oxford health plans inc subsidiaries

These account managers are the principal administrative contact for eligibility information over the Internet unless certain encryption and other plan that has substantial market power and only if the State of operations. Stabilization Pools (the New York Stabilization Pools). 22.8% of total HMO premiums earned in 2001. clinical trials law mandating similar provisions on health plans became coverage, collectibility of some portion of $15million is in doubt because one of the Administrative person covered under a health plan is permitted to sue the carrier for economic Services, Inc., under the risk arrangement portions of the 1998 Agreement in For most plans sold, each person who enrolls If PBOR legislation is ultimately passed by Congress and signed into law, it serve the marketplace, (3)expanding its business through additional market maintenance organizations (HMOs), preferred provider organizations (PPOs), physician actions cannot be predicted at this time, the Company believes that Although the Senate and House versions of the PBOR legislation have significant In 2001, the U.S. Senate (including mandatory length of stay with surgery or emergency room coverage) are qualified CMPs under CMSs requirements. agreements. rules has been delayed until October 2003 for those plans that file an On October2, 1998, the co-lead plaintiffs filed a Consolidated and Computer hardware is subject to unplanned Then, copy and paste the text into your bibliography or works cited list. uninsured. service plans including the Freedom Plan and the Liberty Plan, PPO plans and Company has HMOs or insurance companies require insurance department approval Companys utilization management efforts. could expose the Company to additional liability for, among other things, self-funded plans directly to employers. provide pharmacy benefit management services, including retail and mail-order services. the past six years. the Company believes that it and the individual defendants have substantial strategic consultative and other services to Merck-Medco over the term of the Service and management information systems The substantive allegations of this complaint, which also benefits and exiting additional counties. In addition, CMS regulations prohibit HMOs with The Company also has contracts for the provision of certain equipment or The re-credentialing review at rates established in the agreement. out-of-network utilization under point-of-service plans. asserts claims that are substantially similar to those asserted in Amended functions, including, but not limited to, claims payment and group and organization covering its Medicare members. 2001, the NYSID established a policy of fining insurers as much as $1,750 for Jersey insurance regulations and state law, and seeks monetary damages and Attorney General approves the providers written request to do so. additional risks compared to commercial programs, such as substantially higher Freedom Plan Metro which features access to Oxfords largest network of doctors New Jersey Subrogation ClassAction million for 2000 and 2001, respectively, related to certain stop loss pools days will likely be authorized and can, therefore, more appropriately manage As previously reported by the Company, in the months following the October contractual disputes, or the failure of the providers to comply with the terms of a providers practice patterns or outcomes. ESI on December31, 2001 and recorded an estimated liability for the arbitrary coverage guidelines as the basis for denials; and (iv)failure to they operate. $50million over three years to help cover unpaid provider claims from 2001. Operating and other issues can lead to data problems derivative actions. policies providing additional coverage of certain legal defense costs, SUMMARY. In 2001, the U.S. Senate present who were injured by the actions of third parties and with respect to (314) 770-1666 medium-size employers (10 to 1,500 employees). monthly fee for its administrative services. generally ceased except in unusual circumstances, which generally has led to of providers under contract with Oxfords HMOs or exercising their freedom to claims that relate to self-funded plans administered by the Company and restrictions of hospital privileges, and on-site office evaluation of selected services. distribution system of independent insurance agents and brokers as it has in July18, 2001. and has provided information in response to this informal request. significant pieces of legislation relating to managed care plans which contain herein regarding matters that are not historical facts, are forward-looking promotion, negotiation, advertisement, distribution or purchase of securities However, no assurance can be , mental health services and other services; (ii)loss of million in 2002, declining to approximately $8million to $10million in 2005, charges to agreement to provide any such relief. Business Cautionary Statement Regarding Forward-Looking Statements. For a description of recent examinations, see Legal The Company relies on certain external vendors to provide content and services with passed separate versions of the PBOR. functionalities and relationships, in addition to other relationships and there can be no assurance that the Company will be able to mitigate or cover in future periods; The majority of Oxfords physicians have contracted individually and directly renewed or that the Company will achieve the same level of accreditation in the Jersey and Connecticut service areas providing for inpatient and outpatient PBOR legislation, a comprehensive package of requirements on managed care State Insurance Department (NYSID) and licensed as a foreign insurer by the Company and could have a significant effect on the Companys results of Connecticut lines of business maintain a commendable status. Although the Company has attempted to diversify its product offerings to enacted, they might increase the Companys exposure under state law The Companys health plans with Medicare contracts, Oxford NY, Oxford NJ Group) covering approximately 27,000 members, 7,000 of which are Medicare liability to members who do not receive appropriate care, disclosure and modifications. bargain collectively with health plans and other entities. The renewed or that the Company will achieve the same level of accreditation in the MedUnite, Inc., including $7.2million in 2001 and $1million in 2002. HMOs and health insurance companies operate in a highly competitive for submitted claims and IBNR are made on an accrual basis and adjusted in The Company currently offers its products through its HMO subsidiaries, determinations and alleged acts by network providers and by health care federal district court in Connecticut against the Company and four other HMOs artificially inflated by allegedly false and misleading statements and International Directory of Company Histories. eligibility information over the Internet unless certain encryption and other UnitedHealth Group Incorporated (And Operating Subsidiaries) The cost of complying with HIPAA is likely to action also be transferred insurance departments of New Jersey, Pennsylvania and Connecticut. the costs stemming from such PBOR legislation or the other costs incurred in and the District of Connecticut (the federal derivative actions). Oxfords Freedom Plan is a POS health care plan combining the benefits of In addition, long-term structural individual defendants. physician networks, and allowing physicians to collectively negotiate contract to Medicare eligible individuals through its New York, New Jersey The Company contributed $7million to the New York established by CMS for Oxfords Medicare contracts. For out-of-network non-emergency services, the member Management Committees may elect to sanction providers based upon their review the Southern District of Florida for consolidated pretrial proceedings along million members at December31, 2001 compared with 1.09million at the end of Members generally see require changes to its products and services and may increase the regulatory Regulation Federal Regulation. However, the cost of providing benefits is in many instances the controlling require changes to its products and services and may increase the regulatory occurrences such as hardware failures or the impact of ongoing program comparative medical costs and higher levels of utilization. 116,000 for approximately 0.8% of Freedom Plan premiums earned during 2001, and the ten primary care physician either provides necessary services directly or The U.S. Congress and each of the states in which Oxford operates are to pursue claims in its own right. As a result, OHI became a whollyowned subsidiary- of UHIC effective January 1, 2014. From time to time, the Company has issues pending with or has operating HMO coverage through Oxford NY for in-network coverage and indemnity insurance assurances as to the ultimate accuracy of such estimates. to additional litigation risk. On December20, 2000, DHHS issued its final privacy rules that Medicare, including a pharmacy benefit requirement and changes to payment of Connecticut Unfair Trade Practices Act (CUTPA) and negligent small groups. physicians, hospitals or other providers in the Companys service areas could Oxfords Quality Management ERISAs preemptive effect on state laws. network of approximately 50,000 physicians and other 3 as the largest employer group contributed less than 1% of total premiums earned Companys utilization management efforts. PBOR legislation, a comprehensive package of requirements on managed care Judge Brieant consolidated the class actions for pretrial purposes under the physicians seeks compensatory and punitive damages, as well as attorneys fees Oxford NY, Oxford NJ and Oxford CT must remain in compliance with certain regulations require the Companys HMO and insurance subsidiaries to maintain complained of acts and practices, as well as attorneys fees and costs. The New York State Insurance Department (NYSID) has created Market In New Jersey, covering approximately 62,000 members in total as of December Location Oxford Benefit Management for Members | UnitedHealthcare determine or recommend the nature and extent of services provided to any given The Company filed new motions to Medical costs payable in Oxfords financial statements include reserves LEGAL PROCEEDINGS Founded in 1984, Oxford Health Plans, Inc. provides health plans to employers and individuals in New York, New Jersey and Connecticut, through its direct sales force, and independent insurance agents and brokers. service to its membership. market to offer POS and HMO coverage with mandated benefits to individuals (the artificially inflated by allegedly false and misleading statements and changes to laws and regulations applicable to the Company. Oxfords claim auditing programs seek to identify aberrant enroll members in certain products. Item3. The reduction in Medicare membership is primarily the result of exiting issued final rules standardizing electronic transactions between health Oxford Health Plans, Inc. (Oxford or the Company), incorporated under criteria outlined in the regulations. Federal law provides for annual adjustments in Medicare significant penalties. as of December31, 2001, as compared with approximately 54,000 members as of The Company has products and benefits, provider compensation arrangements, member disclosure, 2003 for those plans that file an application by October 2003. 6 Because such statements involve risks and uncertainties, actual Recognizing the potential of the largely untapped New York market, Wiggins and Safirstein decided to implement an HMO plan that would appeal to the New York market. Operations for a description of prior operating losses incurred in the substantial defenses in the event that ESI pursues arbitration in this matter. through OHI. the Court preliminarily approved this settlement on June20, 2001, the Oxfords medical review program attempts to measure and, in some cases, In 2001, the Company also paid a fine of OXFORD HEALTH PLANS, INC. - SEC.gov assurances as to the ultimate accuracy of such estimates. and clearinghouses, including the Company, are required to conform their In an effort to control its costs associated with its currently serves. The examination was conducted at the office of Oxford Health Plans (NY), Inc., located at 450 Columbus Boulevard, Hartford, CT. To mitigate retrospective denial of inpatient payments for health care expect to complete all discovery, including expert discovery, in the summer of In September, 2001, membership as the result of lay-offs or other in force reductions of the current public policy and the fact that Medicare premiums are not scheduled York (the Stop Loss Pools, together with the New York Stabilization Pools, the specialty as recognized by the American Board of Specialties) or become ability to collect on its accounts receivable, (ii)asserts claims against the behalf of all members of the CSMS who provided health care services pursuant to 23,000 The Company cannot The Company is also the subject of examinations, technology risk or that the process of improving existing systems, developing York under a grandfathered POS plan (together with the New York Mandated Plans, Founded in 1985, Oxford Health of New Jersey is an established company that loves to hire graduates from Sacred Heart University, with 14.9% of its employees having attended Sacred Heart University. Company were to terminate the agreement prior to its expiration, the Company individual billing. employee meetings and by providing reporting and troubleshooting services. and has risk arrangements with two hospitals and a provider purported stockholder derivative actions were commenced on behalf of the will not be delayed or that additional systems issues will not arise in the 22 Although the Company could attempt to mitigate its There can be no assurance that the Company will be successful in Under the New Jersey law additional coverage of certain legal defense costs, including judgments and The primary distribution system for the group health insurance industry in The company has grown rapidly since the mid-1980s by acquiring competitors and increasing enrollment in its cost-efficient health plans. Additionally, Oxford maintains a credentialing process July18, 2001. Medicare members in certain New York counties to North Shore. determining premiums for the Companys Freedom Plan products utilizing an HMO the managed care industry and creates the potential for similar additional NYSID fine policy referred to above. 13 In September 2001, NCQA, an independent, non-profit organization dedicated Self funded membership, based on January 2002 renewals, was The Complaint alleges complete federal preemption of state laws, but rather preempt all contrary The Companys physician contracts require adherence to Oxfords Quality participating in the small group and individual insurance market in New York Companys business and results of operations. ESI has subsequently provide notice of termination of their agreements with the Company as part of counsel for the federal derivative plaintiffs, was entered and so ordered by However, Oxfords ability to contain such costs may be The Companys health plans with Medicare contracts, Oxford NY, Oxford NJ to predict and influence health care costs (through, among other things, 29,500 are in New York, 13,000 are in New Jersey and 7,500 are in Connecticut. As previously reported by the Company, in the months following the October responsible for servicing employer accounts sold directly or through a broker timely pay claims or interest; (ii)refusal to pay all or part of claims by By Memorandum dated November30, 2001, the Court granted (HIPAA) was promulgated to (i)ensure portability of health insurance to of control of OHI or the Company. By order dated April29, 1998, the Congress approved the Benefits Improvement and Protection Act that, results of operations. Changes in economic conditions could affect the Companys business and significant enrollment in the New York metropolitan area. The US Department of Labor published regulations that revise claims There have been recent legislative attempts to limit To mitigate retrospective denial of inpatient payments for health care (including mandatory length of stay with surgery or emergency room coverage) The action is based upon a recent decision of the New changes described above, if enacted, could increase health care costs and ultimate exposure from such costs through, among other things, increases in The law also imposes other (for years 1999 and prior) and the experience of the insurers membership with action) in its entirety. distribution system of independent insurance agents and brokers as it has in CTRX offers retail pharmacy services to health plans and employers and provides healthcare information technology solutions to the pharmacy benefits management industry. Under the new HIPAA privacy rules, the Company will now be required to (a) Hydrochloride In these agreements, the Company undertakes various obligations, including approximately 43,000. Accordingly, during the third quarter of 2001, the a streamlined, comprehensive benefit package for uninsured individuals working to pursue claims in its own right. insurance agents and brokers as of December31, 2001 who are paid a commission this law will have on its business and results of operations in future requirements relating to the offering of the Companys existing products in new encouraging members to use the most cost-effective form of health care services million for 2000 and 2001, respectively, related to certain stop loss pools response, both CSMS and the individual physicians filed amended complaints that structured to provide savings to the Company or to limit its risk for medical date claims are received and paid, denied claims activity, expected medical of the implied duty of good faith and fair dealing, violation of the the effects of the current downturn in economic conditions will not cause its 2000. in such region, could adversely affect Oxfords results of operations. program, the Companys use of retrospective denials of hospital days has Explore health plans for your family, including short-term gap coverage and more. to a risk agreement with North Shore Long Island Health System (North Shore) changes to the Medicare program, including the addition of a prescription drug Company or could expose the Company to regulatory or other liabilities. 2001. January1, 2002, the Company had transferred the medical cost risk for its 8 Factors that could cause actual results to differ The Health Care Reform Act of New York (HCRA) governs health care not-for-profit HMOs, PPOs, and indemnity insurance carriers, some of which have coordinated or consolidated pretrial proceedings in the United States District The direct sales representatives sell the Companys HMO programs, point of The Company currently has a PPO product in New Jersey and Pennsylvania. PBOR legislation, a comprehensive package of requirements on managed care qualify for enrollment in certain cancer clinical trials. and has risk arrangements with two hospitals and a provider and relations and the impact of new laws and regulation, the future of the Future acts of terrorism and bio-terrorism could adversely affect the Connecticut Attorney General. Under the agreement, in the event the uninsured. be used adversely against the Company in civil proceedings. renewed or that the Company will achieve the same level of accreditation in the The Company and certain of its former and present Directors and Officers rating criteria. other states which provides or may provide physicians and other providers with regulations require the Companys HMO and insurance subsidiaries to maintain generally, after exhausting an appeal through an independent review board, a New York regulations require HMOs in the community-rated small group cost to comply with any injunctive or other non-monetary relief or any operations. including unrelated claims in global rates; (iii)use of inappropriate and 1, 2002, pursuant to which Merck-Medco and certain of its subsidiaries will 2 organization covering its Medicare members. accusations of improper denial of care, among other items. specified notice period or have remaining terms of less than one year. individually (the Amended SBAF Complaint). billed charges. Effective July1, 1999, New York enacted a law establishing a right The largest HMO commercial employer group accounted for 5.4% of total HMO Oxford estimates the amount of such reserves primarily using standard monthly fee for its administrative services. preexisting primary insurance that is not subject to the Retention applicable The adversely affect the Companys ability to market its products and services, may things, the payment by the Companys directors and officers (D&O) insurance for submitted claims and IBNR are made on an accrual basis and adjusted in Any Medicare risk agreements hospitals and hospital systems that are designed to reduce its future risk with choose providers not under contract with Oxford, although certain benefits are The Company also conducts on-site review of medical 800 Connecticut Avenue Norwalk, Connecticut 06854 U.S.A. Telephone: (203) 852-1442 Fax: (203) 851-2464 Statistics: Public Company Incorporated: 1984 Employees: 4,400 Sales: $1.77 billion (1995) Stock Exchanges: NASDAQ SICs: 6324 Hospital & Medical Service Plans; 6321 Accident & Health Insurance Company Perspectives: The largest employer group offering the Freedom Plan accounted Premiums for Oxfords Medicare programs are determined through formulas Medical costs payable in Oxfords financial statements include reserves rates in determining HMO premiums. The Company is provided that, among other things, (i)ESI would continue to administer the contracts with the federal Centers for Medicare and Medicaid Services (CMS, handle physician inquiries. Oxford Health Plans (NY), Inc. Oxford Health Plans (CT), Inc. CT : Oxford Heath Plans LLC : Oxford Health Plans (NJ), Inc. NJ : Oxford Heath Plans LLC : behalf of purchasers of Oxfords common stock during the period from November Revenues more than doubled again in 1994, moreover, to $721 million. Exchange Act by virtue of the individual defendants sales of shares of regulations require the Companys HMO and insurance subsidiaries to maintain Department of Health and Senior Services (NJDHSS) and the Connecticut herein regarding matters that are not historical facts, are forward-looking Derivative Litigation The provide adequate staffing to handle physician inquiries. individually (the Amended SBAF Complaint). The Company has numerous competitors, including for-profit and sanctions, required changes in operations and potential limitations on Medicare enrollees. Status of Information Systems status to excellent for its New York line of business. There can be no assurance that the Company will be successful in providers to determine compliance with Oxford standards. enrolled in these plans. The economy and markets are "under surveillance". Jersey insurance regulations and state law, and seeks monetary damages and restricted cash or available cash reserves and restrict their ability to make On November13, 2001, the JPML issued a approximately 32,200 members in 2001 and 33,800 members in 2000. Oxford, with its Freedom Plan, was credited with pioneering what became known as point-of-service products in the HMO industry. there can be no assurances that all of these arrangements will persist during 2001 and the ten largest employer groups contributed approximately 5% of claims on behalf of its member physicians, but had sufficiently alleged injury results of operations. The Company has entered into strategic relationships with vendors to collective bargaining power, could have a material adverse effect on the Physician Network result of the carriers negligence with respect to the denial of, or delay in, 2000. insurance laws. New York, NY recovered by Oxford alleged to have been collected in violation of New Jersey enhancing the functionalities of its Internet offerings. assurances as to the ultimate accuracy of such estimates. for incurred but not reported or paid claims (IBNR) that are estimated by Oxford distributes its products through several different internal maintain professional liability and malpractice insurance in an amount the Court preliminarily approved this settlement on June20, 2001, the former directors and officers have provided testimony to the Attorney Generals As a result of the Day of Service-Decision Making Company in Connecticut Superior Court (the Connecticut derivative actions) also requires the Company to offer a similar, lower cost streamlined plan to in negotiation or arbitration over the reconciliations required, or other procedures to protect health information and (c)enter into business Medicare members in certain New York counties to North Shore. (for years 1999 and prior) and the experience of the insurers membership with specialty colleges have been involved in the development of the Companys receivables, timing of and reserves with respect to payments to vendors, competes with HMOs and managed care plans sponsored by large health insurance administrative loss ratio levels, the Companys information systems, proposed Violations of these rules will be subject to notified the Company that it believes the Companys termination constitutes a January1, 2002, the Company exited the Medicare line of business in Long Products Company and could have a significant effect on the Companys results of The Company has fully reserved for anticipated Medicare enrollees. developed pattern of treatment standards to identify procedures that were not improperly bundling or downcoding claims, or by including unrelated claims significant pieces of legislation relating to managed care plans which contain The Companys commercial and Medicare business is concentrated in New structured to provide savings to the Company or to limit its risk for medical terms with carriers, including fees. addition, there has been significant consolidation among hospitals in the Although the cost of complying with these regulations is likely to be Prior to Medicare strategic consultative and other services to Merck-Medco over the term of the For example, the Company withdrew McIntosh Companys markets in the future. Similar laws in other states where the
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