EMPLOYER STOP-LOSS (EXCESS) INSURERS AND. MANAGING GENERAL UNDERWRITERS (MGUs) QUESTIONNAIRE

Transcription

1 EMPLOYER STOP-LOSS (EXCESS) INSURERS AND MANAGING GENERAL UNDERWRITERS (MGUs) QUESTIONNAIRE Endorsed as an Industry Standard Form for Assistance in the Evaluation of Stop-loss (Excess) Insurers and Managing General Underwriters (MGUs).

2 Protecting and Promoting Self-Insurance and Alternative Risk Transfer since 1981 To the user of the application/questionnaire: As the self-insurance industry continues to expand, a degree of standardization is important to the level of professionalism of our industry. Over the years, a variety of forms and applications have been developed by various interest groups to assist in the evaluation of third party administrators by insurers and underwriting managers. As a result, there has been little conformity of information supplied, resulting in the use of a multiplicity of forms which has added unnecessary cost to doing business. This form, SIIA MGU/AQ has been approved by the Self-Insurance Institute of America, Inc. (SIIA) as an acceptable industry standard form. Please note This questionnaire has been developed solely for the purpose of aiding the user and receiver of data to help establish a certain level of standardization for evaluation purposes. SIIA assumes no responsibility to any party regarding the completeness of questions asked, or any use of the information provided. Evaluation of who to do business with is left to the sole direction of the parties involved. Comments and suggestions may be sent to: SIIA P.O. Box 1237 Simpsonville, SC

3 EMPLOYER STOP-LOSS (EXCESS) INSURERS AND MANAGING GENERAL UNDERWRITERS (MGUs) QUESTIONNAIRE Information provided on this form is to be held in strict confidence by the recipient. 1. Type of entity completing this form: PART I - General Information (Explanation) Employer Stop-Loss Direct Insurance Carrier/Reinsurer Employer Stop-Loss Managing General Underwriter 2. Company Name: Address: City: State: Zip: Phone: Fax: Website: 3. TIN #: Type of Business: Corporation Partnership Sole Proprietor LLC 4. Name of person completing form: Title: List of Primary Officers: CEO: President: Secretary: Treasurer: Attach additional sheet, if necessary. Please submit resumes of senior officers. 5. Please list other companies (i.e., insurance companies, PPO's, HMO's, MGU's, brokerage operations, etc.) with whom you have a financial interest of greater than 10%. 6. Has your business entity been involved in a corporate merger of a share greater than 10% in the past five years? Yes No If yes, please describe. 7. Has your business entity been involved in a corporate merger of a share greater than 51% in the past five years? Yes No If yes, please describe. 3

4 8. Has your business entity had a change in ownership in the past five years? Yes No If yes, please describe: 9. Has your business entity had a change of name and/or used a d.b.a., or is it operating under an assumed name? Yes No If yes, previous name was: 10. Branch Offices: (attach separate sheet, if necessary) Name of Contact: Address: City: State: Zip: Phone: Fax: Name of Contact: Address: City: State: Zip: Phone: Fax: 11. Does your company or any of its subsidiaries or affiliates provide direct third party administrative services? Yes No If no, please advise name of company: 12. Who is eligible to place business with you? (check all that apply) Appointed TPA Broker/Agent Direct Employer Client Other 13. In the event of a change in TPA for a particular plan sponsor (self-funded employer plan), will you: A. Transfer to new TPA based on letter of appointment? Yes No B. Transfer only if TPA is approved by your company? Yes No C. Transfer if TPA meets your requirements? Yes No D. Other, explain: 14. In the event of a change in TPA during the contract year, does this enable you to terminate the stoploss policy/contract? Yes No If yes, please explain: 4

5 15. How are your producers compensated for placement of business? Explain in detail and attach any appropriate commission schedule. 16. In the event you receive a new opportunity for a request to quote for the same Plan Sponsor from more than one TPA, how do you respond? First in, first out (decline to quote for subsequent request) Issue same quote to all approved TPAs Decline all in absent of letter of authority from Plan Sponsor Other, please explain: 17. Do you give exclusive geographical area producer contracts to limit the number of approved TPAs in a given area? Yes No If yes, please explain: 18. Please provide the name, address, telephone, FAX and contact of at least three approved TPAs for reference purposes: 1.) Name: Address: City: State: Phone: Fax: Website: Contact Person: Title: 2.) Name: Address: City: State: Phone: Fax: Website: Contact Person: Title: 3.) Name: Address: City: State: Phone: Fax: Website: Contact Person: Title: Zip: Zip: Zip: 5

6 PART II - MGU - Duties - Relationship to Carriers Represented 1a. If your business entity is an MGU, please provide answers to the following: A. Year you first commenced MGU business: B. List all stop-loss carriers/reinsurers represented in the past five years: Currently Active Yes No Yes No Yes No Yes No Yes No Attach separate sheet, if necessary. 1b. Additional comments: 2. Please list the name of each stop-loss carrier/reinsurer your MGU has current authority to represent. (Attach separate sheet, if necessary) 3. What duties, services does your MGU have authority to provide for on behalf of the stop-loss carriers/reinsurers you represent? Check all that apply. Marketing/Sales Support Product Development Complete Underwriting Authority Underwriting (subject to carrier final approval) Premium Administration Claim Administration/Payment Contract Issuance Commission Payments Other, define: 4. Does your MGU have authority to perform identical duties for each stop-loss carrier/reinsurer represented (listed) above? Yes No If no, please explain: 5. Do you have complete underwriting binding authority? Yes No If no, please explain limitations: 6

7 6. Please describe claim settlement process and level of authority: 7. Do any of the stop-loss carriers/reinsurers that your MGU represents have similar relationships with other MGU's? Yes No If yes, please identify company and other appointed MGUs: Stop-Loss Carrier/Reinsurer Company Name Attach separate sheet, if necessary. MGU Name 8. Have any of the stop-loss carriers/reinsurers that your MGU represents terminated their relationship with you, or placed any restrictions on the services you provide on their behalf? Yes No If yes, please explain: 9. Do you maintain contractual agreements with each stop-loss carrier/reinsurer represented? Yes No 10. Additional comments PART III - Underwriting Administration - Criteria 1. What information do you require to underwrite a case and issue a premium quotation (proposal)? (Check all that apply) Census Data Copy of Plan Document Plan Experience (paid) for Years Claim Lag Reports History of Previous Claims (those in excess of $ ) Other, define: Inforce information, i.e. 50% of the specific deductible, deductible level, contract basis, etc. Note: Attach your standard "checklist" for RFP submissions. 7

8 2. Do you require different information/data for new business submissions as opposed to renewal business submissions? Yes No If yes, please explain: 3. Do you accept the SIIA industry standard disclosure statement? Yes No If not, please explain why and attach copy of the disclosure statement that you employ: 4. For new business submissions, please describe how known on-going claims are handled (i.e. actively at work, deductible variance, laser underwriting, rate surcharges, etc.) Please be specific. 5. Do you offer insurance products other than employer stop-loss? Yes No If yes, check all those that are available: Life AD&D Short Term Disability Long Term Disability Dental Vision Other, define: 6. Do you accept employer stop-loss business submissions for: (check all that apply) Taft-Harley (Union) Franchise Operations Association Sponsored MEWAs VEBA 501(c)(9) Trust Non-association Sponsored MEWAs (open end trust) Employee Leasing Firms (PEO's) Governmental Agencies, i.e. Municipalities, School Districts,etc. 7. Do you exclude certain types of industries/employer professions? Yes No If yes, please list those industries or professions not eligible: 8. How do you evaluate PPO's, UR companies and other managed care discount arrangements? 8

9 9. Do you require specific managed care components for a new business case submission? 10. How do you evaluate program services for utilization management, large case management, and predictive modeling? 11. Please indicate the following as applicable to your new business employer stop-loss submissions: A. Minimum case size number of employees B. Minimum self-insured Specific Retention $ per claims. C. Minimum level of Aggregate Retention % D. Minimum enrollment, i.e. 75% of active employees? E. Minimum enrollment relative to dependents 12. Please indicate the following as applicable to renewal of coverage: 32 A. When do you require renewal data? B. When will renewal rates be provided? 30 days prior to anniversary 60 days prior to anniversary 90 days prior to anniversary Other, define: C. When and under what usual conditions are renewal rates considered bound? D. Have you ever denied renewal solely on the basis of prior experience? Yes No If yes, why: E. Please provide a statement that best reflects your renewal underwriting process. Be specific as it relates to known ongoing claims, laser underwriting, rate surcharges, selective retention's, etc. Attach separate sheet, if necessary. 13. Does your stop-loss policy/contract enable you to change/modify rates or factors during a contract year? Yes No If yes, please explain: 9

10 14. How do you perform underwriting for late entrants (employees or dependents)? PART IV - Excess/Stop Loss Contractual Provisions 1. Please indicate the legal entity to whom the employer stop loss contract/policy will be issued to: (Check all that apply) To the Plan Plan Sponsor Trust Other, explain: 2. What information do you require to issue the contract of insurance? (Be specific.) 3. Does your company (the MGU) issue the stop-loss policy/contract or is it issued by the staff of your stop-loss carrier/reinsurer? We (MGU) issue the stop-loss policy/contract Stop-Loss Carrier/Reinsurer issues the stop-loss policy/contract 4. From the date of receipt of the required data necessary to issue contract, how long does it take to actually issue/deliver the stop-loss contract? Within 5 working days Less than 10 working days Less than 15 working days Other, define: 5. Are there any exclusions/limitations in your excess/stop loss insurance contracts? Yes No If yes, please list, and attach a copy of the stop-loss policy/contract. 6. To what extent do you require specific Plan Document provisions? Require complete copy of Plan Document Plan Document becomes part of, and is binding with excess/stop loss contract Require only summary (primary provisions) of Plan Document Other, define: 10

11 7. Assuming termination of contract, please detail your "run out" provisions/administration relative to specific and/or aggregate excess/stop loss coverage. 8. Does your stop-loss policy/contract include an "actively at work" provision? Yes No Is it in compliance with FMLA and ADA guidelines? Yes No Do you ever waive the "actively at work" provision? Yes No 9. In the event your stop-loss contract's, "actively at work" provision does not follow the Plan Document, what are the procedures for amending and/or waiving the contract s language? 10. Do you cover (assume liability) for claims on participants who incur claims after the date of sale of the excess/stop loss insurance but before the effective date of the contract? Yes No 11. Are your contracts of insurance a "reimbursement only" contract? Yes No If no, please explain: Note: Please provide a specimen contract for both specific/aggregate excess/stop loss insurance. 12. Will all contracts be issued in this format? Yes No If no, please explain: PART V - Claims Administration 1. Staff - Total number of employees in: Adjudication: Support: Management: Name/Job Title of Key Personnel: Name Title Yrs. Exp. Yrs w/ Your Firm 11

12 2. Does your staff have full responsibility for claim settlements? Yes No If no, please explain: 3. In the event the stop-loss carrier/reinsurer you represent purchases reinsurance, does their reinsurer need to review claims before they are paid? Yes No If yes, please explain procedures and time required for review/payment. 4. Please indicate the specific information you require to process: A. Specific excess/stop loss claims: B. Aggregate excess/stop loss claims: C. What proof of payment is required to be submitted by TPA? 5a. Upon receipt of all requisite information, how long does it take to reimburse for a specific claim? Less than 3 working days Less than 5 working days Less than 10 working days - If no additional information is required Other, define: 5b. Do you offer immediate specific claim reimbursement? Yes No 6. Please describe your time frame and process for reimbursement of aggregate claims? 7. Please indicate your stop loss contract's definition of a "paid claim" in relation to the Plan Sponsor? Receipt of claim by TPA Date claim incurred Date claim is processed and E.O.B. issued Date check is issued Date check is presented to bank for payment Date check clears bank Other, define: 12

13 8. Do you require audits of: A. Hospital claims Yes No If yes, at what dollar level $ B. Attending Physician Yes No If yes, at what amount $ 9. In the event you require an audit of any claim, is reimbursement held until after the audit is completed? Yes No 10. In the event you require an audit, do you pay for the cost of audit? Yes No If no, why not? 11. Describe your claim auditing procedures: 12. In the event of a large claim, do you: A. Require large case management services be used? Yes No B. If yes, do you pay for such services? Yes No If no, under what circumstances will you consider paying for large case management? 13. Do you participate in special claims administration cost, such as: Subrogation Expense Yes No Defense of Lawsuits Yes No Transplant Network Access Fees Yes No Claims Negotiation Fees Yes No Other, define: 14. Comments: 15. In the event payment of a claim of a plan participant is delayed by the Plan Sponsor or its TPA as a result of subrogation, audit or other similar situation, and payment is made beyond the excess/stop loss contract period, do you grant a waiver of the time limits for payment if the circumstances are reported to you prior to the end of the period? Yes No If no, how are such claims handled? 13

14 16. Do you accept the Plan Document's definition of reasonable and customary medical care and the Plan Sponsor's determination of such? Yes No If no, explain why not and procedures you follow: PART VI - Financial - Insurance Compliance 1. Does your company carry a Comprehensive General Liability Policy? Yes No If yes, who is the carrier? What is the expiration date of the policy? What are the limits of liability: $ per person $ per occurrence Is there a deductible? Yes No If yes, what is the amount? $ 2. Does your company carry Professional Liability (Errors & Omissions) insurance? Yes No If yes, who is the carrier? What is the expiration date of the policy? What are the limits of liability: $ per person $ per occurrence Is there a deductible? Yes No If yes, what is the amount? $ Is contract a claims made policy? Yes No 3. Does your company carry a Fidelity Bond? Yes No If yes, who is the bond carrier? What is the expiration date? Amount of bond $ Note: Please provide copy of declaration page of each insurance coverage referenced above. 4. Please provide all recent rating agencies (AM Best, S&P, etc.) reports. 5. Please provide specific information of the percentage of risk retained by your company. Please provide a list of all other risk bearing entities (reinsurers, captive arrangements, etc.) to whom risk is ceded and their respective risk percentage. 6. Does your company complete and submit a Form 5500 Schedule A? Yes No If yes, to whom do you send this information to? (check all that apply) Appointed TPA Broker of Record Plan Administrator Plan Sponsor Other, define: 14

15 7. Is all correspondence regarding your services and administration of the excess/stop loss contracts or other insurance placed through your facility directed solely to the appointed TPA? Yes No If no, explain under what circumstances you communicate with: A. The policyholder direct B. The broker of record, if applicable 8. Is your company licensed by any state regulatory authority? Yes No If yes, please list State(s), License type and number, Expiration date. (attach copy of all licenses held) 9. Has any license held been suspended, restricted or revoked? If so, please explain. 10. Has any principal, employee, director or owner been convicted of a felony? Yes No If yes, please provide complete details, name, dates, circumstances, etc. 11. Do you belong to any professional/trade associations? Yes No If yes, please check all that apply: SIIA AHIP MGAA IFEBP RIMS SPBA Other, please list: * * * * * * * * * I certify that the information on this application is accurate to the best of my knowledge and belief. I also understand that routine inquiries, including credit inquiries, may be made of any or all of the individuals and firms noted herein as references. Signature: Print Name: Date: Title: 15