Core Access Producer Guide

Transcription

1 Core Access Producer Guide Business procedures and underwriting guidelines Core Access is a fixed-benefit indemnity plan and provides coverage for covered out-of-pocket expenses incurred due to medical care. Underwritten by Independence American Insurance Company, (IAIC), a member of the IHC Group. For more information about IAIC and the IHC Group, visit This product is not considered to be Minimum Essential Coverage as defined by the Patient Protection and Affordable Care Act (ACA). The Core Access plan series is administered by The Loomis Company. UnitedHealthOne is the brand name that represents a portfolio of insurance options for individuals and families. Producer Guide Core Access

2 How to Use This Guide This guide was designed for the fixed indemnity hospital and surgical insurance plans. It contains important information about new business processing and underwriting guidelines to assist the sales representative in determining the eligibility of prospects and applicants. By following these procedures and guidelines, you will help facilitate the prompt review, processing and issuance of your applications. Throughout this guide, producers will be referred to as You or "Your," The Loomis Company will be referred to as Us and Independence American Insurance Company will be referred to as The Company. Nothing in this guide is intended to guarantee that the described underwriting practices apply in all circumstances. The company s actual underwriting practices in effect at the time an application is reviewed will apply to the processing and underwriting of new business. Also, some states have special benefits and requirements not addressed in this guide. For additional information, please refer to the following documents: Plan brochure Enrollment application Your Producer agreement Independence American Insurance Company (IAIC) Independence American Insurance Company is domiciled in Delaware and licensed to write property and casualty insurance in all 50 states and the District of Columbia. Its products include short-term medical, employer medical stop-loss, hospital indemnity, fixed indemnity limited benefit, group and individual dental, pet insurance, and non-subscriber occupational accident insurance in Texas. Independence American is rated A- (Excellent) for financial strength by A.M. Best Company, a widely recognized rating agency that rates insurance companies on their relative financial strength and ability to meet policyholder obligations (an A++ rating from A.M. Best is its highest rating). America s Business Benefit Association (ABBA) America's Business Benefit Association (ABBA) is a national not-for-profit association that provides individuals, small businesses and self-employed consumers with business benefits, services and healthrelated options, including access to valuable association endorsed health insurance benefits. Communicating for America* (CA) Communicating for America, Inc., (CA) is a national non-profit advocacy organization that supports affordable healthcare for all Americans. Since 1972, more than 100,000 consumers have trusted CA to help them find affordable health insurance and Gap plans to stretch their healthcare dollar while advocating on their behalf with insurance companies, regulators and lawmakers. For Oregon resident only. The Loomis Company The Loomis Company (Loomis), founded in 1955, has been a leading Third Party Administrator (TPA) since Loomis has strategically invested in industry leading ERP platforms, and partnered with well-respected companies to enhance and grow product offerings. Loomis supports a wide spectrum of clients from selffunded municipalities, school districts and employer groups, to large fully insured health plans who operate on and off state and federal marketplaces. Through innovation and a progressive business model, Loomis is able to fully support and interface with its clients and carriers to drive maximum efficiencies required in the ever evolving healthcare environment. 2

3 Eligibility of Applicants Issue Ages for Individual or Family Coverage Adult applicants must be years of age. A spouse currently residing in the same household as the primary applicant and under age 64.5 is considered an eligible dependent. We do not recognize common-law relationships unless required by state law. Dependent children must be under age 26 (may vary by state law). Coverage is not available for children without an adult on the same plan. Child is defined as: An Eligible Person s natural Child An Eligible Person s lawfully adopted Child A Child placed for adoption with an Eligible Person An Eligible Person s stepchild An Eligible Person s foster Child A Child for whom the Eligible Person has been appointed legal guardian by a court of competent jurisdiction and who resides with and who is dependent upon the Eligible Person in a regular parent-child relationship or A Child of the Eligible Person for whom the Eligible Person is obligated to provide medical Child support pursuant to a Qualified Medical Support Order. Resident State The Core Access Plan being applied for must be available for sale in the applicant s primary state of residence. The application must be signed in the applicant s residential state, or you must be licensed in both the residential state and the state in which the application was signed. Premiums are based on the rates applicable to the applicant s primary state of residence and are adjusted to reflect changes in residence when they occur. U.S. Resident Coverage is available to United States residents only. An eligible U.S. resident is a U.S. Citizen or an individual that has been issued a green card or permanent visa. Eligible residents must live in the U.S. on a full-time basis. We request a Social Security Number (SSN) only for adults who are applying for coverage. If an adult does not have or chooses not to provide an SSN, the applicant may provide a tax identification number in the application or enter all zeros. Overseas Travelers Persons to be covered must not be planning or considering extended foreign travel, nor can they live outside the United States for more than three months of the year. Dependents who are studying abroad are ineligible for coverage since they would be residing in a foreign country longer than three months in a year. Medicare Eligible Individuals Applicants who are already eligible to be covered under Medicare are not eligible for coverage under the Core Access Plan. The plan automatically terminates when the insured attains age 65. Acceptable Visa Categories DV-1 H-1B1 IR-2 K-1 L-1 V-1 DV-2 H-1C IR-3 K-2 L-2 V-2 EB-5 H-4 IR-4 K-3 TN V-3 H-1B IR-1 IR-5 K-4 TD 3

4 Underwriting Completion of the Application Each question on the application must be specifically asked of the applicant and the answer recorded as given. It is never allowable for you to ask a general question such as, Are you in good health?, and upon receiving a yes reply, answer all health questions with a no answer. All answers must come directly from the applicant. Underwriting Decisions This guide contains the decision matrix used to underwrite individual(s) for the Hospital Indemnity Plan, as a demonstration of underwriting requirements with regard to height/weight. The underwriting action is based on the condition(s) disclosed by each applicant. Based on negative answers to all the medical questions contained on the application and the height/weight within the acceptable limitations, the application is then allowed to be submitted. If responses on the application are outside the standard guide, a message will appear in a pop up to notify the applicant is not eligible, and the application will not be allowed to be submitted. If the applicant answers yes to any of the medical history questions, coverage is declined. Height/Weight for each applicant for ages 15+ only (under age 15, no action applies) Female Build Chart Ages 15 and Over Height Max Std Decline Male Build Chart Ages 15 and Over Height Max Std Decline

5 Underwriting Continued: Application Questions Is any person whether or not applying for coverage, pregnant, in the process of adopting or undergoing infertility treatment or use of a surrogate mother? In the past 5 years (may vary by state) has any person applying for this coverage been diagnosed with, received medical advice or treatment for (including been prescribed medications), or had symptoms of any of the following conditions: Heart disease, stroke, transient ischemic attack, coronary artery disease, peripheral vascular disease, carotid artery disease, coronary bypass, angioplasty or stent, atherosclerosis, or congenital heart disease? Cancer (other than basal or squamous cell skin cancer), or malignant melanoma? Disease or disorder of the brain or central nervous system including but not limited to brain tumor or cyst, muscular dystrophy, multiple sclerosis, cerebral palsy, mental retardation, chorea (Huntington s, Sydenham s or Wilson s Disease or other) or amyotrophic lateral sclerosis? Emphysema, chronic obstructive lung disease (COPD), cystic fibrosis or other chronic lung or respiratory condition (except for asthma or allergies) Hepatitis B or C, cirrhosis, enlarged liver, liver tumor or hemangioma Insulin dependent diabetes mellitus pancreatitis Alcoholism, alcohol abuse, illegal drug use or prescription drug dependence or addiction Bipolar disorder, schizophrenia, anorexia, bulimia, suicide attempt or other mental or nervous disorder (excluding situational depression, anxiety or attention deficit hyperactivity disorder, ADHD) Kidney or bladder disorder (excluding resolved stones or urinary tract infections) Rheumatoid or psoriatic arthritis, quadriplegia, paraplegia, or are you required to use a wheelchair or other devise to assist you in ambulation? Stem cell transplant, organ transplant or disease of the blood (other than iron deficiency anemia) Autoimmune disorder including but not limited to systemic lupus erythematosus, dermatomyositis, Sjoren syndrome or myasthenia gravis? Acquired immune deficiency syndrome (AIDS), AIDS related complex (ARC) or tested positive for the HIV virus? All members of the family are declined for coverage Underwriting action applies to the applicant to whom the affirmative response applies. 5

6 In the past 2 years has any person applying for this coverage been diagnosed with, received medical advice or treatment for (including been prescribed medications), or had symptoms of any of the following conditions: Herniated or bulging disc, degenerative disk disease of the spine Ulcerative colitis, Crohn s disease, terminal ileitis or diverticulitis Gallbladder disease that has not been cured and/or gallstones that have not been removed Endometriosis, human papilloma virus or chronic menstrual disorder Replacement of the hip(s) or knee(s) Tobacco use (In New Mexico, tobacco users of all ages have an 11% rating.) Underwriting action applies to the applicant to whom the affirmative response applies. Under age 45 = 30% Rating Age 45 or older: 45% Rating Pre-Existing Conditions The certificate/policy defines pre-existing conditions as: A disease, accidental bodily injury, illness or physical condition for which a covered person: Had treatment Incurred charge Took medication or Received a diagnosis or advice from a doctor during the 12 months immediately preceding the covered person's coverage effective date. (The definition of a pre-existing condition may vary by state.) No benefits will be payable for expenses incurred in connection with pre-existing conditions as defined above until coverage has been in effect for a 12-month period. Pre-Existing Condition Review Claims received that are inconsistent with information provided on the application or claims that may be subject to a pre-existing condition limitation are denied if there is not enough information to make a determination. When a claim is reviewed, the analyst looks at the original application. Investigations will determine if the condition on the claim is a pre-existing condition or intentional misrepresentation on the application. The insured will be sent correspondence requesting information needed for a pre-existing investigation. 6

7 Application Submission Checklist 1. Application. Applications should be submitted online. 2. HIPAA Authorization for Release of Health Related Information. This form is required with every application. 3. Payment. The applicant can submit the initial payment by credit card or bank draft (Electronic Funds Transfer or EFT). The first month s premium, including the one-time application fee, will be charged when the application is received. Effective Dates and Billing Effective Dates The applicant may request a plan effective date on any day of the month. The application must be received on or before the requested effective date. The request will be honored if the application can be approved within 15 days of the requested effective date. Payment The applicant s credit card authorization or bank draft information for the first month s premium, including the application, and association fees must accompany the application. Applications received without premiums will be returned. If an applicant requests credit card or bank draft mode of payment, a draft of their account is completed upon application submission. On-going premium will be processed 2-3 days prior to the member's monthly billing date. Upon Issue Once your client's plan is issued, he or she will receive a welcome packet in the mail that includes their ID card. Additionally, it will have information on how to access the Loomis Member Portal, where members can look up providers, view plan benefits, request plan changes and more. 7

8 Plan Changes After Issue Any change requiring a written request and or documentation can be uploaded into the Loomis Member portal (loomisco.com/healthxgateway/member) Type of change Requirements Underwriting Action approval required Name Written request and No Letter to confirm the change, legal documentation new certificate face page and ID cards will be sent to the insured Address Phone or written No Letter to confirm the change request sent to the insure only if the monthly premium is impacted Newborn Baby Written request No within 31 days Letter to confirm addition, Addition within 31 days new certificate face page and ID cards will be sent to the insured Completed application Yes if after 31 days Add a Family Member (other than newborn) Completed application (Application can be found on Loomis Member Portal under "Add Dependent") Yes Letter to confirm addition certificate face page and ID card sent to the insured Remove a Written request from No Letter confirming the change Family Member the primary insured new certificate face page and ID card sent to the insured Lower Deductible Written request from Yes the primary insured with new completed medical section of the application If approved, letter confirming the change, new certificate face page and ID card (if affected by the change); if declined, letter is sent notifying insured of decision Increase Deductible Written request from No Letter confirming the change, the primary insured new certificate face page and ID card (if affected by the change) Add an Optional Benefit Written request from the primary insured with new completed medical section of the application Yes If approved, letter confirming the change, new certificate face page; and ID card if declined, letter is sent notifying insured of decision Remove an Optional Benefit Written request from the primary insured No Letter confirming the change and new certificate face sent to the insured 8

9 Change Requests Type of change Requirements Underwriting Action approval required Plan change to increase benefits Written request from the primary insured with new completed medical section of the application Yes If approved, letter confirming the change and new certificate face page; if declined, letter is sent notifying insured of decision. Termination of Coverage Written request from the primary insured No Letter to confirm the termination sent to insured. Note: The premium due date coinciding with or next following the date after we receive your written request to terminate your coverage under the policy. Rescission of Coverage Fraud or intentional misrepresentation in the application may cause rescission of coverage. Rescission causes coverage to be terminated back to the coverage effective date as if the coverage was never issued. Be sure that the applicant completes the application accurately, including all answers to medical questions and height and weight information. Questions? For additional questions, both applicants and brokers can call the plan administrator, Loomis at Loomis Member Portal: loomisco.com/healthxgateway/member Association Benefits America s Business Benefit Association provides the opportunity to join with thousands of others across the nation and enjoy savings on consumer, business, travel, and health related benefits and services. ABBA is able to provide large company group buying power to the smaller market, and is dedicated to helping small business owners, the self-employed, individuals and families. To view the benefits package, visit 9