Small Business Solutions Underwriting Guidelines

Transcription

1 Small Business Solutions Underwriting Guidelines Oklahoma FOR BUSINESSES WITH 2 50 ELIGIBLE EMPLOYEES Choice. Simplicity. Affordability OK (6/05)

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3 Oklahoma Underwriting Guidelines Note: State and Federal Legislation/Regulations, including Small Group Reform and HIPAA, take precedence over any and all Underwriting Rules. Exceptions to Underwriting Rules require approval of Regional Underwriting Director except where Head Underwriter approval is indicated. This list is meant to be informative and is not intended to be all-inclusive. Other policies and guidelines may apply. ALL PRODUCTS (Except the Aetna Golden Medicare Plan and Aetna Golden Choice Plan) Dependent Eligibility Eligible dependents include an employee s spouse and unmarried children up to age 19 (or age 23 if dependent is a full-time student). For Life, eligible dependents are covered starting at 14 days. Individuals cannot be covered as both an employee and dependent under the same plan, nor may children eligible for coverage through both parents be covered by both under the same plan. If both husband and wife work for the same company, each must be enrolled separately as an employee. Dependents must enroll in the same Medical and Dental benefits option as the employee. An employee or member must be allowed to claim a grandchild as a dependent for insurance purposes; proof of dependency may be required at the time of enrollment. Dependents are not eligible for AD&D or Disability insurance. Effective Date Employer Eligibility Group Submission Deadline The effective date for new contracts must be the first or the fifteenth of the month. All Aetna plans can be offered to sole proprietorships, partnerships, or corporations. Organizations must not be formed solely for the purpose of obtaining health coverage. Non Guaranteed Associations, Taft Hartley groups, Professional Employers Organizations (PEO)/employee leasing firms, closed groups (groups that restrict eligibility through criteria other than employment) and groups where no employer/employee relationship exists are not eligible for Small Group coverage. Dental and Disability have ineligible industries which are listed in the Ineligible Industry section. The Dental list does not apply when Dental is sold in combination with Medical. When a company is Doing Business As (DBA), a copy of the certificate of fictitious name should be provided. Must submit a signed copy of the most recent Oklahoma Workforce Commission (OWC) Employer s Quarterly Report which must contain the names, salaries, etc. of all employees of the employer group. > Employees who have terminated or work part-time should be noted accordingly on the OWC Employer s Quarterly Report. > Employees not listed on the OWC Employer s Quarterly Report must have a copy of their latest payroll stub and letter from employer verifying hours worked. These items should be submitted to verify eligibility. Other documentation may be requested by Underwriting upon receipt and review of sold case documents for final Underwriting approval and installation. Please refer to the Small Employer Proof of Eligibility form for additional required information. In order for Aetna to honor the requested effective date, all completed paperwork must be received by Aetna Small Group Underwriting no later than the last business day prior to the requested effective date. If not received by this date, the effective date may be moved to the first of the following month. 1

4 Initial Premium Check Multiple Companies May Be Quoted As One If: Newly Formed Business Replacing Other Group Coverage Signature Dates Employee Eligibility The initial premium check is not binding. Final premium amount due may vary after Underwriting review. If the request for coverage is denied due to business ineligibility, participation, and/or contribution requirements not being met, the original check will be returned or a refund check will be sent. The initial premium check should be in the amount of the first month s premium and drawn on a company check (personal checks are not accepted). One owner has controlling interest of all businesses to be included; and All businesses filed under one combined tax return must be enrolled as one group. For example, if the employer has three businesses and files all three under one combined tax return, then all three businesses must be enrolled for coverage. If request is for only two of the businesses to be enrolled, the group will be considered a Carve Out and will not be Guarantee Issue, and could be declined; and The two or more groups do not have to have the same Standard Industrial Classification Code, however, the SIC code with the majority of employees will be used. In cases where there are the same number of employees, the SIC code with the higher SIC rating factor will be used; and The common ownership form is completed. Employers must provide the following documentation for consideration: Payroll records or letter from attorney or Certified Public Accountant listing the names of all employees and number of hours worked each week; and Occupational License (not a professional license) or Tax I.D. Number; and Articles of Incorporation, Partnership Agreement and/or assumed name certificate Inquires may be made by the underwriter when the business is operated from the employer s residence, the business appears seasonal, participation appears questionable, or if there is any other questionable aspect of the case at the discretion of the underwriter. A copy of the most recent prior carrier bill must be provided. The employer should not cancel any existing coverage until they have been notified in writing of final approval from the Aetna New Business Underwriting unit. Aetna small group employer application and all employee enrollment applications must be dated and signed within thirty days of the requested effective date. All employee applications must be completed by the employee himself/herself, and must include spousal signature if spousal coverage is being requested. An eligible employee is defined to be any permanent employee who is actively engaged on a full-time basis in the conduct of the business of the small employer, in the small employer s regular place of business and who works a minimum of 24 hours per week and has completed the benefit waiting period. This includes a partner of a partnership, sole proprietor or independent contractor if included as an employee under the health benefits plan of a small employer. Additional information may be required to confirm eligibility for Medical and Dental benefits. These individuals may be eligible for Life and Disability benefits, provided they work at least 24 hours per week. Coverage may not be extended to employees belonging to a union class excluded as the result of a collective bargaining agreement. The definition of eligible excludes: 1) those covered under another health benefit plan; 2) parttime, temporary or substitute employees; and 3) those covered under an employee welfare benefit plan that provides health benefits and is established in accordance with ERISA. Employees who do not meet the definition of a permanent full-time employee will not be eligible (e.g., leased, employees of a PEO, part-time, temporary, seasonal or substitute employees). Retirees Retiree coverage is not available. COBRA COBRA-eligible enrollees are required to be included on the census. Health questions must be answered. COBRA-qualifying reason, length, start and end dates must be provided. 2

5 Eligibility SPECIFIC TO PRODUCTS Medical Dental Life/AD&D/Disability Late Applicants Late applicants without a qualifying event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are not allowed and must wait for the group s next anniversary date to enroll. Late applicants without a qualifying event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are not allowed and must wait for the group s next anniversary date to enroll. In addition, they are subject to the dental Late Entrant Provision: > Coverage limited to Preventive & Diagnostic services for the first 12 months. No coverage for most Basic and Major Services for first 12 months (24 months for Orthodontics). Dental Late Entrant is not applicable to the DMO. Late applicants without a qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are not allowed and must wait for the group s next anniversary date to enroll. Employer Contributions The employer must contribute at least 50% of employee rate. The employer must contribute at least 50% of the employee only cost or 25% of the total cost of the plan. Groups with less than 10 eligible lives: The employer must contribute 100% of the cost of the plan. Groups with eligible lives: The employer must contribute at least 50% of the cost of the plan (excluding Optional Dependent Life). Participation Groups with 2 eligible employees: 100% participation required. Groups with 3 50 eligible employees: 75% of eligible (rounded up), excluding those with coverage through another employer s plan, must participate. Example: > 12 lives, 3 covered under spouse s coverage 12 3 = 9 X 75% = 6.75 rounded up, 7 must enroll Groups with 2 3 eligible employees: 100% participation is required, excluding those with other qualifying existing Dental coverage. Groups with 4 50 eligible employees: 75% participation is required, excluding those with other qualifying existing dental coverage. A minimum of 50% of total employees must enroll in the Dental plan. 100% participation is required for non-contributory plans. All employees, excluding those with other qualifying existing Dental coverage, must enroll. Employees may select coverage for eligible dependents under the Dental plan even if they selected single coverage on the Medical plan or vice versa. Groups with less than 10 eligible lives: 100% participation is required Groups with eligible lives: 75% participation is required if the plans are at least partially contributory. For non-contributory plans, 100% participation is required. 3

6 Eligibility (Continued) Medical Dental Basic Life and Packaged Life & Disability Participation (cont.) Employees waiving due to individual, governmental (Medicare, Champus, etc.) or spousal coverage must provide proof of other coverage by providing a copy of their insurance card and must complete the waiver section of the employee application. If the coverage is not from a qualifying group plan, the employee may not be considered a valid waiver and will count towards the minimum participation requirement. Product Availability Union employees are the only class of employees that may be excluded by an employer as not being eligible for coverage. Management carve outs are not allowed. Dual Option and High/Low benefit plans are available. At least one employee must enroll in each benefit plan offered. For groups of 2 9 eligible employees, Dental must be sold with Medical and cannot be sold on a standalone basis. Dental may be installed on an unbundled basis with the Medical offering (i.e., an eligible employee may enroll into Dental and not the Medical and vice versa) but Medical and Dental must be offered to all employees. For groups of 10 or more eligible, Dental may be sold on a standalone basis or along with Medical on a bundled or unbundled basis. Orthodontic coverage is available to groups with 10 or more eligible employees. Orthodontic coverage on all plans is for dependent children only. Carve outs are not allowed. Life and Disability plans are available to groups of 2 9 eligible if packaged with Medical. It is available to groups with eligible employees if packaged with Medical or Dental. Group Life and Disability is available on a standalone basis for groups with eligible employees. Dependent Term Life for Spouses and Children is available at an additional cost for groups with eligible employees when purchasing just the Basic Life/AD&D. It is automatically included in all of the Packaged Life & Disability plans and Packaged Life/Disability/Dental plans for groups with 2 50 eligible lives at no additional cost. Dependent Life offered is a flat $5,000 for spouse and $2,000 per child. Dependents are not eligible for AD&D and Disability insurance. Life and AD&D is a bundled product and must be sold together. Carve outs are not allowed. 4

7 Medical Dental Basic Life and Packaged Life & Disability Product Availability (cont.) Out-of-Area within Oklahoma (Employees residing out of any Aetna network service area within Oklahoma) Must enroll into the Aetna Indemnity plan. Aetna Indemnity plan is only available if the employee resides outside of both the Aetna PPO network service areas and the Aetna HMO network service areas. Out-of-State (Employees residing outside of Oklahoma) Must enroll into an Out-Of- State PPO plan if PPO network and product is available where the out-of-state employee resides, otherwise Indemnity is only product available. Indemnity Only States OOS PPO not available in AL, HI, ID, MN, MT, ND, NM, RI, UT, VT, WI, and WY. OOS TC not available in VT and HI. Out-of-Area within Oklahoma (Employees residing out of any Aetna network service area within Oklahoma) Employees who still reside within Oklahoma but outside of a DMO service area can be offered an In-State PDN or Scheduled plan. Out-of-State (Employees residing outside of Oklahoma) Out-of-state employees can only be offered one of the specific Out-of-State Dental plans; 3 PPO and 3 Indemnity plan designs. Maximum out-of-state employee percentage (and/or number of employees) will agree with the Medical guidelines for each state. Orthodontic coverage is included for groups with 10 eligible employees. Out-of- State plans offer orthodontic coverage to dependent children only. Indemnity Only States No PPO is available in the following states: AR, AK, HI, ID, ME, MT, ND, NH, NM, SD, VT, WY. Open Enrollment Periods 30 days prior to the groups renewal date Prohibited Prohibited Rating Tier 2 10 enrolled employees: tabular rating applies* enrolled employees: 4-Tier composite rating applies* All out-of-state employees will be tabular rated.* 4-tier composite rating applies Life/AD&D: tabular rates apply Disability: tabular rates apply Life & Disability packaged plan: per employee per month rate Dental, Life & Disability packaged plan: per employee per month rate *All out-of-state employees will be tabular rated. 5

8 Ineligible Industries Medical Dental Basic Life and Packaged Life & Disability Note: Both the Dental and Life/AD&D/ Disability ineligible industries lists apply to the Dental, Life & Disability packaged plan. Not Applicable. Ineligible industry list applies only when Dental is sold standalone or packaged only with Group Life or Disability insurance. SIC Description SIC Range Employment Agencies Dance Studios, Schools 7911 Theatrical Producers, Bands,Orchestras, Actors Bowling Centers 7933 Professional Sports Clubs & Producers, Race Tracks Physical Fitness Facilities 7991 Public Golf Courses, Amusements, Sports & Recreation Clubs Miscellaneous Amusements & Recreation 7999 Business Associations 8611 Professional Membership Organizations, Labor Unions, Civic Social & Fraternal Organizations, Political Organizations Religious Organizations 8661 Miscellaneous Membership Organizations 8699 Private Households 8811 Miscellaneous Services 8999 There are no ineligible industries for the Life/AD&D insurance benefit only. The packaged Life and Disability plan has the following ineligible industries: SIC Description SIC Range Mining Explosives, Bombs & Pyrotechnics Asbestos Products Primary Metal Industries Fire Arms & Ammunition Liquor Stores 5921 Security Brokers 6211 Real Estate Agents 6531 Service-Detective Services 7381 Automotive Repairs /Services Motion Picture /Amusement Offices and Clinics of Medical Doctors Membership Associations Services-Private Households Non-classified Establishments \

9 SPECIFIC TO ONE PRODUCT ONLY Medical Only An Oklahoma small employer subject to guarantee issue cannot be declined based on medical conditions or claims experience; however, rates may be adjusted for known medical conditions. All eligible employees and COBRA enrollees applying for Medical coverage are required to complete the individual health questionnaire section of the Employee Enrollment/Change form. Failure to do so may result in a maximum medical rate-up determination. Dental Only Coverage-Waiting Period For Major and Orthodontic Services, employees must be an enrolled member of the plan for 1 year (not applicable to DMO). The Coverage-Waiting Period is waived separately for Major or Orthodontic Services for employees who were covered by the group s immediately preceding dental plan. To waive the Waiting Period for Orthodontic Services, the immediately preceding group plan must have included Orthodontic coverage. Product Packaging DMO can either be sold standalone or packaged with any PDN Option as a Dual Option. PDN or the Scheduled Plan can be sold standalone or packaged with the DMO as a Dual Option. Freedom of Choice cannot be packaged with any other option. Life/AD&D/Disability Only Job Classification (Position) Schedules Varying levels of coverage based on job classifications are available for groups with 10 or more lives. Up to 3 separate classes are allowed. Items such as probationary periods must be applied consistently within a class of employees. The benefit for the class with the richest benefit must not be greater than five (5) times the benefit of the class with the lowest benefit. Guaranteed Issue Coverage Aetna provides certain amounts of life insurance without requiring an employee to answer any medical questions. These insurance amounts are called guaranteed issue. Employees wishing to obtain increased insurance amounts will be required to submit Evidence of Insurability which means they must complete a medical questionnaire and may be required to submit to a medical exam. Evidence of Insurability (EOI) EOI is required when one or more of the following conditions exist: Life insurance coverage amounts requested are above the Guaranteed Standard Issue Limit. Coverage is not requested within 31 days of eligibility for contributory coverage. New coverage is requested during the anniversary period. Coverage is requested outside of the employer s anniversary period due to a qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.). Reinstatement or restoration of coverage is requested. Actively-at-Work Employees who are both disabled and away from work on the date they become eligible for coverage will become insured on the date they return for one full day to active full-time work. 7

10 OKLAHOMA DUAL OPTION GRID DUAL OPTION GRID PLAN DESIGN NAME PLAN ID HMO HMO AETNA AETNA PPO PPO PPO PPO CDH CDH CDH BASIC OA POS OA POS PPO PPO PPO PPO % (HSACompatible) (HSA Compatible) (HSA Compatible) PLAN ID Aetna HMO Aetna HMO Aetna Open Access POS 500 Aetna Open Access POS 1000 PPO PPO PPO PPO CDH PPO % HSA Compatible CDH PPO HSA Compatible CDH PPO HSA Compatible Basic PPO

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12 Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. These companies include Aetna Health Inc., Aetna Dental Inc. and/or Aetna Life Insurance Company. This information is the property of Aetna, and may only be used or transmitted with respect to Aetna products and procedures, as specifically authorized by Aetna, in writing. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna arranges for the provision of health care/dental services. However, Aetna itself is not a provider of health care/dental services and therefore, cannot guarantee any results or outcomes. Consult the plan documents (Schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group Insurance Certificate, Booklet, Booklet-certificate, Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. The availability of a plan or program may vary by geographic service area and by plan design. With the exception of Aetna Rx Home Delivery service, participating providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law. Certain primary care providers are affiliated with integrated delivery systems or other provider groups (such as independent practice associations and physician-hospital organizations), and members who select these providers will generally be referred to specialists and hospitals within those systems or groups. However, if a system or group does not include a provider qualified to meet member s medical needs, member may request to have services provided by non-system or non-group providers. Member s request will be reviewed and will require prior authorization from the system or group and/or Aetna to be a covered benefit. Information supplied by Aetna InteliHealth is for informational purposes only, is not medical advice and is not intended to be a substitute for proper medical care provided by a physician. Informed Health Line nurses cannot diagnose, prescribe or give medical advice. Specific questions should be addressed to your doctor. Alternative health care programs, Vision One and the fitness program are rate-access programs and may be in addition to any plan benefits. Program providers are solely responsible for the products and services provided thereunder. Aetna does not endorse any vendor, product or service associated with these programs. Discounts offered hereunder are not insurance. Some benefits are subject to limitations or visit maximums. Members or Providers may be required to precertify, or obtain prior approval of coverage for certain services such as non-emergency inpatient hospital care. If your plan covers outpatient prescription drugs, your plan may include a drug formulary (preferred drug list). A formulary is a list of prescription drugs generally covered under your prescription drug benefits plan on a preferred basis subject to applicable limitations and conditions. Your pharmacy benefit is generally not limited to the drugs listed on the formulary. The medications listed on the formulary are subject to change in accordance with applicable state law. For information regarding how medications are reviewed and selected for the formulary, formulary information, and information about other pharmacy programs such as precertification and step-therapy, please refer to Aetna s website at or the Aetna Medication Formulary Guide. Many drugs, including many of those listed on the formulary, are subject to rebate arrangements between Aetna and the manufacturer of the drugs. Rebates received by Aetna from drug manufacturers are not reflected in the cost paid by a member for a prescription drug. In addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on a percentage basis or a deductible, use of formulary drugs may not necessarily result in lower costs for the member. Members should consult with their treating physicians regarding questions about specific medications. Refer to your plan documents or contact Member Services for information regarding the terms and limitations of coverage. Closed formularies and step-therapy do not apply to Oklahoma plan options. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna Inc., that is a licensed pharmacy providing mail-order pharmacy services. Aetna s negotiated charge with Aetna Rx Home Delivery may be higher than Aetna Rx Home Delivery s cost of purchasing drugs and providing mail-order pharmacy services. Aetna does not credential or otherwise make any representations as to the quality or appropriateness of long-term care providers offering discounts to Aetna members. While this material is believed to be accurate as of the print date, it is subject to change OK (6/05) 2005 Aetna Inc.