California Dental Carrier 411 Small Group

Transcription

1 California Dental Carrier 411 Small Group Aetna Anthem Blue Cross Blue Shield of California Delta Dental Guardian Health Net Humana Kaiser MetLife Premier Access Principal UnitedHealthcare T: (800) F: (800) Warner Pacific Insurance Services Agoura Road Westlake Village, CA CA Insurance License CO lnsurance License

2 TABLE OF CONTENTS 1. UNDERWRITING Pages 4-7 Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Minimum number of employees required o Participation o Contribution Pages 8-11 Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Orthodontia eligibility o Plan Combinations Page Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Carve outs o 1099 employees o Are seasonal employees eligible? o Will carrier write a group with leased employees? o Percentage of COBRA allowed o Percentage allowed out-of-state o Effective dates o Carrier new submission deadline Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o New hire waiting periods o At initial enrollment can the waiting period be waived for new hires? o Dependent age maximum o Written alongside another carrier? o Length of time a company must be in business o Retirees o Carrier write domestic household staff o Length of time signatures are valid o E-Signatures o What are the requirements to cover part-time employees? o Is workers compensation required on employees? Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Percentage of related employees allowed o Can a husband and wife who work for the same company enroll together or separate? o Who is considered an eligible dependent o Within the U.S., available plans to employees and dependents who live outside of CA? o Available plans to dependents that reside or attend school outside of CA and the employee lives in CA o Available plans to dependents that reside or attend school outside of CA and the employee lives in CA & is on an HMO plan P a g e 1

3 Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Is a DE-9C and/or payroll roster required for enrollment? o Can a group enroll using list billing enrollment? 2. RATING Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Rate guarantee o Carrier rule for re-applying due to requested cancellation or non-payment of dues o Employee rates based on home or work zip code o Out-of-state employee rates are based on home or work zip code o Are SIC codes used for rating purposes? o What rating tiers are used? 3. COBRA LEGAL Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Who is administering CalCOBRA? o Who is administering Federal COBRA? 4. PROVIDER NETWORK Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o How often can a member change a dental office? o Can each family member choose different dental offices? o Name of provider network used o What rating tiers are used? 5. CLAIMS/BENEFITS Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Which plans pay UCR out of network and at what percentile? o If a member had prior coverage do they receive a new annual maximum? o Is takeover of treatment in progress available? (New group transfers) o Is takeover of orthodontic treatment in progress available? (New group transfers) Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Coverage waiting periods o Implant coverage P a g e 2

4 Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Is the deductible credit given when coming from a prior group carrier? o Is the dental deductible and benefit maximum calendar or plan year? o Cleaning allowances 6. MEMBERSHIP Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Cancellation notice o What online services are available for a group administrator? o Cut off age to add dependent child 6. MISCELLANEOUS Pages Aetna, Anthem, Blue Shield Delta Dental, Guardian, Health Net Humana, Kaiser, MetLife Premier Access, Principal, UHC o Carrier options for monthly billing payment o Website o Are split commissions allowed? If yes, what is the maximum allowed? o Agent appointments o AM Best / Standard & Poor s rating 7. FOOTNOTES Page P a g e 3

5 UNDERWRITING Minimum number of employees required See separate topic, Orthodontia Eligibility, for orthodontic plan requirements With Aetna medical: 2+ eligible/2 enrolling required. Stand-alone: 3+ eligible/3 enrolling required. Legacy With Anthem medical: 1+ enrolling Stand-alone: 1+ enrolling Dual Option: Anthem medical or standalone: All plans are available to a group with 1+ enrolling Dual Option DMO and PPO only. Prime and Complete Anthem BC medical: 2+ enrolling Single Option With Blue Shield medical: 1+ eligible; 1 enrolling. Standalone: 1 W-2 or 2 eligible, owner only is fine; 1 enrolling. Dual/Triple Option With Blue Shield medical: 1+ eligible; 1 enrolling. Freedom-of-Choice is not available alongside any other Aetna dental plans. SIC restriction only applies to standalone policies. Stand-alone: 2+ enrolling Dual Option, Anthem medical or stand-alone: 10+ net eligible employees. Minimum of 2 employees must enroll in each of the two options selected with at least a 20% rate differential between the two plans. Stand-alone: 1 W-2 or 2 eligible, owner only is fine; 1 enrolling. Plans allowed: 2 Prime and Complete plans or 1 Prime and Complete plan plus Dental Net. Participation 2-3: 100% eligible employees, min. 2 required. 3 if standalone. 4-50: 75% with a minimum of 2 lives and 50% of total eligible enrolled, rounded down. Stand-alone dental has ineligible industries. Legacy With Anthem Medical: 1-14 Eligible: 70% participation 15+ Eligible: 50% participation Standalone: 75% of eligible employees 100% if non-contributory Prime and Complete 2-4 lives: 100% of eligible employees & a minimum of 2 enrolled lives: 60% of eligible employees Relaxed Participation Guidelines from 5/1/14-9/30/15: 25% participation for groups with 5+ enrolled. Blue Shield must be the sole carrier. 65% of eligible employees less valid waivers for groups of 1-4 enrolled. Waivers and declines for standalone dental are only required when enrollment is down to one enrolled employee. Contribution (employer minimum) 2-50: 50% of employee premium or 25% of the total employee + dependent premium. EmployeeElect: 50% or $15 of employee premium. Prime & Complete: minimum contribution required. 50% of employee premium. P a g e 4

6 UNDERWRITING Minimum number of employees required See separate topic, Orthodontia Eligibility for orthodontic plan requirements 2+ eligible/2+ enrolling. Guardian requires a minimum premium of $1,000/year. Participation Contribution (employer minimum) Classic Standalone (2-4) PPO A & C 1000 and HMOs: 2+ enrolled All other PPO plans: 5+ enrolled Classic Dual Choice (2-4) PPO A & C 1000 and HMOs: 4+ enrolled with at least 2 enrolled on each plan All PPO and HMO plans (5-99): The greater of 10 enrolled or 80%, min. 2 enrolled on one plan and balance on the other plan Options Standalone (50-99) PPO: 35+ enrolled HMO: 5+ enrolled Options Dual Option (50-99) 50+ enrolling with min. 10 enrolled on one plan and balance on the other plan If employer contributes 100%, all eligible employees and dependents must enroll. PPO Classic (2-49): Employer contributes 75% % of the employee premium a minimum of 2-4 or 5+ (depending on plan selected) or 80%, whichever is greater must enroll. PPO Options (50-99): Employer contributes 75% % of the employee premium a minimum of 35 or 80%, whichever is greater must enroll. DeltaCare USA DMO (2-99): Employer contributes 75% % of the employee premium a min. of 2 or 80%, whichever is greater must enroll. See footnote (3) for dependent coverage information. PPO: 75% of employee premium. DMO Option A (n-voluntary): Employer contributes 100% of the employee/dependent premium. DMO Option B: Employer contributes 75% to 99.9% of the employee premium and 0% to 99.9% for dependent coverage. DMO Option C (Voluntary): Employer contributes 0% to 74.9% of the cost for employees and 0% for dependents. 2-3 eligible employees: 100% 4 eligible employees: 75% 5-50 eligible employees: Greater of 25% and 5 enrolled lives. For standard rates to apply, Guardian must receive 65% or greater participation, otherwise rate loads apply. 20% of the employee premium. With HN medical: 2-50 enrolling. Standalone: 2-50 enrolling. Proof of immediately prior coverage is required for employer paid rates. PPO: 75% of eligible employees. DHMO: 50% of eligible employees. Dual option requires 75% overall participation: 1 DHMO and 1 DPPO with a minimum of 4 eligible employees enrolled and 2 on each plan. 2 DHMO and 2 DPPO with a minimum of 10 eligible employees enrolled and a minimum of 2 on a given plan. DHMO/PPO: 50% of employee premium. Dual Option: 50% of employee premium. P a g e 5

7 UNDERWRITING Minimum number of employees required See separate topic, Orthodontia Eligibility for orthodontic plan requirements Single plan PPO: 2+ enrolled; DHMO: 2+ enrolled. Must match medical enrollment. DeltaCare HMO may not be offered with PPO plans. Dual Option 10+ enrolled, minimum 2 on DHMO. If offering 2 PPO plans Humana requires the group to have different coinsurance amounts. Triple option is available. Please call your Humana Sales Representative for case by case exceptions. DHMO: 30% total eligible; minimum 5 enrolled required. PPO (2-4 eligible): 100% total eligible; minimum 2 enrolled required. PPO (5+ eligible): 50% eligible; minimum 3 enrolled. Dual Option DHMO/DHMO (10-50 eligible): 30% total eligible; minimum 3 enrolled in each plan. Dual Option DHMO/PPO (10-24 eligible): 50% eligible; minimum 5 enrolled on each plan (25-49 eligible): 50% eligible; minimum 5 on DHMO and 10 on PPO. Participation Single plan OR Dual option: Employer contributes 100% of employee premium: 100% of eligible. Must match medical enrollment. See the first category in this column for complete guidelines. Minimum number of employees required. Employer contributes 25%-99% of employee premium: 75% of eligible. HumanaDental will lower participation requirement to 50% if 25% of more of the eligible employees waive due to other creditable coverage. Contribution (employer minimum) Employer-paid: 25% of employee premium. Must match medical contribution selected. 50% of employee premium. Groups with contribution less than 25% will receive voluntary rates which are approximately 5-6% less. P a g e 6

8 UNDERWRITING Minimum number of employees required See separate topic, Orthodontia Eligibility for orthodontic plan requirements DHMO: 3 enrolled employees. Premier Advantage: 3 enrolled employees. Stand-alone: 3+ eligible/3+ enrolling. Dual Option: 10 enrolled employees. Dental Choice: 10+ enrolled. At least one employee must be enrolled in each design of the choice offering. Stand-alone: 2+ enrolling With UnitedHealthcare medical: 2+ enrolling. Dual Choice: PPO/HMO or HMO/HMO: 5 eligible, 3 enrolled. PPO/PPO: 10 eligible, 10 enrolled. Participation Contribution (employer minimum) DHMO 3-9 enrolled employees: 100% of eligible enrolled employees: 75% of eligible employees. Premier Advantage 3-9 enrolled employees: 100% of eligible enrolled employees: 75% of eligible employees if the employer contribution is less than 100%. Dual Option enrolled employees: min. 2 enrolled in the DHMO and 5+ enrolled in the Premier Advantage Plan, with the balance in either plan. DHMO, Premier Advantage 3-9 enrolled employees: 100% of employee premium enrolled employees: 75% or more of the employee premium. 75% of eligible employees. 75% of eligible employees, not less than 50% after waivers. 50% of employee premium. 50% of employee premium. P a g e 7

9 UNDERWRITING Orthodontia eligibility See footnote (5) for overage dependent child eligibility All plans require10+ eligible employees, 5 enrolled. All plans include coverage for adult and children. EmployeeElect: 2+ enrolled. DMO, Freedom of Choice, and PPO plans. Optional coverage for adult and children. Prime and Complete: 10+ enrolled. All plans (except the Smile Value, Smile, Smile Basic, Smile Deluxe 2000, and Ultimate Dental) include coverage for adult and children. With Blue Shield medical or Standalone: 1+ eligible. All orthodontia benefits are based on a calendar year maximum vs. a traditional lifetime maximum. Plan combinations 2-9 eligible: 1 DMO with 1 PPO, no orthodontics. 1 employee minimum on each plan. Voluntary and Freedom of Choice plans cannot be offered eligible: 1 DHMO with 1 PPO, with or without orthodontics. Both plans must be employer-paid or voluntary. Voluntary groups must enroll 3 with a minimum of 1 on each plan. Employer-paid groups must enroll 2 with a minimum of 1 on each plan. Freedom of Choice plans cannot be offered. EmployeeElect: A choice of Anthem Blue Cross dental plans. A minimum of 10 eligible employees, minimum 75% participation, minimum of 20% enrollment in PPO or Prime and Complete Program, minimum of 2 enrolled in each plan. Employer-paid Prime and Complete: DHMO/PPO: 10 net eligible employees, minimum 75% participation, minimum of 20% enrollment in PPO, Dental Prime or Dental Complete, minimum of 2 enrolled in each plan. PPO/PPO: 10 net eligible employees, minimum 75% participation, minimum of 20% of enrollees must enroll in the higher cost plan, minimum 2 on each plan and a 20% minimum rate differential between the two plans. Dual Option: Groups with a minimum of one enrollee may select a combination of any two dental plans. When a nonvoluntary plan is combined with a voluntary plan or two nonvoluntary plans are offered, a 50% employer contribution and 65% participation of eligible employees is required. When two voluntary dental plans are offered, there are no contribution requirements. Triple Option: Groups with a minimum of one enrollee may select a combination of the following three plans: 3 HMO s, 2 HMO s and 1 PPO or 2 HMO s and 1 INO. When a nonvoluntary plan is combined with a voluntary plan or three nonvoluntary plans are offered, a 50% employer contribution and 65% participation of eligible employees is required. When three voluntary dental plans are offered, there are no contribution requirements. P a g e 8

10 UNDERWRITING Orthodontia eligibility See footnote (5) for overage dependent child eligibility Classic (5-49) HMO: 5+ enrolled employees required. 3+ enrolled required for dual option. Includes coverage for adult and children. 2-4 enrolled employees: t available enrolled employees: Optional coverage for children only. PPO: 10+ enrolled employees required. Optional coverage for children only. Options (50-99) HMO: 5+ enrolled employees required. 3+ enrolled required for dual option. Includes coverage for adult and children. PPO: 10+ enrolled employees required. Optional coverage for child only or adult and children. Ortho maximum guidelines: 5-15 enrolled employees: Less than or equal to in-network dental maximum, but no greater than $ enrolled employees: Less than or equal to in-network dental maximum enrolled employees: May be up to $500 higher than dental maximum. HMO: 2+ enrolled employees required. Includes coverage for adult and children. Classic & Essential PPO plans: 10+ enrolled employees required. 2+ if the group had immediately prior group indemnity orthodontic coverage. Optional coverage, select plans only, for adult and children. Plan combinations Delta Dental must the sole carrier. Employer contribution percentage for employee and dependent coverage must be identical for both plans. Classic PPO / DeltaCare USA (10-49 enrolled): A minimum enrollment of 10 eligible employees. A minimum 3 enrolled in PPO and a minimum 3 enrolled in HMO is required. Cannot offer the 2-4 enrolled plans as Dual Option. 1 PPO plan. DHMO may be available upon request. Dual Choice: 1 DHMO and 1 DPPO with a minimum of 4 eligible enrolled and 2 on each plan. Groups may select 2 DHMO or 2 DPPO plans with a minimum of 10 eligible enrolled, with a minimum of 2 on a given plan. 50% employer contribution and 75% overall participation is required. Options PPO / DeltaCare USA (50-99 enrolled: A minimum enrollment of 50 eligible employees. A minimum 10 enrolled in one plan and the balance in another. P a g e 9

11 UNDERWRITING Orthodontia eligibility See footnote (5) for overage dependent child eligibility HMO: 2+ enrolled employees required. Includes coverage for adult and children. HMO: 2+ enrolled employees required. Includes coverage for adult and children. Traditional Preferred & PPO plans: 10+ enrolled employees required and offers optional coverage for children only. OR 25+ enrolled employees required and offer optional coverage for adult and children. Preventive Plus: Orthodontia is not covered on this plan. Premier plans: 10+ enrolled employees required. Optional coverage, select plans only for children only. PPO: t Covered. HMO: 30% total eligible; minimum 5 enrolled required. Includes coverage for adult and children. PPO (10-50 eligible): 75% total eligible; minimum 8 enrolled required. Optional coverage, select plans only for adult and children. Dual Option DHMO/DHMO (10-50 eligible): 30% total eligible; minimum 3 enrolled in each plan Dual Option DHMO/PPO (10-50 eligible): 75% total eligible; minimum 3 enrolled in each plan. Plan Combinations DHMO/PPO or PPO/PPO: 10+ enrolled, minimum 2 on DHMO balance on PPO (both plans must be voluntary or employersponsored). Orthodontic options must be selected on both products or not at all, with exceptions on Preventive Plus and some DHMO/Prepaid plans. If orthodontics is chosen on the PPO plan(s), then a minimum of 10 must enroll on each plan(s). If electing PPO/PPO combination, the coinsurance schedules must be different between the two plans. Groups may only offer a single dental plan. Plans with orthodontia coverage are available only if there has been no lapse in coverage from a prior PPO/Indemnity based orthodontic plan. Groups 5-9 enrolled require prior orthodontic coverage 10+ enrolled requires prior major coverage. PPO/DHMO: (10-24 eligible): 50% eligible; minimum 5 enrolled on each plan (25-49 eligible): 50% eligible; minimum 5 on DHMO and 10 on PPO. DHMO/DHMO: (10-50 eligible): 30% total eligible; minimum 3 enrolled in each plan. P a g e 10

12 UNDERWRITING Orthodontia eligibility See footnote (5) for overage dependent child eligibility DHMO: 3-50 enrolled employees required. Includes coverage for Adult & Children. Plan Combinations Premier Advantage: enrolled employees required. Coverage is optional for children only. If the group is less than 10 enrolled employees but more than 3 enrolled employees, they have current orthodontia coverage and there is no lapse in coverage they may be able to offer orthodontia coverage. Dual Option: enrolled, a minimum of 2+ enrolled in DHMO and 5+ enrolled in a Premier Advantage plan, with the balance in either/both plans. All plans: Greater of 20% of eligible employees or 5+ enrolled employees required and offers optional coverage for children only. OR 25+ enrolled employees required and offer optional coverage for adult and children. Dual Option: Allows either a DHMO or Hi/Low setup. Requires a minimum of 10 lives with at least 1 enrolled in each plan option. Single plan offering HMO: 2+ eligible / enrolled employees required. Includes coverage for adult and children PPO: 10+ eligible/ 8 enrolled employees required. Includes coverage, select plans only, for adult and children. Dual option HMO: See above. PPO: See above. PPO/PPO: 8+ enrolled on each plan with orthodontia. Includes coverage, select plans only, for adult and children. SBS: 10+ eligible/ 8 enrolled employees required. Optional coverage, select plans only, for children only HMO/PPO: 5 eligible with 3 enrolled. If orthodontic is offered on the PPO plan, then there must be 10 eligible with 8 enrolled on PPO and 2 enrolled on HMO. HMO/HMO: 5 eligible with 3 enrolled. PPO/PPO: 10 eligible with 10 enrolled. If orthodontic is included in either option, then at least 8 must enroll on the plan with orthodontics. P a g e 11

13 UNDERWRITING Carve-outs Only Union/n Union. n-union only. Total group size must meet definition of a small employer. Requires 5+ enrolled lives and Union Roster for verification. Anthem does not consider this a carve-out provided the total group size is less than 51, union and non-union. The union employees are considered eligible waivers. A copy of the Union Roster will be required employees n-union only. See footnote (6) for guidelines. Blue Shield must be the only carrier offered. Are seasonal employees eligible? Will carrier write a group with leased employees? Percentage of COBRA allowed maximum. maximum. maximum. Percentage allowed outof-state (see separate topic for plans available to employees and dependents who reside out-of-state) Group must have at least 51% of their eligible employees residing in California. (2) Hawaii employees are not eligible and will be considered valid waivers. more than 49% of the group. more than 49% HMO not available. Effective dates 1 st /15 th 1 st /15 th Carrier New Business Submission Deadline 1 st normally the 5 th business day of the same month. (cycle will change to 1st month) 1 st normally the 5 th business day of the same month. 1 st /15 th : PPO with or without medical. 1 st /15 th : INO with or without medical. 1 st : HMO with or without medical. (15 th only if currently written this way) rmally the 5 th business day of the same month. 15 th around the 21 st of the same month. 15 th around the 14 th of the same month. P a g e 12

14 UNDERWRITING Carve-outs Management / n-management, Yes, must be defined by class. t available. Salary/Hourly, Union/n-union. Delta Dental PPO can be offered to one population and DeltaCare USA can be offered to another. Multiple PPO plans are not allowed. t allowed with another carrier, level 2 rating applies regardless of industry, ER must provide DE-9C identifying the carve-out employees, and all other underwriting guidelines apply employee Are seasonal employees eligible? Yes, see full underwriting guidelines to determine eligibility. Will carrier write a group with leased employees? Percentage of COBRA allowed Percentage allowed outof-state (see separate topic for plans available to employees and dependents who reside out-of-state) See PEO guidelines. maximum. maximum. maximum. PPO (2-3 eligible): all employees must be located in California. PPO (4 eligible): 1 eligible employee may be located outside of California. PPO (5-99 eligible): more than 50% of primary enrollees may reside outside of California. maximum. If the group contains Texas enrollees, Guardian must be contacted. Group must be headquartered in California. PPO: Group must have at least 51% of their eligible employees employed in California. Hawaii employees are not eligible and will be considered valid waivers. DHMO: Plan not available out of state. Effective dates DeltaCare USA (DMO): t available. 1 st only. PPO (stand-alone): 1 st or 15 th DHMO/Dual Option: 1 st only. 1 st only (15 th of the month effective date is only available if the group s current policy is on a 15 th of the month cycle) Carrier New Business Submission Deadline HMO normally the 15 th of the prior month. rmally the 30 th or 31 st of the prior month. 1 st normally the 5 th business day of the same month. PPO normally the 24 th of the prior month. 15 th around the 21 st of the same month. P a g e 13

15 UNDERWRITING Carve-outs Yes, regardless if they currently had a carve-out arrangement with their current carrier or not. Must match medical enrollment. Yes, MetLife must be the only carrier offered and 100% of the eligible carve out population must enroll. See topic minimum number of employees required for participation guidelines employees Yes Are seasonal employees eligible? Will carrier write a group with leased employees? Percentage of COBRA allowed Percentage allowed outof-state (see separate topic for plans available to employees and dependents who reside out-of-state) Yes, if the employer chooses to cover them. te: these members will count toward the overall group size. Yes more than 10%. maximum. more than 15% enrolled. more than 10% in New Jersey, New York or Washington State. Since the dental enrollment must match the medical enrollment and only one dental plan can be chosen by the employer, if there are out of state employees then the employer would want to offer a PPO or Indemnity dental plan as the DeltaCare HMO plans are not available out of state. Effective dates 1 st only 1 st only 1 st or 15 th Carrier New Business Submission Deadline rmally the 20 th of the prior month. rmally 1 st of the same month. Dental plan rates quoted in Warner Pacific s system are applicable to groups sitused in CA with a maximum of 25% of employees outside of CA. The WP Rating Analyst can request a quote from MetLife if the OOS population is more than 25%. Groups with employees located in the extraterritorial states of Louisiana, Mississippi, Montana and Texas are only allowed to have Dental PPO Plans with matching in and out-of-network coinsurance. (renewal will be the first of the following month) 1 st the 30 th or 31 st day of the prior month, no exceptions. 15 th rmally the 14 th of the same month. P a g e 14

16 UNDERWRITING Carve-outs Yes, salaried, hourly, union, nonunion, management and employees at specified location. Yes, contact your Principal Sales Representative with details to determine eligibility. n-union carve outs are allowed. Requires a minimum of 5 enrolled lives and union bill for verification. SBS: Carve outs are not allowed employees Are seasonal employees eligible? Will carrier write a group with leased employees? Percentage of COBRA allowed Percentage allowed outof-state (see separate topic for plans available to employees and dependents who reside out-of-state) Effective dates Carrier New Business Submission Deadline Yes, if the group utilizes a PEO for payroll services only. more than 15% enrolled. more than 20%. maximum. Dental plan rates quoted in Warner Pacific s system are applicable to groups situated in CA with a maximum of 49% of employees outside of CA. The WP Rating Analyst can request a quote from Premier Access if the OOS population is more than 49%. 1 st or 15 th (renewal will be the first of the following month) HMO normally the 25 th of the prior month. PPO normally the 30 th or 31 st of the prior month. Principal will take headquarters location, SIC, and current census and quote the offerings available. 1 st or 15 th available (billing cycle will be on the 1st regardless of the new case effective date) rmally the 21 th of the prior month. PPO: max. Majority will determine situs state for rates and benefits. If no one state has the majority of the enrolled employees, the situs state for rates and benefits will be determined by corporate headquarters of the company. DHMO: All DHMO participants must live within CA and reside within the service area. Dual option with PPO out of state employees is available. max., see PPO guides and dual option guides for specifics. PPO/DHMO: 1 st or 15 th SBS: 1st only (15 th of the month effective date available if the group is offering Medical PPO or Ancillary Plan Options Only) 1 st normally the 5 th business day of the same month. 15 th around the 21 st of the same month. P a g e 15

17 UNDERWRITING New hire waiting periods New hire waiting period have been updated to: Employer shall determine waiting period for new hires, which shall not exceed the waiting period permitted by applicable state or federal law (4) First of the month following: - DOH - 1 month - 2 months, not to exceed 90 days. If it exceeds 90 days, the effective date will First of the month following: - DOH - 30 days - 60 days 91st Day following DOH (4) be the FOMF 1 month (4) At initial enrollment can the waiting period be waived for new hires? Full-time employees: Yes Part-time employees: Yes Full-time employees: Yes Part-time employees: Full-time employees: Yes Part-time employees: Yes Dependent age maximum Written alongside another carrier? Length of time a company must be in business P a g e 16 n-fulltime/fulltime through age 25 regardless of student status. t allowed. 50% of previous calendar year or quarter Newly formed groups: 6 weeks (Additional requirements may be requested) n-fulltime/fulltime through age 25 regardless of student status. Legacy: Yes, 75% of eligible employees must enroll with Anthem Blue Cross. Prime & Complete: 50% of the previous calendar quarter or year Newly formed groups: 1-50 eligible FT/PT W2 before the requested effective date as long as the group can provide 30 days of payroll within 45 days of the approval n-fulltime/fulltime through age 25 regardless of student status. t allowed. Stand-alone dental: 0 days With medical: 1 to 50 permanent full-time eligible employees on at least 50% of its working days during the preceding calendar quarter or calendar year. A start-up group must provide 6 weeks of payroll and other supporting documents. The payroll records must cover the 6 weeks preceding the requested effective date for at least one eligible full time EE. Retirees Carrier write domestic Yes, provided the items in household staff footnote (1) are met. Length of time signatures are valid 90 days prior to the requested effective date. 60 days prior to the requested effective date. 45 days prior to the requested effective date. E-Signatures Yes Yes Yes What are the requirements to cover part-time employees? Is workers compensation required on employees? hours for 50% of the Prior Calendar Quarter. Group must stipulate at time of enrollment. Adding part time employees may be done at anniversary only. t subject to underwriting., however, 24-hour coverage is not offered to employees. If the medical expense is work-related, Aetna would not consider it for benefits hours hours. Group must stipulate at time of enrollment. The part-time employee must have worked hours per normal work week, for at least 50% of the working days in the previous calendar quarter. t required.

18 UNDERWRITING New hire waiting periods Standard: 1 st of the month following minimum 90 days OR Custom: As mirrors our group medical plan: (a) 1 st of the month following DOH (b) DOH (c) 1 st of the month, following days of employment (min. of 30 days). (4) 1st of the month following: days - 60 days - 90 days days days days (4) First of the month following: - DOH - 1 month - 30 days - 60 days Must match Health Net medical selection (if applicable). (4) At initial enrollment can the waiting period be waived for new hires? Full-time employees: Yes Part-time employees: t eligible Yes, by exception request. Full-time employees: Yes Part-time employees: Yes Dependent age maximum Written alongside another carrier? Length of time a company must be in business Retirees Carrier write domestic household staff n-fulltime/fulltime through age 25 regardless of student status. Yes, other carrier must be opposite type plan. t available for groups writing a carve-out or dual choice. n-fulltime/fulltime through age 25 regardless of student status. t allowed n-fulltime/fulltime through age 25 regardless of student status. 0 days 0 days 1-5 active subscribers: Must qualify through the 50% calendar quarter/year test in order to qualify active subscribers: 50% of the preceding calendar. quarter/year or at least 6 weeks of payroll. Yes-contribution must be same for all and there can be no break in coverage. As long as the client can provide the required DE-9C establishing the ER/EE relationship. Must use 8741 SIC which are Level 2 rates. Length of time signatures are valid 90 days prior to the requested effective date. 31 days prior to the requested effective date. 60 days prior to the requested effective date. E-Signatures Case by case basis Case by case basis Yes What are the requirements to cover part-time employees? t eligible Is workers compensation required on employees? Minimum 20 hours per week required. Must be stipulated at time of enrollment. Yes hours, Group must stipulate at time of enrollment. Adding parttime employees on the plan they may do so at anniversary only. t subject to underwriting. P a g e 17

19 UNDERWRITING New hire waiting periods - 0 days - 30 days - 60 days - 90 days - Other, specify (employer can pick an amount more than 90 days) (4) Employer shall determine waiting period for new hires, which shall not exceed the waiting period permitted by applicable state or federal law(4) 1st of month following: - Date of hire - 30 days - 60 days - 90 days days days (4) At initial enrollment can the waiting period be waived for new hires? Yes, with proof of prior coverage. Full-time employees: Yes Part-time employees: Yes Full-time employees: Yes Part-time employees: Employer s discretion Dependent age maximum Written alongside another carrier? Length of time a company must be in business n-fulltime/fulltime through age 25 regardless of student status. Management carve-out only. n-fulltime/fulltime through age 25 regardless of student status. Yes, one employee with a minimum of 70% of eligible employees in a group plan. 0 days 1-5 eligible: 50% of the preceding calendar quarter or year; 6-50 eligible: at least 6 consecutive weeks prior to the effective date. 12 months 100+ eligible: no more than 20% Yes Yes Retirees 2-99 eligible: no more than 10% Carrier write domestic household staff Length of time signatures are valid restrictions 60 days prior to the requested effective date. n-fulltime/fulltime through age 25 regardless of student status. 30 days prior to the requested effective date. E-Signatures ER- EE-Yes ER- EE-Yes What are the requirements to cover part-time employees? Employer definition, example 20 to 30 hours hours: nothing is required To add part-time employees on the plan they may do so only at anniversary. t subject to underwriting. t eligible Is workers compensation required on employees? t required Yes, however; 24-hour coverage is not offered to owners. If the medical expense is workrelated, Kaiser would not consider it for benefits. t required P a g e 18

20 UNDERWRITING New hire waiting periods 1st of the month following date of hire 12 months (4) 1st of month following date of hire 12 months (4) First of the month following: - DOH or 0 days - 1 month or 30 days - 2 months or 60 days (4) At initial enrollment can the waiting period be waived for new hires? Dependent age maximum Written alongside another carrier? Length of time a they must be in business Retirees Full-time employees: Yes Part-time employees: t eligible Full-time employees: Yes Full-time employees: Yes Part-time employees: t eligible Part-time employees: t eligible n-fulltime/fulltime through age n-fulltime/fulltime through n-fulltime/fulltime through 25 regardless of student status. age 25 regardless of student age 25 regardless of student status. status. Yes, as long as plans are opposite types. 75% of eligible EEs between both ER plans and the greater of 25% or 5 lives enrolled in the Principal dental. Rates subject to a load. 0 days 12 months 50% of the preceding calendar quarter or calendar year. Yes, Employer s choice. more than 15% of the group may be retirees. Yes, Employer s choice. more than 15% of the group may be retirees. Carrier write domestic household staff Length of time signatures are valid 30 days prior to the requested effective date. 30 days prior to the requested effective date. 60 days prior to the requested effective date. E-Signatures Case-by-case basis What are the t eligible Part-time employees are not hours for 50% of the Prior requirements to cover eligible. Calendar Quarter. Group must part-time employees? stipulate at time of enrollment. To add part time EEs on the plan they may do so at anniversary only and is subject to UW approval. SBS: Part time EEs are not eligible. Is workers compensation required on employees? t required t required Stand-alone: With medical: Yes, it is required. P a g e 19

21 UNDERWRITING Percentage of related employees allowed maximum maximum Husband/wife only groups are not eligible. maximum Husband/wife only groups are not eligible when written with BS medical. Can a husband and wife who work for the same company enroll together or separate? Who is considered an eligible dependent Within the U.S., available plans to employees and dependents who live outside of CA? Available plans to dependents that reside or attend school outside of CA and the employee lives in CA Available plans to dependents that reside or attend school outside of CA and the employee lives in CA & is on an HMO plan May enroll separately or together as one being the dependent under the other. If enrolling separate or enrolling one as a dependent no declination is required. (N/A on Husband/Wife only groups). Spouse/qualifying domestic partner, children up to 26. EE s biological, adopted, & stepchildren. Grandchildren only if court ordered. May enroll separately or together as one being the dependent under the other. If enrolling separate or enrolling one as a dependent no declination is required. Spouse/qualifying domestic partner, children up to the limiting age of the plan. Included are the employee s biological children, stepchildren, domestic partner s natural children, legally adopted children, & children for whom the employee, spouse or domestic partner has been appointed permanent legal guardian by a final court order. All plan types may be available. All PPO plan types are available PPO & INO See footnote (2) All plan types may be available. See footnote (2) Dependent may be eligible for the HMO plan (based on state rules and network availability). All PPO plan types are available. Dependent would not have coverage. May enroll separately or together as one being the dependent under the other. If enrolling separate, no declination required. When enrolling one as a dependent no declination is required except in instances of standalone dental at 1 employee enrolled total for the group. Spouse, qualifying domestic partner, children under the age of 26. Included are the employee s biological children, stepchild, child placed for adoption, or any other child for whom the employee or domestic partner has been appointed as a non-temporary legal guardian by a court. PPO & INO plans available, employee must be enrolled in a PPO or INO dental option. P a g e 20

22 UNDERWRITING Percentage of related employees allowed maximum; however, in the 2-4 segment, group cannot be comprised of family members only maximum maximum Can a husband and wife who work for the same company enroll together or separate? Who is considered an eligible dependent Within the U.S., available plans to employees and dependents who live outside of CA? Available plans to dependents that reside or attend school outside of CA and the employee lives in CA Available plans to dependents that reside or attend school outside of CA and the employee lives in CA & is on an HMO plan P a g e :Group cannot be comprised entirely of employees who could enroll as a dependent of one employee 5+: May enroll separately or as one being the dependent under the other If enrolling separate no declination is required by each. If enrolling one as a dependent a declination is required from the member enrolling as a dependent. Spouse/qualifying domestic partner, children up to the limiting age of the plan. Children include employee s biological children, stepchildren, legally adopted children, children placed for adoption, children of a domestic partner and foster children. PPO Plans PPO Plans The DeltaCare USA (DMO) plans are not available to dependents out of state. Must enroll separately Guardian will write a 2 life related employee group. Dental rates are loaded 15% for these types of groups. Spouse/domestic partner, children up to the limiting age of the plan including adopted children and step-children, if they depend on the employee for support and maintenance. All dental plans are available provided the state has approved the specific plan design. Those members in states that have not approved the plan sold to CA members will be offered an appropriate plan for their state. All dental plans are available provided the state has approved the specific plan design. Those members in states that have not approved the plan sold to CA members will be offered an appropriate plan for their state The dependent would not be eligible for coverage. May enroll separately or together as one being the dependent under the other (unless it is a 2 life group then they must enroll separately). If enrolling separate or enrolling one as a dependent no declination is required. Related employees enrolling together will count as 1 enrolling. Spouse/qualifying domestic partner, children up to the limiting age of the plan. Children include employee s biological children, stepchildren, legally adopted children, domestic partner s natural child, children for whom the employee, spouse or domestic partner has been court-appointed legal guardian. PPO Dental only PPO Dental only Dependent would not have coverage.

23 UNDERWRITING Percentage of related employees allowed restriction maximum more than 75% of the group can be related with less than 10 employees. Husband & wife only groups and are not eligible Can a husband and wife who work for the same company enroll together or separate? Who is considered an eligible dependent Within the U.S., available plans to employees and dependents who live outside of CA? Available plans to dependents that reside or attend school outside of CA and the employee lives in CA Available plans to dependents that reside or attend school outside of CA and the employee lives in CA & is on an HMO plan May enroll separate or as one being the dependent under the other. If enrolling separate a declination is required by each. If enrolling as a dependent a declination is required from the member enrolling. Dependent: A covered employee s: 1. Lawful spouse or domestic partner; and 2. Natural blood related child, stepchild, a child placed for adoption, existing child of a domestic partner, or legally adopted child whose age is less than the limiting age. PPO/Traditional plans are offered in most states. States which Humana does not have a license in will allow no more than 10% of the EEs covered in that state. Example: Humana limits covered EE to 10% in NJ, NY or WA. PPO, Traditional Dental or DHMO where available DHMO Plan Only May enroll separately or together as one being the dependent under the other. If enrolling separate or enrolling one as a dependent no declination is required. Spouse/qualifying domestic partner, children up to the limiting age of the plan. Children include the EE s biological and adopted, stepchildren, children for whom the employee, spouse or domestic partner have been appointed permanent legal guardian by a final court order. Grandchildren can be covered as follows: (1) The grandchild s parent is enrolled, or (2) without coverage for the grandchild s parent, if the eligible employee is the court appointed guardian. Since the employer can only offer one dental plan, it would be suggested to offer a PPO or Indemnity plan. Only the PPO or Indemnity plan offered by the employer. If the HMO dental is offered then there is no plan available to the dependent. The dependent will have emergency only care. Enroll separately or together as one being the dependent under the other. If enrolling separate or one as a dependent, no declination is required. Husband & wife only groups are not eligible. Spouse, qualifying domestic partner, unmarried children up to the limiting age of the plan. Children include the employee s biological children, stepchildren, legally adopted children, domestic partner s natural child, foster children, grandchildren, or other children for whom the employee is required to provide dental care pursuant to a court or administrative order. PPO plans are available. DHMO plans are available in CA, FL, NJ, NY & TX. Rate card plan options are for CA companies only. Please refer to UW guidelines for OOS employee availability. PPO plans avail. DHMO plans are avail in CA, FL, NJ, NY & TX. Rate card plan options are for CA companies only. Refer to UW guidelines for OOS EE availability. DHMO plans are available in CA, FL, NJ, NY & TX. Rate card plan options 2-50 enrolled are for CA companies and CA employees only. P a g e 22

24 UNDERWRITING Percentage of related employees allowed more than 75% of the group can be related on groups with less than 10 employees. Husband & wife only groups are not eligible. maximum maximum Can a husband and wife who work for the same company enroll together or separate? Who is considered an eligible dependent Within the U.S., available plans to employees and dependents who live outside of CA? Available plans to dependents that reside or attend school outside of CA and the employee lives in CA May enroll separately or together as one being the dependent under the other. If enrolling separate or one as a dependent no declination is required. Husband and wife only groups are not eligible. Spouse, qualifying domestic partner, unmarried children up to the limiting age of the plan. Children include the employee s biological children, stepchildren, legally adopted children, domestic partner s natural child, foster children, grandchildren, or other children for whom the employee is required to provide dental care pursuant to a court or administrative order. PPO plans available. DHMO plans are available in CA. Rate card plan options are for CA companies only. Refer to UW guidelines for OOS EE availability. Same guidelines as above May enroll separately or together as one being the dependent under the other. If enrolling separate or enrolling one as a dependent no declination is required. Spouse/ qualifying domestic partner, children up to the limiting age of the plan. Children include the employee s biological children, stepchildren, legally adopted children, domestic partner s natural child and foster children. PPO and Indemnity plans are available. PPO and Indemnity plans are available. May enroll separately or as one being the dependent under the other (unless it is a 2 life group they must enroll separately). If enrolling separate or one as a dependent, no declination is required. Spouse/ qualifying DP, children up to the limiting age of the plan. Children include the EE s biological and adopted children, stepchildren, DP s natural child, child for whom the EE, spouse/dp has been appointed permanent legal guardian by a court order, children for whom the EE, spouse/dp is required to provide health insurance pursuant to a qualified medical child support order PPO or Indemnity is available in all 50 states. DHMO is not available out of state. PPO or Indemnity is available in all 50 states. DHMO is not available out of state. Available plans to dependents that reside or attend school outside of CA and the EE lives in CA & is on an HMO plan DHMO plans are available in CA, (DHMO pending in NV, AZ & UT) Rate card plan options are for CA companies and CA employees only. N/A Principal does not have a DHMO program. coverage unless the employee selects a PPO or Indemnity option. DHMO: coverage P a g e 23

25 UNDERWRITING Is a DE-9C and/or payroll roster required for enrollment? Aetna Employer Dental Certification form may be completed in lieu of DE-9C Legacy & Prime & Complete: With medical: yes Without medical: yes With medical: yes Without medical: no Can a group enroll using list billing enrollment? Legacy: Prime & Complete: Yes, you must use Anthem s Enrollment Spreadsheet RATING / RATES Rate guarantee 12 months Legacy: 12 months Prime & Complete: 12 & 24 month options Carrier rule for reapplying due to requested cancellation or non-payment of dues Employee rates based on home or work zip code Out-of-state employee rates are based on home or work zip code Are SIC codes used for rating purposes? What rating tiers are used? Must wait 12 months. If cancelled for non-pay, groups must pay any outstanding premiums before a policy is issued. Aetna does not charge any reinstatement fee. Must wait 12 months. Earlier reviews by carrier underwriting available on a case by case basis Anthem charges a $50 reinstatement fee if cancelled for non-payment of dues 12 months Work zip code Work zip code Work zip code Work zip code Work zip code Work zip code Yes, SIC restriction only applies to standalone policies All plans 4 tier (Single, Couple, EE &Children, Family) Legacy: Prime & Complete: Yes Legacy plans: 5 tier (Employee, EE+Spouse, EE+Child, EE+Children, Family) Prime & Complete: 4 tier (Employee, EE+Spouse, EE+Child(ren), Family) Within 2 months from cancellation: Group will need to pay any outstanding premium, provide a letter on company letterhead, and work with Account Management for reinstatement process After 2 months from cancellation: Group will need to reapply as a new group Blue Shield does not charge a reinstatement fee Age-rated Age 0-25 (3 member max)* or Age 26+ *The primary subscriber and spouse/domestic partner do not count toward the 3 member max. P a g e 24