Small Business Broker Reference Guide. Illinois & Northwest Indiana

Transcription

1 Small Business Broker Reference Guide Illinois & Northwest Indiana 2-50 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: Pre-Sale guidelines Post-sale administrative options and eligibility provisions Specialty Benefits Guidelines. 2

3 Pre-sale requirements Pre-sale requirements may change and installation 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. Category Applications (Medical questions do not need to be completed) Rating structure Submit to: or send to your local General Agent representative. Multi-Choice Excluding classes (Not permitted in Indiana) Required for submission Quarterly wage & tax report Payroll record requirements Explanation/Requirements Employees at groups with 2 to 50 Average Total Number of Employees will be required to complete. Illinois Standard Health Employee Application for Small Employers Form # (2-50) (located on UnitedeServices.com under Forms IL Employee) NW Indiana (Lake, Porter & LaPorte Counties) Form # (2-50) (located on UnitedeServices.com under Forms IL Employee) Illinois ONLY: Rating structure is based on the Average Total Number of Employees (ATNE*). NW Indiana ONLY: Rating structure is based on Full Time Eligible employees Employees will be table rated. Please note: Dependent count such as # of children and dates of birth does impact rates and is needed for quoting. Available for groups with 2-50 average total number of employees. Any number of benefit design options can be grouped together. On groups with 2 to 50 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 enrollment forms including COBRA for all eligible employees Completed Pre-Sale Coversheet (located on UnitedeServices.com under Forms IL Broker) Name of current carrier and group tax ID number Most recent statement All pages submitted Mark each employee to indicate part-time, full-time, terminated, and ineligible. Wage & Tax is needed for out of area employee(s) For groups of 2-50 eligible employees, a quarterly wage & tax report is always required. Dated payroll and/or date of pay period Name of company Total number of hours worked by each employee Total number of employees Total taxes withheld, itemized Groups of 6+ eligible employees may submit a current Payroll in lieu of a quarterly wage & tax report. ATNE Defined: ATNE information is required in all states for MLR reporting. Some states also require fully insured customers to provide ATNE data for rating purposes. Under ATNE, all employees should be counted, including those who work full-time, part-time, and seasonally. Generally, employees who receive a W-2 should be counted while independent contractors who receive a 1099 would not. ATNE should be totaled at the end of each month. Annual ATNE is calculated by adding the total number of employees for each month and dividing by the number of months in business (generally 12). The resulting number is the ATNE number used for new business and renewal rating process. 3

4 Case Installation Category Requirements for new business submission Submit to: Fax: Mail: UnitedHealthcare Small Group New Case Submission Suite E. Randolph St. Chicago, IL Or submit to your General Agent office. Wage & tax alternatives Type of business C corporation S corporation Partnership/limited liability partnership Sole proprietorship Limited liability company (LLC) Church Farms Billing statement requirements Enrollment form requirements Explanation/Requirements (Medical questions DO NOT need to be completed) 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. Medical questions DO NOT need to be completed) Completed Indiana Employer Application for Small Business Form # (located on UnitedeServices.com under Forms - IN - Employer. Medical questions DO NOT need to be completed) Copy of the groups most recent billing statement from the current carrier (2-50) Copy of the most recent quarterly wage & tax statement (2-50) Completed and signed enrollment forms including COBRA for all eligible employees (2-50) Different company names listed on past bill, wage & tax, group application, etc. will need an explanation and possible proof (2-50) UnitedHealthcare Multi-Choice Benefit Selection Form (2-50) (located on UnitedeServices.com under Forms - IL - Employer) Name of current carrier and group tax ID number (2-50) IL: This information is good for groups with 2-50 Average Total Number of Employees NW IN: This information is good for groups with 2-50 eligible employees Required Documentation Form 1120 (pages 1 & 2) which includes Schedule E & current wage and tax or current payroll records. Schedule K-1(Form 1120S) for all enrolling Owners/Partners & wage and tax or current payroll records. IRS Schedule K-1 (Form 1065) for all enrolling partners or Partnership Agreement signed by all partners & wage and tax or current payroll records. Business license (if in business less than one year and a Schedule C has not been filed yet) or Schedule C, and current payroll records for employees other than the owner. LLC Agreement signed by all managers/members/parties or copies of appropriate tax returns (follow the guidelines for either a Partnership or S-Corp based on how the LLC was formed) & wage and tax or current payroll records. IRS Form 941 & current payroll records. IRS Schedule F (Form 1040) & current payroll records. Most recent statement (all pages) All terminated employees clearly marked, including termination date(s) Cobra/Continuation applications included if terminated within days and still listed on billing statement All information fully completed and signed by subscriber 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 24-Hour coverage (AO coverage) Seasonal employees PEO ( Professional Employee Organization ) groups Retiree coverage Employers utilizing leased employees Waiting periods Multi-Choice Navigate (IL only) Explanation/Requirements Minimum of 50% the average cost of the lowest plan. Illinois ONLY: 25% floor of total eligible employees with no waivers. NW Indiana ONLY: 50% floor of total eligible employees with no waivers. 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 submitted no later than the 10th of the month in order to back date coverage to the 1st of the month 15th of the month effective date: A group must be submitted no later than the 25th of the month in order to back date 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) 24-hour medical coverage is available to owners, officers and partners of a company who are not covered under workers compensation. This option provides medical coverage for injuries and illnesses stemming from occupational exposures. A premium load may be assessed to the entire group, determined by the percent of employees being covered. 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 or post 65 Retiree coverage is not available Exception: Retirees of the IMFR (IL Municipal Retirement Fund) that work for a municipality in IL are considered eligible. 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 Employer must fill out Multi-Choice benefit selection form. (located on UnitedeServices.com under Forms IL Employer) All plans selected will be installed whether there are enrolled employees or not. 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 Wage & tax statement or current payroll Prior billing statement Common Ownership Multi-Choice Benefit Selection Form Copy of binder check/direct debit form 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 UnitedHealthcare Employer application Form # (located on UnitedeServices.com under Forms - IL - Employer) UnitedHealthcare Employer application Form # (located on UnitedeServices.com under Forms - IN - Employer) Requirement for all products (not product specific) *Standalone dental and vision will accept a current bill and payroll for all size groups in lieu of W&T docs* Medical prior billing statement not required Dental prior & current billing statement not required Requirement for all products. (Common Ownership Form located on UnitedeServices.com under Forms - IL - Employer) Multi-Choice Benefit Selection Form (located on UnitedeServices.com under Forms - IL - Employer) Medical premium Life premium Dental premium No binder check is needed for voluntary dental. 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 from Broker with approved rates Verification approval Need copy of Ues Proposal or Rate card. (If rate relief given by SSC also need copy of Field Underwriting Form from rate bank tool.) Employee: UnitedHealthcare Medical and Life Enrollment Form including PCP selection for IL Navigate HMO EE application business. (State specific) 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. All states have adopted the renewal rule member s age is frozen as of age they were on renewal date (or initial effective date) of the plan year. Up to 3 children who are under the age of 21. (All children who are over the age of 21 are rated additionally) 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 Category 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 Explanation/Requirements 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) or policy period date 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) or policy period date with 31-day notice. 1st of the policy month (1st, 15th, 28th) or policy period date 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. Groups previously terminated for non-payment Groups previously terminated for non-payment are not eligible to reapply for coverage until one year from the date 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 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 Minimum of 51%, including waivers Voluntary 2 enrolled minimum 8 enrolled minimum with ortho 10+ eligible 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 and should have a minimum premium spread of at least 20% between plans. Ortho available for groups with a minimum of 10 eligible employees with a minimum of 8 enrolled. Vision Guidelines Contribution Participation Employer Paid: % employer contribution for both employees and dependents. 50% Employer Paid: 50-74% employer contribution for employees. No employer contribution requirements for dependents. Employee Core/Voluntary Dependents: % employer contribution for employees. No employer contribution requirements for dependents. Voluntary: 0-49% contribution for employees. No employer contribution requirements for dependents. Employer Paid: At least 75% participation of eligible employees less valid waivers, not to fall below 50% or total eligible employees. 50% Employer Paid: At least 75% participation of eligible employees less valid waivers, not to fall below 50% or total eligible employees. Employee Core/Voluntary Dependents: At least 75% participation of eligible employees less valid waivers, not to fall below 50% or total eligible employees. Voluntary: Two eligible, only 1 to enroll. 9

10 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 Groups with 2-5 eligible employees must be sold with medical Groups with 6-9 eligible employees may be sold without Medical Selected types of businesses are ineligible (see SIC code list) 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, 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 Basic Dependent Life Must be sold with Employee Life Employee must elect Employee Life to elect Basic Dep Life Cannot be sold with Supp Dep Life Not Applicable LTD Installation Platform Case Requirements Availability Portal Access Employer Eligibility PRIME Must be sold with at least one Contrib and Non-Contrib product; Medical, Dental, Vision, Basic Life or STD (10-50) LTD if sold with medical, must have another ancillary benefit regardless of funding method 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 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 STD Installation Platform Case Requirements Availability Portal Access Employer Eligibility Employee Participation Requirements Employer Contributions Rating Methodology Eligibility Requirements Eligibility Waiting Period Min. # Hours PRIME Must be sold with at least one Contrib or Non-Contrib product (Medical, Dental, Vision, Basic Life or STD) 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 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) 2-9: non-contributory plans only available : can do non-contributory, voluntary or contributory. Voluntary: 25% participation, 0% ER contribution. Contributory: 50% participation, 50-99% ER contribution 100% employer paid Composite per $10 of Weekly Benefit; Age banded rates available. 24 Month Rate Guarantee 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-A 4/ UnitedHealthcare Services, Inc. 11