Citi Benefits Handbook
How the Plan Works
In-Network Coverage
To receive the highest level of benefits, referred to as the in-network level of benefits, from the Oxford PPO, you must receive care from a preferred provider. In NY, NJ & CT, Citi members have access to the Oxford Freedom Direct network. Outside of the Tri-state area, Citi members have access to the UnitedHealthcare Choice Plus Network nationwide. Citi members have access to the UnitedHealthcare Choice Plus Network nationwide. A current directory of the network providers who participate in the Oxford PPO is available at www.oxhp.com or at 1 (800) 760-4566 (if you are currently not participating in the plan) or 1 (800) 396-1909 (if you are a plan participant).
Deductible
If you use physicians or other providers in the network, you will need to meet an annual deductible ($500 individual/$1,000 family) before any benefits will be paid. Once you meet your deductible, the plan will generally pay 80% of covered in-network expenses.
The individual deductibles apply to all covered expenses except preventive care (which is covered at 100% in-network) and must be met each calendar year before any benefits will be paid.
The family deductible represents the most a family will have to pay in individual deductibles in any calendar year. Only covered expenses that count toward your or your dependent's individual deductible can be applied toward the family deductibles. The family deductible can be met as follows:
  • Two in a family: Each member must meet the $500 individual deductible; or
  • Three or more in a family: Expenses can be combined to meet the $1,000 family deductible, but no one person can apply more than the individual deductible ($500) toward the family deductible amounts
Deductible expenses do not cross-apply between in-network and out-of-network limits.
Coinsurance
Coinsurance refers to the portion of a covered expense that you pay after you have met the deductible. For example, if the plan pays 80% of certain covered expenses, your coinsurance for these expenses is 20%.
Medical Out-of-Pocket Maximum
The out-of-pocket maximum for medical services rendered in the network is $3,000 individual/$6,000 family. This amount represents the most you will have to pay out of your own pocket in a calendar year for services received in the network. This amount does not include penalties, prescription drug expenses, or services not covered under the Oxford PPO. Once this out-of-pocket maximum is met, covered medical expenses are payable at 100% of the negotiated rate contracted with the Claims Administrator for the remainder of the calendar year.
Eligible expenses within a family can be combined to meet the family out-of-pocket maximum, but no one person can apply more than the individual out-of-pocket maximum amount ($3,000) to the family out-of-pocket maximum ($6,000).
Not all expenses count toward your out-of-pocket maximum. Among those that do not count are:
  • Penalties;
  • Expenses that exceed MAA;
  • Prescription drug expenses (which apply to a separate prescription drug out-of-pocket maximum); and
  • Charges for services not covered under the plan.
To help you manage the high cost of prescription drugs, there is also a separate annual prescription drug out-of-pocket maximum. Once you reach the prescription drug out-of-pocket maximum $1,500 (individual)/$3,000 (family), the plan pays the full cost of prescription drug expenses for the remainder of the year.
Out-of-pocket maximum expenses do not cross-apply between in-network and out-of-network limits.
Primary Care Physician (PCP)
When seeking primary care services, you should choose a provider from primary care physicians in the directory of network providers. You may choose a pediatrician as a PCP for your covered child. Women may also select an OB/GYN without a referral from their PCP. A directory of the network providers who participate in the Oxford PPO is available from the Claims Administrator. You may call or visit the Claims Administrator's website at www.oxhp.com or 1 (800) 760-4566 (if you are not currently participating in the plan) or 1 (800) 396-1909 (if you are currently participating in the plan).
Once you meet your deductible, the plan will pay 80% of covered in-network expenses.
Specialists
If you need the services of a specialist, you may seek care from a specialist directly without a referral. Once you meet your deductible, the plan will pay 80% of covered in-network expenses.
Allergist
When you see an in-network allergist, once you meet your deductible, you will be expected to pay 20% of the first office visit. If you receive an allergy injection only (without a physician office visit charge), benefits will be covered at 100%.If services are for other than an allergy injection and you are charged for an office visit, coinsurance will apply.
Preventive Care
Preventive care services are covered at 100%, not subject to deductible. The plan pays benefits for preventive care services provided on an outpatient basis at a physician's office, an alternate facility or a hospital.
Preventive care services encompass medical services that have been demonstrated by clinical evidence to be safe and effective in either the early detection of disease or in the prevention of disease, have been proven to have a beneficial effect on health outcomes and include the following as required under applicable law:
  • Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;
  • Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
  • With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
  • With respect to women, such additional preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.
For more specific information regarding what is considered to be Preventive Care, see "Preventive Care."
Routine Care
The Oxford PPO offers additional coverage for routine care services to help in the early detection of health problems.
  • Routine vision exam: Covered at 100%, not subject to deductible, one exam per calendar year, performed by an in-network ophthalmologist or optometrist; and
  • Routine hearing exam: Covered at 100%, not subject to deductible, one exam per calendar year, performed by an in-network otolaryngologist or otologist.
Infertility
Treatment of infertility must be pre-authorized. Penalties may apply if the treatment is received without pre-certification. Contact the plan for details.
Emergency Care
Coverage for emergency care is subject to deductible and paid at 80%.
Charges Not Covered
An in-network provider contracts with the Oxford PPO Claims Administrator to participate in the network. Under the terms of this contract, an in-network provider may not charge you or the Claims Administrator for the balance of the charges above the contracted negotiated rate for covered services.
You may agree with the in-network provider to pay any charges for services or supplies not covered under the Oxford PPO or not approved by the Oxford PPO. In that case, the in-network provider may bill charges to you. However, these charges are not covered expenses under Oxford PPO and are not payable by the Claims Administrator.
For information about how to file a claim or appeal a denied claim, see "Claims and Appeals for Oxford Health Plans Medical Plans."
Out-of-Network Coverage
You can use an out-of-network provider for medical services and still receive reimbursement under the Oxford PPO. These expenses generally are reimbursed at a lower level than in-network expenses, and you will have to meet a deductible.
For information about how to file a claim for out-of-network services or appeal a denied claim, see "Claims and Appeals for Oxford Health Plans Medical Plans."
Deductible and Coinsurance
If you use physicians or other providers outside the network, you will need to meet an annual deductible ($1,500 individual/$3,000 family) before any benefit will be paid. Once you meet your deductible, you must submit a claim form accompanied by your itemized bill to be reimbursed for covered expenses.
The individual deductibles apply to all covered expenses except routine preventive care (which is covered at 100%) and must be met each calendar year before any benefits will be paid.
The family deductibles represent the most a family will have to pay in individual deductibles in any calendar year. Only covered expenses that count toward your or your dependent's individual deductible can be applied toward the family deductible. The family deductible can be met as follows:
  • Two in a family: Each member must meet the $1,500 individual deductible or
  • Three or more in a family: Expenses can be combined to meet the $3,000 family deductible, but no one person can apply more than the individual deductible ($1,500) toward the family deductible amount.
Once you have met the deductible, Oxford PPO normally pays 60% of maximum allowed amount (MAA) charges for covered expenses that are received out-of-network.
Deductible expenses do not cross-apply between in-network and out-of-network limits.
Medical Out-of-Pocket Maximum
The out-of-pocket maximum for medical services rendered outside of the network is $6,000 individual/$12,000 family. This amount includes the ($1,500 individual and $3,000 family) deductible, medical coinsurance and any medical copayments and represents the most you will have to pay out of your own pocket in a calendar year for medical services received outside the network, excluding charges that exceed MAA, penalties, or services not covered under the Oxford PPO. Once this out-of-pocket maximum is met, covered expenses are payable at 100% of MAA for the remainder of the calendar year.
Eligible expenses within a family can be combined to meet the family out-of-pocket maximum, but no one person can apply more than the individual out-of-pocket maximum amount ($6,000) to the family out-of-pocket maximum ($12,000).
Not all expenses count toward your medical out-of-pocket maximum. Among those that do not count are:
  • Penalties;
  • Expenses that exceed MAA;
  • Prescription drug expenses (which apply toward the separate prescription drug out-of-pocket maximum); and
  • Charges for services not covered under the plan.
To help you manage the high cost of prescription drugs, there is also a separate annual prescription drug out-of-pocket maximum. Once you reach the prescription drug out-of-pocket maximum $1,500 (individual)/$3,000 (family), the plan pays the full cost of prescription drug expenses for the remainder of the year.
In addition, expenses incurred when using in-network services count toward your out-of-network, out-of-pocket maximum.
Out-of-pocket maximum expenses do not cross-apply between in-network and out-of-network limits.
Preventive Care
Each participant has a $250 annual credit toward all out-of-network wellness services. Thereafter, covered expenses are not subject to the deductible and expenses that exceed the $250 credit are covered at 60% of MAA. Preventive care services include:
  • Routine physical exams: Well-child care and adult care, performed by the patient's PCP at a frequency based on American Medical Association guidelines. For frequency guidelines, contact your Claims Administrator;
  • Routine diagnostic tests: For example, CBC (complete blood count), cholesterol blood test, urinalysis;
  • Well-child services and routine pediatric care;
  • Routine well-woman exams;
  • Routine cancer screenings;
  • Routine vision exams; and
  • Routine hearing exams.
In addition, the Oxford PPO will cover well adult and well child routine immunizations performed by out-of-network providers. Well adult and well child routine immunizations are covered 60% of MAA, with no deductible to meet.
Infertility
Treatment of infertility must be pre-authorized. Penalties may apply if the treatment is received without pre-certification. Contact the plan for details.
Hospital
Hospital care (inpatient and outpatient) will be reimbursed at 60% of MAA, after you meet your annual deductible. Coverage for room and board is limited to expenses for the regular daily charge made by the hospital for a semi-private room (or private room when medically appropriate or if it is the only room type available). Notification of an inpatient admission is required. Notification is recommended for certain outpatient procedures and services.
Emergency Care
Coverage for emergency care is subject to deductible and paid at 80%.
Urgent Care
Services provided by an urgent care center are covered at 80% for covered services after the deductible has been met.
Mental Health/Substance Abuse: In and Out-of-Network
The Oxford PPO provides confidential mental health and substance abuse coverage through a network of participating counselors and specialized practitioners.
When you call the customer service telephone number on your ID card, you will be put in touch with an intake coordinator who will gather information from you and help find the right provider for you. In an emergency, the intake coordinator will also provide immediate assistance, and, if necessary, arrange for treatment in an appropriate facility.
You must call your plan before seeking treatment for mental health or substance abuse treatment.
Action (all visits are reviewed for medical necessity)
Inpatient
Outpatient
If you call the plan and use its network provider/facility
After the deductible, eligible expenses are covered at 80% of the negotiated rate; precertification required
After the deductible, eligible expenses are covered at 80% of the negotiated rate; precertification required for certain outpatient procedures
If you call the plan but do not use its network provider/ facility
After the deductible, eligible expenses covered at 60% of MAA; precertification required
After the deductible, eligible expenses covered at 60% of MAA; precertification required for certain outpatient procedures
Coverage Levels
Mental health and substance abuse treatment benefits are subject to the plan's medical necessity requirements, coverage limitations, and deductibles.
Mental health benefits include, but are not limited to:
  • Assessment, diagnosis, and treatment;
  • Medication management;
  • Individual, family, and group psychotherapy;
  • Acute inpatient care;
  • Partial hospitalization programs;
  • Facility based intensive outpatient program services; and
  • Psychological testing that is not primarily educational in nature.
No benefit will be paid for services that are not considered to be medically necessary.
Inpatient Services
The Oxford PPO pays benefits at the in-network level (80% of the negotiated rate contracted with the Claims Administrator) if you call the plan, use an in-network provider, and the treatment is medically necessary and in the appropriate level-of-care setting. If you do not use an in-network provider, you will be reimbursed at 60% of MAA after the deductible is met provided that the treatment is medically necessary and in the appropriate level-of-care setting.
In general, inpatient services are covered only if they are determined to be medically necessary and there is no less intensive or more appropriate level of care in lieu of an inpatient hospital stay. If it is determined that a less intensive or more appropriate level of treatment could have been given, no benefits will be payable.
Generally, inpatient services must be rendered in the state in which the patient resides, unless precertified in advance of the admission.
Outpatient Services
You are encouraged to call the Oxford PPO for outpatient referrals or visit the Oxford Health Plans website for a list of in-network providers. If you use an in-network provider, you will be reimbursed at 80% of covered expenses after the deductible is met. If you do not use an in-network provider, you will be reimbursed at 60% of MAA for covered services after the deductible is met.
Emergency Care
Emergency care for mental health or substance abuse treatment does not require a referral. However you are required to call the Oxford PPO within 48 hours after an emergency admission. The Oxford PPO behavioral health providers are available 24/7 to accept calls.
Medically Necessary
Oxford PPO will help you and your physician determine the best course of treatment based on your diagnosis and acceptable medical practice. The Behavioral Health department will determine whether certain covered services and supplies are medically necessary solely for purposes of determining what the medical plans will reimburse. No benefits are payable unless the Behavioral Health department determines that the covered services and supplies are medically necessary. Please refer to the Glossary section for the definition of medical necessity.
For more information about what your plan covers, see "Covered Services and Supplies." You may also contact the plan directly to confirm coverage of a particular service or supply and to find out what limits may apply.
Concurrent Review and Discharge Planning
The following items apply if the Oxford PPO requires certification of any confinement, services, supplies, procedures, or treatments:
  • Concurrent review: The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review.
  • Discharge planning: Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during precertification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be used by the member upon discharge from an inpatient stay.
Clinical Trials for Cancer or Disabling or Life Threatening Chronic Disease
The Oxford Health PPO plan will cover the routine patient costs associated with a qualifying clinical trial for cancer or a disabling or life-threatening chronic disease.
  • Cancer or other life-threatening disease or condition. For purposes of this benefit, a life-threatening disease or condition is one from which the likelihood of death is probable unless the course of the disease or condition is interrupted.
  • Cardiovascular disease (cardiac/stroke) which is not life threatening, for which, as Oxford determines, a clinical trial meets the qualifying clinical trial criteria stated below.
  • Surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, for which, as Oxford determines, a clinical trial meets the qualifying clinical trial criteria stated below.
  • Other diseases or disorders which are not life threatening for which, as Oxford determines, a clinical trial meets the qualifying clinical trial criteria stated below. Benefits include the reasonable and necessary items and services used to prevent, diagnose and treat complications arising from participation in a qualifying clinical trial.
  • Benefits are available only when the covered person is clinically eligible for participation in the qualifying clinical trial as defined by the researcher.
Routine patient care costs for qualifying clinical trials include:
  • Covered health services for which benefits are typically provided absent a clinical trial.
  • Covered health services required solely for the provision of the Investigational item or service, the clinically appropriate monitoring of the effects of the item or service, or the prevention of complications.
  • Covered health services needed for reasonable and necessary care arising from the provision of an Investigational item or service.
Routine costs for clinical trials do not include:
  • The experimental or investigational service or item. The only exceptions to this are:
    • Certain Category B devices.
    • Certain promising interventions for patients with terminal illnesses.
    • Other items and services that meet specified criteria in accordance with Oxford's medical and drug policies.
  • Items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient.
  • A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.
  • Items and services provided by the research sponsors free of charge for any person enrolled in the trial.
With respect to cancer or other life-threatening diseases or conditions, a qualifying clinical trial is a Phase I, Phase II, Phase III, or Phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of cancer or life-threatening disease or condition and which meets any of the following criteria in the bulleted list below.
With respect to cardiovascular disease or musculoskeletal disorders of the spine, hip and knees and other diseases or disorders which are not life-threatening, a qualifying clinical trial is a Phase I, Phase II, or Phase III clinical trial that is conducted in relation to the detection or treatment of such non-life-threatening disease or disorder and which meets any of the following criteria in the bulleted list below.
  • Federally funded trials. The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:
    • National Institutes of Health (NIH). (Includes National Cancer Institute (NCI).)
    • Centers for Disease Control and Prevention (CDC).
    • Agency for Healthcare Research and Quality (AHRQ).
    • Centers for Medicare and Medicaid Services (CMS).
  • A cooperative group or center of any of the entities described above or the Department of Defense (DOD) or the Veterans Administration (VA).
  • A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants.
  • The Department of Veterans Affairs, the Department of Defense or the Department of Energy as long as the study or investigation has been reviewed and approved through a system of peer review that is determined by the Secretary of Health and Human Services to meet both of the following criteria:
    • Comparable to the system of peer review of studies and investigations used by the National Institutes of Health.
    • Ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
  • The study or investigation is conducted under an investigational new drug application reviewed by the U.S. Food and Drug Administration.
  • The study or investigation is a drug trial that is exempt from having such an investigational new drug application.
  • The clinical trial must have a written protocol that describes a scientifically sound study and have been approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial. Oxford may, at any time, request documentation about the trial.
  • The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a covered health service and is not otherwise excluded under the Plan.
Please remember, the covered service must be precertified.