Small Business Broker Reference Guide. Illinois & Northwest Indiana

Transcription

1 Small Business Broker Reference Guide Illinois & Northwest Indiana segment January 1, 2014

2 We are proud of our commitment to agents throughout Illinois and Northwest Indiana. We recognize the value you bring to small business, and your critical role in the partnership between small employers and UnitedHealthcare. Our staff is dedicated to servicing your needs and those of the employer. The information in this guide is intended as a tool designed to help you better understand: Medical underwriting requirements Pre-sale Guidelines Post-sale administrative options and eligibility provisions Specialty Benefits Guidelines. 2

3 Medical underwriting requirements Medical Underwriting requirements may change and Medical Underwriting reserves the right to request additional information as they deem necessary. In addition, if there are discrepancies between this document and any employer contract or certificate of coverage, the contract or certificate of coverage will prevail. Document Updated: November 2013 Category Medical history requirement (Applications and requirements may vary by state.) Rating structure Submit to: or send to your local General Agent representative. Dual, Triple, and Flexible Options Excluding classes (Not permitted in Indiana) Requirements for competitor application prescreen IL and NW IN or send to your local General Agent representative. Required for fast track submission Requirements for Medical Underwriting Explanation/Requirements Employees at groups with eligible employees will be required to complete. Illinois Enrollment Application Form # (located on UnitedeServices.com under Forms IL Employee) Indiana Enrollment Application Form # (located on UnitedeServices.com under Forms IN Employee) Rating structure is based on the Average Total Number of Employees (ATNE). Employees will be composite rated. Available for groups with 51 or more enrolling employees. For groups with 51 to 99 eligible employees, there should not be more than a 50% spread between the highest and lowest rated plan. Groups may select up to 5 benefit plan options.. On groups with 51 to 99 eligible employees, up to two classes will be permitted. Examples of acceptable classes include: hourly and salaried, union and non-union, management and non-management. Completed and signed Competitor Applications (height and weight required for all enrolling members) Employer Authorization form (located on UnitedeServices.com under Forms IL Employer) Completed Fast Track Coversheet (located on UnitedeServices.com under Forms IL Broker) Completed and signed enrollment forms including COBRA and Waivers for all eligible employees (height and weight required for all enrolling members) Completed Fast Track Coversheet (located on UnitedeServices.com under Forms IL Broker) Name of current carrier and group tax ID number For all new business with groups with 51 to 99 eligible employees. A renewal from the current carrier is required to receive individual medically underwritten rates. 3

4 Post Medical Underwriting / Case Installation Category Requirements for new business submission Submit to: new_case_submissions_chicago@uhc.com Fax: Mail: UnitedHealthcare Small Group New Case Submission Suite E. Randolph St. Chicago, IL Or submit to your General Agent office. Billing statement requirements Enrollment form requirements Explanation/Requirements Enroll with direct deposit or submit a binder check for one months, premium payable to UnitedHealthcare of Illinois, Inc. (direct debit form located on UnitedeServices. com under Forms - IL - Employer) Completed Illinois Employer Application for Small Business Form # (located on UnitedeServices.com under Forms - IL - Employer) Completed Indiana Employer Application for Small Business Form # ) (located on UnitedeServices.com under Forms - IN - Employer) Completed and signed enrollment forms including COBRA and Waivers for all eligible employees (height and weight required for all enrolling members) Name of current carrier and group tax ID number Most recent statement (all pages) All terminated employees clearly marked, including termination date(s) Cobra/Continuation applications or waivers included if terminated within days and still listed on billing statement All medical history questions answered and explained All information fully completed and signed by subscriber and spouse (if spouse is electing coverage) All applications must be signed and dated within 90 days of requested effective date Date of hire filled in on all applications Number of hours worked filled in all applications Other coverage information (Section D) must be filled in on all applications Members electing Navigate HMO must select a PCP - live or work rule applies 4

5 Category Employer contribution requirements Participation requirements Employees in waiting period Effective dates/backdating Independent contractor (1099) guidelines Common Ownership Seasonal employees PEO ( Professional Employee Organization ) groups Retiree coverage Employers utilizing leased employees Waiting periods Navigate (IL only) Explanation/Requirements Minimum of 50% of the average cost of the lowest plan. For all cases renewing, 70% of total eligible employees must be enrolled in coverage AFTER valid waivers are removed from consideration and there is no minimum requirement. Illinois ONLY: 25% floor of total eligible employees with no waivers. NW Indiana ONLY: 75% of total eligible employees must enroll in coverage, with no less than 50% of the total population. New clients will have the following compliant member waiting period options: No waiting period Date of event: 1 to 90 calendar days, 1 or 2 months First of month: following the event (such as date of hire), 1 or 2 month(s), or 1 to 60 calendar days 1st of the month effective date: A group must be medically underwritten no later than the 10th of the month in order to backdate coverage to the 1st of the month 15th of the month effective date: A group must be medically underwritten no later than the 25th of the month in order to backdate coverage to the 15th of the month Employers may select to offer coverage to their independent contractor (1099 employees), if the following conditions are met: The maximum number of 1099 contractors may not exceed 35% of the total number of enrolled subscribers. The Independent Contractor paid by 1099 must work for your company on a full time, year-round basis The 1099 contractor must work a minimum of 30 hours per week The employer agrees to contribute the same amount of money toward the premium as regular taxed employees The employer agrees to require the same waiting period for Independent Contractors as regular taxed employees The employer agrees to extend the coverage offering to all Independent Contractors who meet these qualifications, including any future 1099 employees The business has a minimum of two regular, taxed, employees who are applying (1099 form located on UnitedeServices.com under Forms - IL - Employer) (located on UnitedeServices.com under Forms - IL - Employer) Coverage for Seasonal Employees as defined as employees working a minimum of 30 hours per week less than 9 months per year is not offered. Coverage to PEOs and their employees is not offered pre 65 retiree coverage is available, no more than 20%. Post 65 coverage not available. All leased employees must be eligible for coverage on the same basis as other employees The employer must complete and sign the application for coverage UnitedHealthcare will bill the employer for coverage, not the PEO UnitedHealthcare must be the sole provider of health insurance for all eligible employees The required eligibility information will include the standard documents for any small employer group Waiting period before coverage is in place cannot exceed 90 days Primary Care Physician(PCP) selection will be required for installation. If a PCP is not selected, a PCP will be assigned by default. Submissions required 10 business days prior to the effective date. 5

6 Forms required for case installation Requirements Medical Life 1 Dental 1 Vision 1 Employer: ER application Prior billing statement Common Ownership Copy of binder check/direct debit form UnitedHealthcare Employer application Form # (located on UnitedeServices.com under Forms - IL - Employer) UnitedHealthcare Employer application Form # (located on UnitedeServices.com under Forms - IN - Employer) Medical pri or billing statement not required Dental prior & current billing statement not required Requirement for all products. (Commonwership Form located on UnitedeServices.com under Forms - IL - Employer) Medical premium Life premium Dental premium No binder check for voluntary dental and vision only Vision premium, Voluntary 2 not required Premium payment can be combined when multiple products are sold 1099 Requirement for all products. (1099 Form located on UnitedeServices.com under Forms - IL - Employer) Verification approval Verification approval from Broker with approved rates Employee: UnitedHealthcare Medical and Life Enrollment Form including PCP selection for IL Navigate HMO EE application business. (State specific) EE waiver Waivers not required for groups with 51 to 99 eligible employees. 1 For Life, Dental and Vision products, if there is an existing Medical product on another UnitedHealthcare platform we will not require the binder check or Wage & Tax docs and we can accept an enrollment spreadsheet in place of the employee enrollment forms (with the exception of Life over guaranteed issue which will require enrollment forms for underwriting review). 2 Voluntary definition Employer contributes less than 50% 3 For 100% Employer Paid Plans 6

7 Standard administrative guidelines/post-sale Category Effective date Payment grace period Delinquent policy Mandatory enrollment into products Date of birth calculation (age-banded rate changes) Maximum number of children billed (age/sex-rated groups) Open enrollment period Explanation/Requirements 1st or 15th of the month. All products regardless of effective date will share the same renewal date. Premium payment is due the 1st of each month. A 31-day grace period is allowed all premiums must be received and booked before the end of the grace period to avoid a policy termination. A policy that is not paid by the due date (including the grace period) is considered delinquent and may result in termination. If the employer contributes 100% toward any specialty benefits (life and AD&D, dependent life, or dental) premium, then the employees must elect that product s coverage. Northwest Indiana - All employees enrolled in Medical benefits must enroll in Life as well. 1st of the insurance month following date of age change 3 Month prior to renewal. Medical cards Mailed to employees home within 7 to 10 business days of the policy being issued. Employees can also log into myuhc.com within 72 hours of the policy being issued to print temporary ID cards Certificate of coverage Available online at myuhc.com within 72 hours of the policy being issued. Covered dependents Navigate (IL only) Employee s spouse Civil Union (IL Only) Handicap/Disabled dependent Any unmarried dependent child under 26 years of age or Any unmarried dependent child under 30 years of age if the dependent (i) is an Illinois resident, (ii) served as an active or reserve member of any U.S. Armed Forces and (iii) received release or discharge other than dishonorable discharge. To be eligible the dependent must meet all three (3) of the conditions above and must submit to the insurer a form approved by the Illinois Department of Veterans Affairs stating the date on which the dependent was released from service. Adopted children Dependents such as nieces and nephews that are court ordered to be covered by member s group plan Grandchildren that are claimed as dependent(s) for federal tax purposes Members can change primary care physicians monthly Contact Customer Service or log on to myuhc.com to change primary care physicians New member health plan ID cards will be issued whenever a member changes their primary physician Changes submitted by the 15th of the month are effective the 1st of the next month (e.g. change submitted on June 15th effective July 1st) Changes submitted on/after the 16th of the month will be effective the 1st of the month after the next month (e.g. change submitted on June 16th effective August 1st) Retroactive changes are not permitted 7

8 Standard administrative guidelines/post-sale Deductible and out of pocket credit Effective date for new hires Minimum hours worked per week to be eligible Effective date of termination Effective date for return to employment (leave, strike, layoff ) Date for status change Qualifying events Dual coverage (employee works for 2 employers and is covered under both policies) Double coverage (husband/wife work for same employer and cover each other) Handicapped coverage Employer plan termination UnitedHealthcare groups are eligible at the group level for individual mid-year deductible and out of pocket credit from previous carrier. To obtain credit, the employee must have been enrolled on the plan prior to the transition. 1st of the policy month (1st, 15th, 28th) with 31-day notice hours per week if the groups elect medical-only coverage. (determined by employer group) hours per week if the groups elect ancillary coverage. (determined by employer group) Last day of the policy month (1st, 15th, 28th) in which the term occurs with 31-day notice. 1st of the policy month (1st, 15th, 28th) following date of return. 1st of the insurance month following change Newborns, new marriages and late adds with a qualifying event that we are notified of within 30 days are added on the date of the event Newborn, marriage, divorce, adoption, hardship, death and loss of other coverage Not allowed Not allowed Coverage can exceed standard dependent age requirements. Statement of Dependent Eligibility Beyond Limiting Age Due to Mental or Physical Disability (form # M46637) must be completed by the dependents physician. (Form located on UnitedeServices.com under Forms - IL - Employee) UnitedHealthcare may terminate group coverage for: Nonpayment of premiums (The group is liable for payment of premiums for the entire term the policy is in force, including the grace period.) Not meeting contribution requirements (31 days advance notice) Not meeting participation requirements (31 days advance notice) Voluntary termination Coverage may be terminated on the date specified by the policyholder, with at least 31 days prior written notice to UnitedHealthcare. The written notice must be on company letterhead signed by an officer of the group/policyholder. Application for group coverage within 6 months of termination date will result in the same or greater premium cost as was in effect at time of termination. Exclusions and coverage limitations are detailed in the group contract and the member certificate of coverage. If this document conflicts in any way with the group contract or the certificate of coverage, the contract/certificates provisions prevail. 8

9 Groups previously terminated for non-payment Specialty Guidelines Dental Guidelines Contribution Participation Waiting period for major services Dental Dual Option Voluntary Employer contributes less than 50% of single premium. Employer Paid Employer contributes 50% or more of single premium. Employer Paid 75% of eligible employees, net of waivers Voluntary 2 enrolled minimum 8 enrolled minimum with ortho 10+ eligible Minimum of 51%, including waivers Note: It is not required that the same employees that choose medical coverage also choose dental coverage. The waiting period is waived if group had prior dental coverage. Please Note: Proof of 12 months prior coverage (including major services or ortho, if applicable) is required in order to waive the waiting period. Available with any dental plan for groups with a minimum of 10 dental enrollees. Ortho available for groups with a minimum of 10 eligible employees with a minimum of 8 enrolled. Critical Illness Protection Plan (51-99 only) Participation Employer Paid base with employee buy-up 100% of 20% Voluntary (100% Employee paid) 20% participation Non-Contributory (100% Employer paid) 100% participation Benefit Amount Non-Contributory Option 1 $5,000 Employee only Option 2 $10,000 Employee only Voluntary Option 1 $5,000 Employee only Option 2 $10,000 Employee, $5,000 Spouse, $2,500 child(ren) Employer Paid base with employee buy-up Option 1 $5,000 Employee paid base, $10,000 Employee, $5,000 Spouse, $2,500 child(ren) Option 2 $10,000 Employee paid base, $10,000 Employee, $5,000 Spouse, $2,500 child(ren) 9

10 Lives Employee/Dependent Basic Life & ADD Installation Platform Case Requirements Availability Portal Access Employee Participation Requirements Employer Contributions Rating Methodology Eligibility Requirements Eligibility Waiting Period PRIME Basic Employee Life & AD&D Selected types of businesses are ineligible (see SIC code list) Must be sold with Employee Life Basic Dependent Life Employee must elect Employee Life to elect Basic Dep Life Employee access to COC on myuhc.com available only if sold with Medical Employer access to eservices is available Non-Contributory - 100% Not Applicable Contributory - minimum of 75% participation Non-Contributory - 100% employer paid 0% employer paid Contributory - 25% employer paid Composite Rates Flat Rate per employee 24 Month Rate Guarantee the 1st of the month after date of hire the date of hire Waiting Period: X or 1st of month after X, Not Applicable where X = months may be expressed in months Min. # Hours Full-time = 20 hour/week Not Applicable Open Enrollment Not available to Small Business Not Applicable Domestic Partners Not Applicable Available Lives LTD Installation Platform PRIME Case Requirements Availability May be sold as stand-alone (51-99) Portal Access Employer access to eservices available only if sold with Medical, Dental, Vision or Basic Life Employee access to COC on myuhc.com available only if sold with Medical Employer Eligibility Groups must be in business for a minimum of 2 years Groups must not contain more than 50% immediate family members Selected types of businesses ineligible (see SIC code list) Employee Participation Requirements Non-Contributory-100% (2-99) Contributory-50% (10-99) Voluntary-25% (10-99) Employer Contributions Non-Contributory - 100% employer paid (2-99) Contributory - Employer & Employee share (10-99) Voluntary- 0% employer paid (10-99) Rating Methodology Contributory/Non-Contributory - Composite per $100 of Monthly Covered Payroll (MCP) Voluntary - Age banded per $100 of MCP 24 Month Rate Guarantee Eligibility Requirements Eligibility Waiting Period: X or 1st of month after X, where X = months Waiting Period may be expressed in months Min. # Hours Full-time = 30 hour/week 10

11 Lives STD Installation Platform PRIME Case Requirements Availability Can be sold stand alone Portal Access Employer access to eservices available only if sold with Medical, Dental, Vision or Basic Life Employee access to COC on myuhc.com available only if sold with Medical Employer Eligibility Groups must be in business for a minimum of 2 years (1 year if preferred industry) Groups must not contain more than 50% immediate family members Employees working in CA, HI, RI, NY, NJ and Puerto Rico are not eligible for STD coverage. Selected types of businesses ineligible (see SIC code list) Employee Participation Requirements EE participation: Non-Contributory - 100% participation Contributory - minimum of 50% participation Voluntary - minimum of 25% participation ER Contribution: Non-Contributory - 100% employer paid Contributory - minimum 25% employer paid Voluntary - 0% employer paid Employer Contributions 100% employer paid Rating Methodology Composite per $10 of Weekly Benefit; Age banded rates available. 24 Month Rate Guarantee Eligibility Requirements Eligibility Waiting Period Min. # Hours Waiting Period: X or 1st of month after X, where X = 30 days 60 days 90 days may be expressed in months Full-time = 30 hour/week The Definity SM Health Savings Account (HSA) high deductible health plan (HDHP) is designed to comply with IRS requirements so eligible enrollees may open a Health Savings Account with a bank of their choice or through OptumHealth Bank, Member of FDIC. Definity HSA refers generally to the Definity SM HSA product, which includes a HDHP, although at times Definity HSA may refer only and specifically to the Definity Health Savings Account, provided in conjunction with OptumHealth Bank and not to the associated HDHP. UnitedHealthcare s Definity SM Health Reimbursement Account, or HRA, combines the flexibility of a medical benefit plan with an employer-funded reimbursement account. UnitedHealthcare Vision coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates. UnitedHealthcare Dental coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by Dental Benefit Providers, Inc., Dental Benefit Administrative Services (CA only), United HealthCare Services, Inc. or their affiliates. UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company, Unimerica Insurance Company or Unimerica Life Insurance Company of New York. UnitedHealth Wellness is a collection of programs and services offered to UnitedHealthcare enrollees to help them stay healthy. It is not an insurance product but is offered to existing enrollees of certain products underwritten or provided by UnitedHealthcare Insurance Company or its affiliates to encourage their participation in wellness programs. Health care professional availability for certain services may be dependent on licensure, scope of practice restrictions or other requirements in the state. Some UnitedHealth Wellness programs and services may not be available in all states or for all group sizes. Components subject to change. For a complete description of the UnitedHealth Premium Designation program, including details on the methodology used, geographic availability, program limitations and medical specialties participating, please see myuhc.com. The Healthy Pregnancy Program follows national practice standards from the Institute for Clinical Systems Improvement. The Healthy Pregnancy Program can not diagnose problems or recommend specific treatment. The information provided is not a substitute for your doctor s care. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by UnitedHealthcare Insurance Company, United HealthCare Services, Inc. or their affiliates. Insurance coverage provided by or through UnitedHealthcare Insurance Company and UnitedHealthcare Insurance Company of Illinois or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of Illinois, Inc. M41786-B 1/ UnitedHealthcare Services, Inc. 11