Arise Health Plan Individual Policy Field Underwriting Guide

Transcription

1 Arise Health Plan Individual Policy Field Underwriting Guide Eligibility The Arise Health Plan Healthy1 individual medical plan is available for individuals or families. Applicants must be between the ages of 18 and 64. Eligibility for Healthy1 Individual coverage ends when the member reaches the age of 65. The Arise Health Plan individual policy is only available for individuals not covered by another individual or group health insurance plan during the same period. Applicant must be a resident of the State of Wisconsin and be a citizen of the United States or a resident legal alien. The applicant s home address must be within the counties in Arise Health Plan s defined service area and they must reside within this area 12 months of the year. If individual medical coverage is issued for three or more employees of the same employer with premiums being paid for by the employer, Wisconsin considers this as small employer group coverage, and those employees do not qualify for individual coverage. When single, non-divorced males apply for coverage for dependent children, or apply to add a dependent child, legal proof of paternity in the form of paternity papers or a Voluntary Paternity Acknowledgement will be required. WPS Health Plan, Inc. dba Arise Health Plan P.O. Box 11625, Green Bay, Wisconsin T: (920) T: (888) (toll free) F: (920)

2 Enrollment Applications must be completed and dated within 60 days of the effective date. All sections of the application must be completed and the application must be signed by the agent and each person listed on the application over the age of 18. Applications and requests for changes must be received on or before the 25 th of the month prior to the requested effective date. Effective dates are only the first of the month. Premium options are automatic withdrawal from a personal checking or savings account, credit card or direct billing. Direct billing options are available quarterly, semiannually or annually. For automatic withdrawal or credit card payment, monthly drafts are also available. Applicant must include a blank voided check or deposit slip for all automatic withdrawals. We cannot direct bill to a business address or accept premium from an employer or business account. Underwriting All individuals are health underwritten and each person listed on the application over the age of 18 is subject to acceptance, rider, rating, or when applicable, denial of coverage based on their health history as applied to our underwriting guidelines. Individuals may be accepted with or without restriction of benefit. A waiver of benefit endorsement (rider) may be required which excludes specific named conditions or excludes a named individual. If a rider or rating surcharge is required, it will be mailed to the applicant for signature of acceptance and will become part of the policy. Eligible dependents under 19 are accepted standard or with a rate surcharge for additional risk as applied to our underwriting guidelines. Applicants will be notified of the underwriting decision in writing with a copy sent to the agent. Approval letter will include the effective date and policy number. If an individual is declined, rated, or an exclusion rider is offered, we will provide you with information regarding the Wisconsin Health Insurance Risk Sharing Plan (HIRSP), grievance process and any applicable external review process. Requests for changes on in-force policies must complete and submit applicable change and/or application form(s). Changes for any upgrade in coverage will require underwriting approval. Requests to cover additional individuals other than a timely request for a newborn or adopted child also require underwriting approval. Requests for changes must be received by the 25 th of the month prior to the requested date of change. See policy for details

3 Arise Health Plan Declinable Health Conditions The health conditions listed below are examples of reasons that will cause Arise Health Plan to decline individuals over the age of 18 applying for individual coverage. This list is not all inclusive and is subject to change without notice. AIDS Alzheimer s Disease Alcohol or drug abuse within last 5 years ALS, Lou Gehrig s Disease Amnesia within the last 5 years Aneurysm within the last 5 years Aphasia within the last 5 years AV Block Barrett s Esophagus Bechet s syndrome Bi polar Disorder Bone Marrow Transplant Buerger s Disease Brain Disorders (Abscess, Chronic brain syndrome, Tumors, Brain Injury) Brittle Bones Bulimia within the last 5 years Cardiomyopathy Cancer (depending on type) within the last 3-5 years Celiac Sprue Disease Cerebral Palsy Cerebral Vascular Accident (CVA) within last 5 years Chronic Hepatitis Cirrhosis of the Liver Congestive Heart Failure Coronary Artery Disease within the last 5 years Crohn s Disease within the last 2 years Cystic Fibrosis Dementia Diabetes and or Glucose Intolerance Dialysis Down s Syndrome Drug Abuse within the last 5 years depending on type of drug DWI within the last year Eating disorders within the last 5 years Emphysema Enlargement of the heart Epilepsy with a seizure within the last 5 years Factor IV Farmer s Lung

4 Declinable Health Conditions (continued) Fatty Liver Fibromyalgia Gilbert s Syndrome Guillain-Barre Syndrome within the last 5 years Heart attack within the last 5 years Heart Disorders (Aortic Stenosis, Atrial Fibrillation, bypass surgery within 5 years, Coronary Artery Disease, Mitral Insufficiency, Mitral Stenosis, complete Right Bundle Branch Block) Hemochromatosis Hemophilia Hepatitis A within the last 2 years Hepatitis B within the last 5 years Hepatitis C High Blood Pressure along with taking two or more medication for it (excluding water pill) High Blood Pressure and taking the medication Lotrel, Lexxel, or Tarka High cholesterol levels treated with two or more medications HIV Positive Hodgkin s Disease Huntington s Chorea Hysterectomy within 6 months Idiopathic Thrombocytopenia Ischemic Heart Disease within the last 5 years Kidney Disorders (Dialysis, Nephrectomy within the last 6 months, Nephrosis, Polycystic Disease, Uremia) Left Bundle Branch Block Legg-Calve-Perthes Disease Leukemia Liver Disease or disorders (Abscess, Cirrhosis, Enlarged, Fatty Liver, elevated liver enzyme levels) Lou Gehrig s Disease Lupus Marfan Syndrome Mental Retardation Monoclonal Gammopathy Multiple Sclerosis Muscular Dystrophy s Myasthenia Gravis (MG) Narcolepsy Neurofibromatosis Obsessive-Complusive Disorder Osteochondritis Osteogenesis Imperfect Oxygen Use Pacemaker

5 Declinable Health Conditions (continued) Parkinson s Panic Disorder within the last 5 years Peripheral Vascular Disease Pick s Disease Pregnancy Quadriplegia Rhabdomyolysis Renal Failure/Renal Insufficiency Restless Leg Syndrome Retinitis Pigmentosa Rheumatoid Arthritis and other Connective Tissue Disorders Schizophrenia Scleroderma Seizure within the last 5 years Senility Sickle Cell Anemia Sinus Bradycardia within the last 2 years Sinus Tachycardia within the last 2 years Sleep Apnea (history of) Sleeping Disorders, Narcolepsy Stroke within the last 10 years Suicide Attempt within the last 5 years Tourette s Syndrome Transient Ischemic Attack (TIA) within last 5 years Transplants Turner Syndrome Ulcerative Colitis within the last 2 years Usher Syndrome Three or more required riders

6 Height/Weight Charts The female and male height and weight charts provide the maximum allowable weight for each category for individuals with and without hypertension. Any person whose weight exceeds the weight shown on these charts for their height will be declined. Underwriting may require documentation of height and weight from a health care professional. Female Height/Weight Chart Max Height Weight Max Weight w/ Hypertension 4'8" '9" '10" '11" '0" '1" '2" '3" '4" '5" '6" " '8" '9" '10" '11" '0" '1" '2"

7 Male Height/Weight Chart Max Height Weight Max Weight w/ Hypertension 5'2" '3" '4" '5" '6" " '8" '9" '10" '11" '0" '1" '2" '3" '4" '5" '6" '7" '8"