OXFORD HEALTH INSURANCE, INC.
New York Small Group Silver Oxford Standard PPO Plan (INN/OON) - Gated
SUMMARY OF COVERAGE
Representative Sample
Liberty Network
BENEFIT
FINANCIAL
Deductible:
Single
Family
Coinsurance
Single
Maximum Out-Of-Pocket:
(Including Deductible) Family
Financial Accumulation Period:
Out-of-Network Reimbursement:
IN-NETWORK
OUT-OF-NETWORK
$2,000
$4,000
30%
$5,500
$11,000
Calendar Year
Not Applicable
$3,000
$6,000
30%
$7,500
$15,000
Calendar Year
140% of Medicare¹
Please Note: All Copayments, Deductibles, and Coinsurance (medical and prescription) paid for In-Network Covered Services contribute to the In-Network, Out-of-Pocket
Maximum.
PREVENTIVE CARE
Adult Preventive Care
Infant and Pediatric Preventive Care
Preventive Dental for Children (Up to age 19)**
Pediatric Vision Exam (Up to age 19)
Pediatric Vision Hardware (Up to age 19)
No Charge
No Charge
Deductible then $30 copay per visit
Deductible then $30 copay per visit
Deductible then 30% Coinsurance
Not Covered
Deductible then 30% Coinsurance
Deductible then 50% Coinsurance
Deductible then 50% Coinsurance
Deductible then 50% Coinsurance
OUTPATIENT CARE
Primary Care Physician Office Visits
Specialist Office Visits*
Outpatient Surgery - Hospital Setting**
Outpatient Surgery - Freestanding Facility**
Laboratory Services**
Radiology Services**
Deductible then $30 copay per visit
Deductible then $50 copay per visit
Deductible then $100 copay per visit
Deductible then $100 copay per visit
Deductible then $50 copay per service
Deductible then $50 copay per service
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
MRIs, MRAs, CT SCANS, AND PET SCANS
Outpatient Hospital Services**
Freestanding Radiology Facility**
Deductible then $50 copay per service
Deductible then $50 copay per service
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
HOSPITAL CARE
Physician's and Surgeon's Services **
Semi-Private Room and Board **
All Drugs and Medication
Deductible then $100 copay per visit
Deductible then $1,500 copay per admission
No Charge
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then $150 copay
Deductible then $150 copay per visit
Deductible then $150 copay
Deductible then $150 copay per visit
Deductible then $70 copay per visit
Deductible then 30% Coinsurance
MATERNITY CARE
Prenatal and Post-Natal Care **
Hospital Services for Mother and Child **
No Charge
Deductible then $1,500 copay per admission
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
SKILLED NURSING FACILITY
200 days per Contract Year.**
Deductible then $1,500 copay per admission
Deductible then 30% Coinsurance
HOSPICE CARE
Inpatient Care**
Home Hospice - 210 days combined (Inpatient & Home) per
Calendar Year.
Deductible then $1,500 copay per admission
Deductible then $30 copay per visit
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
HOME HEALTH CARE
Home Care Visits - 40 visits per Calendar Year.**
Physician House Calls
Deductible then $30 copay per visit
Deductible then $50 copay per visit
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
SUBSTANCE USE DISORDER SERVICES
Inpatient Rehabilitation**
Outpatient Rehabilitation
Deductible then $1,500 copay per admission
Deductible then $30 copay per visit
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
EMERGENCY CARE
Ambulance Service When Medically Necessary**
At Hospital Emergency Room (waived if admitted)
(If member is admitted to the hospital, notification is required.)
Emergency Care in Urgi-Center
New York Small Group Silver Oxford Standard PPO Plan (INN/OON) - Liberty Network, Gated
Representative Sample
Page 1 of 2
BENEFIT
IN-NETWORK
OUT-OF-NETWORK
MENTAL HEALTH CARE
Inpatient Care**
Outpatient Visits
Deductible then $1,500 copay per admission
Deductible then $30 copay per visit
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
ALLERGY CARE
Testing and Treatment**
Deductible then $50 copay per visit
Deductible then 30% Coinsurance
ALTERNATIVE MEDICINE
Chiropractic Care - Unlimited Visits**
Deductible then $50 copay per visit
Deductible then 30% Coinsurance
SHORT TERM REHAB & HABILITATIVE SERVICES
Inpatient limited to 60 days per Calendar Year.**
Outpatient limited to 60 visits per Calendar Year (combined
with Habilitative Service).**
Deductible then $1,500 copay per admission
$30 copay per visit
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
DURABLE MEDICAL EQUIPMENT
Durable Medical Equipment - Unlimited**
Precertification required for items over $500
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
MEDICAL SUPPLIES
Medical Supplies When Medically Necessary**
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
Deductible then 30% Coinsurance
$200 reimbursement per 6 month period
$100 reimbursement per 6 month period
$200 reimbursement per 6 month period
$100 reimbursement per 6 month period
HEARING AIDS
Hearing Aids - Coverage is limited to a single purchase
(including repair/replacement) per hearing impaired ear every
three years.
EXERCISE FACILITY
Subscriber
Spouse
OUTPATIENT PRESCRIPTION DRUGS - RETAIL
The Prescription Drug Benefit is based on a Per Calendar Year limit for any applicable deductibles and/or maximum limits.
Tier 1
$10 copay
Tier 2
$35 copay
Tier 3
$70 copay
Not Covered
Not Covered
Not Covered
OUTPATIENT PRESCRIPTION DRUGS - MAIL ORDER
Tier 1
Tier 2
Tier 3
Not Covered
Not Covered
Not Covered
$25 copay
$87.50 copay
$175 copay
DEPENDENT ELIGIBILITY:
Eligible dependents include the employee's spouse and dependent children until the child reaches age 26.
*Visits to an Oxford participating Specialist require an authorized referral from the member's Primary Care Physician.
**These services require precertification through Oxford. Members must call Oxford at 1-800-444-6222 at least 14 days in advance of request of treatment to request
precertification.
**Mental health and substance use disorder services can be precertified through Oxford's Behavioral Health Department by calling 1-800-201-6991.
**Precertification is required for Pediatric Orthodontia services only
Please Note: This sample summary of coverage is provided for informational purposes only. The applicable Summary of Benefits will be issued to eligible enrolled
members as part of the Certificate of Coverage. Coverage is subject to the terms and conditions of the Certificate.
Refer to the Certificate of Coverage for a more complete listing of all benefits, limitations, and exclusions which include, among other services not authorized by Oxford,
cosmetic surgery, routine foot care, custodial care, personal comfort or convenience items, private or special duty nursing, learning and behavioral disorders, Worker's
Compensation, military service-related conditions, or, unless otherwise stated, dental services and vision correction services and supplies.
Benefits are subject to final approval by the Department of Insurance and therefore may be subject to change.
1When a Medicare rate is not available, reimbursement is based upon certain gap methodology, including a gap methodology using relative value data from FAIR
Health, Inc. When a gap methodology is not available, reimbursement is based upon 50% of the provider’s billed charge.
New York Small Group Silver Oxford Standard PPO Plan (INN/OON) - Liberty Network, Gated
Representative Sample
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