to electronic file submission. We provide a specified file layout and coordinate regular submissions ofyour 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 & Disenrollment in Your State Eligibility requirements and enrollment instructions vary by state laws and by the size of your group and can beconfusing. That’s why we’ve created an easy-to-read Large Group Member Eligibility Requirements chart forNew 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

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

Who is an eligibleemployee?

Three easy ways to enroll

When enrollment formsmust be submitted

Pre-existing conditions

Retirees

Who is eligible as aspouse

When a spouse can beenrolled

Three easy ways to enrolla Member’s spouse

When enrollment andATC forms must be submitted

Any full-time employee meeting the eligibility requirements of the group canenroll as an Oxford 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” • New York Member Enrollment Form OHI (NY),

New Jersey Large Member Enrollment/Change Request Form (NJ) or Member Enrollment and Physician Selection Form (CT),

• Tape: Groups with 100+ employees should contact an Account Manager formore information.

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

Does not apply for large groups

Coverage for retirees must be specified in the contract

• Legal spouse• Domestic partner (only if the group purchased a Domestic Partner Rider)

Spouse may be added to an existing policy effective for:• Open Enrollment• Date of marriage• Date of U.S. immigration on passport• Date of HIPAA event (See HIPAA Section)• Domestic partner — date they meet the required relationship time frame, as

specified by the group

• Online: www.oxfordhealth.com • Addition/Termination/Change Form (NY and CT) or New Jersey Large Member

Enrollment/Change Request Form (NJ)• EDI: Groups with 100+ employees should contact an Account Manager for

more information.• With HIPAA Certificate (only if enrolled for loss of coverage)• Domestic Partner Affidavit (only if enrolled as a domestic partner)

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

requested effective date• Received by Oxford within 31 days of the requested effective date

ENROLLMENT: EMPLOYEE/SUBSCRIBER

SPOUSE

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Who is eligibleas a dependent?

When a dependentcan be enrolled

Student verification

Important enrollmenttime 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)

• Regardless of age, any child incapable of self-sustaining employment who is disabled with proof of disability (as defined in their Certificate of Coverage). Thedisabling 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 ofthe group.

Acceptable Proof of Verification• The Student Verification Parent Affidavit Form must:

– Be completed and signed by the covered parent on the Oxford insurance policy

– Confirm full-time status in an accredited educational institution – Be submitted at time of enrollment to confirm eligibility

Every fall semester thereafter, the student will be required to submit a valid fall verification.

Unacceptable Proof of Verification• Unpaid bill• Acceptance letter from an educational institution• Preregistration forms from an educational institution• Class schedule

Note: The student’s Social Security number must appear on any student verification information.

Dependents that fail to provide valid verification by November 14 will be terminated effective December 31 of that year or other such date set forth in theGroup Enrollment Agreement. (Note: The deadline to provide fall verification willchange every year.)

• NJ/CT: Coverage is automatically provided for children of the subscriber or thesubscriber’s spouse for the first 31 days from date of birth; for coverage to con-tinue beyond the first 31 days, a request to enroll the newborn must be receivedwithin 31 days of the birth. No premium is required for the first 31 days.

• NY: Coverage for a newborn is provided ONLY if the child is enrolled within 31days of the birth and submits any applicable premium to the group within 31days following the birth.

• All adopted children under the age of 18 are eligible for coverage from thedate of acceptance or permanent placement in the home.

• NY: Same provision for enrollment of newborns applies to enrollment of newlyborn adopted children.

DEPENDENT

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Three easy waysto enroll a dependent

When enrollment andATC forms must be submitted

Types of changes toinform Oxford about

Method of requestingchange

Special enrollment period

• Online: www.oxfordhealth.com • Addition/Termination/Change Form (ATC)(NY and CT)with HIPAA Certificate

(only if enrolled for loss of coverage) or New Jersey Large MemberEnrollment/Change Request Form (NJ)Adoption: The subscriber must also submit a copy of legal adoption papers.

• Tape — Groups with 100+ employees should contact an Account Manager formore information

Enrollment and ATC forms and New Jersey Large Member Enrollment/Change RequestForm (NJ) must be: • Signed by the employer and employee within 31 days of the

requested effective date• Received by Oxford within 31 days of the requested effective date

Any change that needs to be made to the Member’s personal information (i.e.,address, name, date of birth, etc.)It is the Member’s responsibility to notify Oxford of any personal or family statuschanges that affect eligibility for services and benefits, as defined in yourCertificate of Coverage.

Changes that must be reported to Oxford include, but are not limited to:• Social Security numbers for newborn children• Termination or addition of any other group health insurance• Changes in:

– Name– Mailing address and Zip Code– Primary care physician or OB/GYN– Student status– Disability or handicapped status– Medicare status– COBRA (See the Continuation Coverage section.)– Family status– Retirement*– Death*– Divorce*

*The group may report these types of changes to Oxford in lieu of the Member.Please note that some of these changes may require the group’s approval inorder to terminate and/or add a Member and to elect COBRA.

• ATC form(NY and CT) or New Jersey Large Member Enrollment/Change Request Form (NJ)

• Online: www.oxfordhealth.com

Members may be added to the plan off-cycle for the effective date of any of thefollowing: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 exhausted

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

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DEPENDENT (CONT.)

CHANGES TO EXISTING MEMBER INFORMATION

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

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How to Enroll DuringHIPAA SpecialEnrollment Period

When Enrollment andATC forms must be submitted

When an EmployeeShould be Disenrolled

How to Report EmployeeTermination orDisenrollment

When to Notify Oxfordof Termination orDisenrollment?

Dates of termination

When shoulda spouse/dependentbe terminated

• Online: www.oxfordhealth.com • If subscriber is electing coverage:

– Member Enrollment Form (NY and CT) or New Jersey Large MemberEnrollment/Change Request Form (NJ)

– HIPAA Certificate (only if enrolled for loss of coverage)• If adding spouse and/or dependent to existing policy:

– ATC (NY and CT) or New Jersey Large Member Enrollment/Change Request Form(NJ)

– HIPAA Certificate (only if enrolled for loss of coverage)– Domestic Partner Affidavit — if enrolling a domestic partner– Adoption paperwork

Enrollment and ATC forms must be: • Signed by the employer and employee

within 31 days of the requested effective date• Received by Oxford within 31 days of the requested effective date

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

• Online: www.oxfordhealth.com • ATC Form (NY, CT) or New Jersey Large Member Enrollment/Change Req. Form (NJ)

ATC Form must be:• Signed by the Employer within 31 days of the requested date of termination• Received by Oxford, within 31 days of the requested date of termination. If an

ATC Form is received more than 31 days after an employee or dependent isterminated, you will be responsible for the premium payments for a certainperiod following the termination.

Please refer to your Group Enrollment Agreement 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 Memberterminated employment

2. Termination Date — coverage will be terminated for the same date employment was terminated

Coverage for 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 materials)• 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 Carrier

When Oxford is the secondary carrier for a Member, all claims for healthcare services must be evaluated by theprimary insurer before Oxford benefits will be considered. This includes all claims that are covered by:

■ Another health insurance company;

■ Auto insurance; and/or

■ Worker’s Compensation insurance

Please refer to the Coordination of Benefits (COB) section for more details.

Verifying Enrollment of New Subscribers

Where to Find Newly Enrolled Employee Information on Your StatementAll 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 InvoicePlease be sure to carefully review the Invoice Details section of your Oxford billing statement and immediately notify Oxford of any omissions or changes to avoid denial ofcoverage at a later date. Please note: Oxford does not enroll individuals more than 31 days from their eligibility date.

See the Billing section, to view a sample Invoice Detail.

Spouses 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 Group Services at 1-888-201-4216 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 Oxford statements should be reviewed to ensure accuracy and corrected in the mannerdescribed 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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Pre-existing Condition Clause

What is a Pre-existing Condition?A pre-existing condition is a physical or mental condition for which medical advice, diagnosis, care, or treatment was recommended or received within the prior 6 months of joining Oxford. During the pre-existingperiod, Oxford may opt not to cover or pay for treatment of a medical condition based on the fact that thecondition was present prior to a Member's enrollment date with Oxford.

Oxford currently applies pre-existing condition limitations to New Jersey and New York small group plans, andindividual plans.

Exceptions:

Oxford does not impose pre-existing conditions on the following:

■ Pregnancies;

■ Newborns enrolled within 31 days of birth; and

■ Adopted children or children placed for adoption who are under age 18 and enrolled within days of the event.

Additionally, genetically inherited medical conditions cannot be treated as pre-existing conditions.

Oxford waives this limitation for a covered person’s pre-existing condition if the condition was payable underanother plan that insured the covered person right before the covered person’s coverage under Oxford’s policy started.

A Pre-existing Condition Limitation Applies to Self-funded GroupsWhat is a pre-existing condition? A pre-existing condition is a physical or mental condition for which the Member sought medical advice,received a diagnosis, or received recommended care or treatment within the six months prior to their effectivedate with Oxford.

How much prior coverage must a Member have in order for a pre-existing condition to be covered?Pre-existing conditions always apply, unless otherwise noted in a group’s policy.

What is an acceptable lapse in coverage between the prior coverage and the Oxford coverage?This will vary by group. However, the allowable gap in coverage cannot be more than 63 days.

How long would a Member be subject to a pre-existing condition?This will vary by group. However, the length of time that coverage can be denied for a pre-existing conditioncannot be more than 12 months.

How is credit for prior coverage determined?Prior coverage credit will vary by group.

Reporting Changes to Group Information

Changes to Group Information You Should Report■ Group name

■ Address

■ Tax identification number

■ Benefits administrator (BA) contact

How to Report ChangesTo report changes to Oxford’s Enrollment Department:

■ All Oxford employer groups may submit your request in writing on your company’s letterhead, signed by anofficer 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 TerminationAll requests for voluntary termination must be submitted to Oxford by submitting a:

■ 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 agentunless the authorized benefits administrator has completed,signed, and returned an Authorization for Broker to Act asBenefits Administrator Form.

Please refer to your Group Enrollment Agreement (GEA) for details on terminating your group’s policy.

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Medical Leave of Absence

How Oxford’s Medical Leave Policy WorksOxford 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 consistentwith the company’s written leave-of-absence policy. Note that this written leave-of-absence policy must have beenestablished by your company and reviewed and approved by Oxford.

Oxford reserves the right to determine:

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

■ Whether the employee is entitled to such a leave.

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

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

■ There must be a reasonable expectation by Oxford 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 Oxford?Please note that in the absence of a reasonable, established medical leave policy (other than a state or federallymandated medical leave policy), 60 days is the maximum period for which an employee will be covered. IfOxford determines, in its sole discretion, that the employee has actually been terminated, or if it is clear thatthe 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 statelaw may retain coverage on the same basis as active employees. Please refer to your Certificate of Coverage fordetails. If necessary, contact Group 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, he or she may now elect coverage duringopen 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 OxfordAccount Executive or broker/consultant.

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RENEWAL NOTICE(Your broker/consult-ant is sent yourrenewal 60 days priorto your renewal date)

Call your broker, consultant orOxford Account Executive.

NOTIFY OXFORD OR YOUR BROKERWITH CHANGES TO YOUR PLAN(i.e., add, drop or change riders,change waiting periods, increase ordecrease deductible and coinsurancelevels, change copayments)

Don't do anything, and your plan willrenew as is with new rates.

RENEWAL CONTRACT Confirmation of your renewalplan design will be sent to you.

Your signature is required if yousubmit the renewal, either as-isor with changes, by mail or faxto Group Enrollment.

No signature is required if you oryour broker renew as-is.

Notes:■ If submitting by mail, changes should be submitted up to the 15th prior to the renewal date.

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

■ It is your responsibility to notify Oxford of any changes to your plan. No revisions will be processed after therenewal 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 & Accountability Act (HIPAA)

Notice to Oxford Health Plans Members Regarding Oxford’s Privacy PracticesThis notice describes how medical information about you may be used and disclosed and how you can accessthis 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 demographicinformation, 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 servesas 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 effectApril 14, 2003, and will remain in effect until such time that it is amended or replaced.

Oxford reserves the right to change our privacy practices and the terms of this Notice at any time, provided thatapplicable law permits such changes. We reserve the right to make the changes in our privacy practices and the newterms of our Notice effective for all PHI that we maintain, including information we created or received prior to anysuch changes. When Oxford makes a significant change in our privacy practices, we will revise this Notice and sendthe revised Notice to our health plan subscribers.

For additional copies of this Notice, please call our Customer Service Department at the toll-free number on your Oxford IDcard, or visit our web site at www.oxfordhealth.com.

Q. How does Oxford use or disclose your PHI?

A. Oxford may use or disclose your PHI, without your consent or authorization, under the following circumstances:

■ Treatment: We may disclose your PHI to a healthcare provider who requests it in order to provide you withnecessary medical treatment, such as emergency care, X-rays or lab work. A provider might be a doctor, ahospital, a home healthcare agency, etc.

■ Payment: We may use or disclose your PHI to pay claims submitted by a healthcare provider for treatment provided to you. For example, we may ask a hospital emergency department for details aboutthe treatment you received so that we can accurately pay the hospital for your care.

■ Healthcare Operations: We may use or disclose your PHI to manage our business. Examples include usingit to determine appropriate premiums, to conduct quality improvement activities, to contact you regardingbenefits or services that might be of interest to you, and to provide you with preventative health advisories.

■ Plan Sponsor: We may disclose limited PHI to your health plan sponsor, benefits administrator, or grouphealth 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 tothe creation, renewal or replacement of a contract of health insurance or health benefits. Once an OxfordMember, 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 researchpurposes or to a coroner, medical examiner, funeral director or an organ procurement center.

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upon request, we would disclose PHI to the U.S. Department of Health and Human Services so that thisagency can verify Oxford compliance with federal privacy laws.

■ Health Oversight Activities: We may disclose your PHI to health oversight organizations and agencies aspart 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 toyour 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 Oxford’s business to another party.

■ Law Enforcement: We may disclose limited information to law enforcement officials concerning the PHIof 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 fornational security or intelligence activities.

■ To Family and Friends: If, in the event of a medical emergency, you are unable to provide any requiredauthorization, we may disclose PHI to a family member, friend or other person to the extent necessary toensure appropriate medical treatment or to facilitate payment for that treatment.

Q. Does Oxford ever need an authorization to use or disclose your PHI?

A. Yes. Except for the purposes described above, Oxford cannot use or disclose your PHI without a signedauthorization from you. If you provide such an authorization to Oxford, 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 Oxford’s possession?

A. Yes. You have the right to inspect or receive copies of your PHI with certain exceptions. You must make arequest to Oxford in writing. Oxford reserves the right to charge a reasonable fee for the cost of producingand mailing the PHI. Request forms are available on the Oxford web site or by calling the number listed atthe end of this Notice.

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

A. Yes. You have the right to receive an accounting of all occasions when Oxford disclosed your PHI for any purpose other than treatment, payment, healthcare operations and certain other instances. Beginning withdisclosures made on or after April 14, 2003, we will maintain a record of disclosures for six (6) years. Arequest for an accounting must be submitted to Oxford 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 morethan once in a 12-month period. Please note, that Connecticut and New Jersey Members will automaticallyget 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 Oxford place additional restrictions on the use or disclosure of yourPHI. We are not required by law to agree to these restrictions. However, if we do agree to the restrictions, wewill abide by them except in the event of an emergency.

Q. Can you request that Oxford use alternate means to confidentially communicate with you about your PHI orcommunicate with you at an alternate location?

A. You must inform Oxford, 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 collectionof premiums, the payment of claims, or the administration of your health insurance coverage.

Q. Do you have the right to request that Oxford 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. Oxford 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 disagreement to be added to the information you sought to change. If we accept your request tocorrect, amend, or delete the PHI, we will make reasonable efforts to inform others of the changes and toinclude the changes in any future disclosures of that information.

Complaints

To express concern about a decision Oxford made about access to your PHI, to report a concern that we violatedyour privacy rights, or to express a complaint about any aspect of Oxford’s privacy practices, please contact theHIPAA Member Rights Unit at the address below. You may also submit a written complaint to the Secretary of theU.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

Oxford supports 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 writtencopy of the Notice as well. To request a written copy of the Notice, please call our Customer Service Departmentat the toll-free number on your Oxford ID card, or call 1-800-444-6222. You can also contact us by mail at:

HIPAA Member Rights Unit Oxford Health Plans48 Monroe TurnpikeTrumbull, CT 06611

All written communications related to this Notice and your rights under HIPAA should be mailed to the HIPAAMember 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 ourcustomers 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. Thisnotice describes our policy regarding the confidentiality and disclosure of customer and Member personal financial information that Oxford collects in the course of conducting its business. Our policy applies to bothcurrent and former customers and Members.

The Information Oxford Collects

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 Securitynumber and date of birth.)

■ Information about your transactions with us, our affiliates (companies controlled or owned by Oxford), orothers; and

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

The Information Oxford Discloses

We do not disclose any non-public, personal financial information about our current and former customers andMembers to anyone, except as permitted by law. For example, we may disclose information to affiliates andother third parties to service or process an insurance transaction; or provide information to insurance regulatorsor law enforcement authorities upon request.

Oxford Security Practices

We emphasize the importance of confidentiality through employee training, the implementation of proceduresdesigned 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 toperform their job responsibilities. We maintain physical, electronic, and procedural safeguards that comply withfederal 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.Investors Guaranty Life Insurance CompanyOxford Benefit Management, Inc.

■ If you would like a copy of these Notices in Spanish, please contact Oxford Customer Service at the number on the back of your Oxford Member ID card.

■ If you would like a copy of these Notices in Chinese, please contact Oxford Customer Service at the number on the back of your Oxford Member ID card.

■ If you would like a copy of these Notices in Korean, please contact Oxford Customer Service at the number on the back of your Oxford Member ID card.

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Overview of Oxford’s Policy Regarding the Release of Confidential Member Information

Confidential Member InformationWhen it comes to personal medical records, Oxford strongly believes that it must safeguard all medical information about its Members. Oxford will disclose confidential medical information only if authorized by aMember or when required by law. Confidential medical information is considered to be any Member-specificinformation gathered as part of the patient care process, including, but not limited to, information on servicesreceived, referrals/provider names, results of services, diagnoses/CPT codes, treatment, copies of Explanation ofBenefits (EOBs), and appointment information.

At Oxford, medical records are treated with utmost respect and confidentiality. Access to medical records is limited to persons who need to see them, such as Oxford Medical Management staff responsible for reviewingand authorizing treatment. Oxford employees with access to medical information are trained in the standardsand protocols that come with this responsibility and are monitored to ensure that they are in compliance withconfidentiality policies and procedures.

How to Request Confidential Member InformationIn order for an Oxford Group Service Associate to release confidential medical information regarding aMember’s claims, Oxford requires that the Member complete and sign the HIPAA Member Authorization Form.This authorization form provides Oxford with:

■ A signed, written release from the Member in question (or from a legal guardian/power of attorney, withappropriate documentation), authorizing us to release the confidential information to the benefits admin-istrator or broker.

■ In addition, the authorization form has a box to check to authorize the Member’s BA or broker to file aninitial 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 BAor 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 contact Oxford Group Services at1-888-654-0065 or download it from the Employer home page at www.oxfordhealth.com.

Prior to submitting the authorization form to Oxford, please contact Oxford Group Services to obtain the proper mailing address or fax number for submitting the authorization form. Once Oxford receives the com-pleted authorization form, employee claim information will be made available over the phone by a GroupService Associate. Due to privacy concerns, BAs and brokers cannot access employee claims information throughour web site; however, Oxford Members can view their own claim information online through our Member website at www.oxfordhealth.com. Members can also contact Oxford’s Customer Service Department to discuss theirown 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 theMember’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, Oxford HealthPlans must obtain an authorization before using or disclosing protected health information (“PHI”). Upon receipt of a valid authorization for its use and/or disclosure of PHI, Oxford will make such use and/ordisclosure in a manner consistent with such authorization.

To: Oxford Health PlansAttn: CorrespondenceP.O. Box 7081Bridgeport, 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 Oxford is authorizedto 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 Oxford is authorized to make the use or disclo-sure to also have the authority to file an appeal and/or grievance on behalf of the Member?

(check one) ❐ Yes ❐ No

Expiration:

This authorization will expire:

❐ Remain in place until____________. (Date)

❐ On occurrence of the following event (which must relate to the Member or to the purpose of the use and/ordisclosure 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 theHIPAA Member Rights Unit at the address provided below. I understand that any revocation of this authorizationwill not affect any action Oxford took in reliance on this authorization before Oxford received my written noticeof revocation. I also understand that any revocation of this authorization will not result in my disenrollmentfrom Oxford or denial of my eligibility for benefits.

HIPAA Member Rights UnitOxford Health Plans48 Monroe TurnpikeTrumbull, CT 06611

Note the following:

• As an Oxford Member, your decision to sign this Authorization is voluntary and said decision will not impacttreatment, payment, enrollment or eligibility for benefits under your Oxford coverage plan.

• If you instruct Oxford to release all of your PHI, please be aware that such release may include informationrelating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It many also include information relating to alcohol or drug abuse, genetictesting, 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 nolonger 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 termsof 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.