FIELD UNDERWRITING GUIDE

Transcription

1 FIELD UNDERWRITING GUIDE Please note: The information in this Guide is not all inclusive. WPS Underwriting reserves the right to revise these guidelines at any time without advance notice. January 2015

2 Table of Contents All Groups 5 Eligible Groups 5 Standard Groups 5 Labor Unions 6 Classing Out Employees 6 Health and Welfare Trust Funds 7 Eligibility Rules 7 Eligible Person(s) Domestic Partners on all Risk Groups Employee(s) 11 Ineligible Person(s) 13 New Hires 13 PPACA Special Enrollment Reasons 14 Late Enrollees 14 Loss of Eligibility 15 Covered Members Regaining Eligibility 15 Military Leave 15 Employee 15 Dependent Child(ren) discharged 16 Leave of Absence due to Military Leave 16 Group Quotes 16 Census Information 16 Effective Date 16 Group Size 2-50 Total Employees 16 Group Size 51+ Total Employees 17 Guidelines for Quoting Groups With Out-of-State Residents 17 Carve-Out Rates 17 All Groups Reporting 18 Paid Claim Information 18 Prognosis Information 20 Deductible/Out of Pocket Crediting 20 Back Billing and Credit Adjustments 21 Clerical Errors All Groups - Group Changes 21 Benefit Changes 21 Customer Network Changes 21 Group Adding Network 22 Acquisition of a Subsidiary or Buy-out (Common Ownership or Affiliation) 22 All Groups - Group Renewal 23 Renewal Premium Rates 23 Change in Group Status 23 Changes to Group Anniversary Date 23 All Groups - Group Policy 23 Terminations Reason for Termination 23 Reinstatement 24 All Group s - Group Coverage Discontinuance and Replacement 24 Military Leave Continuation 24 Liability of Prior and Succeeding 25 Carriers in Group Replacement Situations 25 Groups of 2 to Group Size Definition 25 Benefits 26 Health 26 Group Rate Quotes 51+ Total Employees 26 Internet Quoting 26 Information Needed to Request a Quote 26 Quote Guidelines for Groups with 2-50 Total Employees 27 Age Adjustments 27 Effective Date of Quote 27 January

3 New Group Enrollment 2 to Required Group Enrollment Material 28 Groups Subject to ACA 28 Non-ACA Groups 28 Required Tax Documents for New Group Sales 29 Medically Underwritten 30 Transitional Non-ACA Groups Process for Full Underwriting 30 Effective Dates 30 General Underwriting Issues 31 Participation 31 Probationary Period Insureds Insureds 32 Retiree Coverage 33 Dual Option Underwriting Regulations 33 Group Renewal and Changes 34 Premium Rates & Increase 34 Groups of 51 or More 34 Group Size Definition 34 Group Rate Quotes 35 Effective Date 35 Information Needed to 35 Request a Quote Groups Without Experience 35 Groups With Experience 36 Groups Freedom Essentials 25+ Insureds Freedom Flex 51+ Insureds Groups of 51 or More Total Employees - New Group Enrollment 41 Group Enrollment Material Groups of 51 or More Total Employees - Medically Underwritten 41 Process for Full Underwriting January 2015 Groups of 51 or more Enrolled - General Underwriting Issues 42 Matching/Duplicating Benefits 42 and/or Administration Negotiated Commissions 42 Retiree Segments 43 Multiple Option Underwriting 43 Groups of 51 or more - Medical Open Enrollment 44 Groups of 51 or more - Group Renewal and Changes 44 Changes in Group Census Changes to Group Anniversary Date Dental Group Guidelines 45 Available Plans 45 Small Employer Plans General Guidelines Special Requirements 47 Plans with 2-4 enrolled Plans with 5-49 enrolled Small Employer Plans - New Group Enrollment 48 Small Employer Plans group size Dental Individual Guidelines 49 Individual ACA Guidelines 50 Eligibility Rules 50 Eligibility Loss of Eligibility Enrollment 51 Open Enrollment Periods 51 3

4 Individual Applications 51 Effective Date 52 Changes to Policies 53 Submission Requirements for Special Enrollments 53 Submission Requirements for 54 Limited Enrollment Out of Pocket Crediting 55 Tobacco Rates 56 Individual ACP 57 (Alternative Choice Plan) Eligibility Rules 57 Eligibility Waiting Periods for Pre-existing Conditions Enrollment 58 Individual Applications 58 Effective Date 59 Tobacco Rates 59 Medical Records 59 Consumer Reporting Agencies 60 MIB Ingenix - MedPoint Underwriting Decisions 61 Tele-underwriting Services 61 Height and Weight Charts 61 Female Height and Weight Chart 62 Male Height and Weight Chart 63 Declinable Health Conditions Forms 68 Appendix A 68 (Controlled Group Questionnaire) Appendix B 69 (Common Ownership Confirmation Form) Declaration of Domestic Partnership Form 1099 Form 73 January

5 WPS Underwriting Guide - All Group All Groups Eligible Groups Standard Groups Sole proprietorships, partnerships, limited liability companies and corporations are eligible when the group policy is issued to the employer covering his/her employees. There are three distinct categories of employer groups, including large risk groups, small risk groups and administrative services only (ASO) groups. Large Risk Groups: Employer groups with 51+ total employees (including full-time, part-time, and seasonal) Small Risk Groups: Employer groups with 2-50 total employees (including full-time, parttime, and seasonal) ASO Groups: Self-insured employer groups To determine whether a group is eligible for large or small group coverage, group size must be determined based on number of total employees (including full-time, part-time and seasonal). Organizations of Employers (Controlled Groups, Associations, etc.) With very limited exception (see below), in order for WPS to issue a single group policy to an organization of multiple distinct employers, the organization of distinct employers must attest that it meets the definition of a controlled group. A controlled group is a combination of two or more corporations that are under common control. The controlled group is considered a single employer even though they have different names and different tax ID numbers. There are two common types of controlled groups. (1) Parent-subsidiary and (2) Brother-sister. A parent-subsidiary controlled group consists of one or more chains of corporations. A brother-sister controlled group consists of two or more corporations with the same five or fewer owners (i.e. individuals, trusts or estates). If an employer has a unique Tax ID, it has the option to purchase coverage as a single employer even if it is part of a controlled group. An employer with a unique Tax ID who is a member of a controlled group can choose to offer employee benefits independently or in combination with the other members of the controlled group. Whichever way the employer chooses to go, it has guarantee issue into the market it is a part of given the basis on which it chooses to provide benefits. A collection of employers that does not meet the definition of a controlled group is not eligible for coverage under a large group policy. This is true regardless of what the collection of employers calls itself. Common names for such collections of employers include, but are not January

6 limited to: associations, trusts, multiple employer welfare arrangements (MEWAs), purchasing alliances, purchasing cooperatives, coalitions, collaborative. There are two possible exceptions to this: A collection of employers deemed an employer by the US DOL. This is incredibly rare, and unless the collection of employers can produce documentation from the US DOL, verifying its designation as an employer a policy cannot be issued under this exception. A collection of employers organized as a cooperative under ch.185. Wis. Stat. The collection of employers must, (1) be legally organized and comply with all applicable statutory requirements, and (2) not include any small employer groups. The Wisconsin cooperative statute is pre-empted by Federal law with respect to small employer groups. See Appendix A for the Controlled Group Questionnaire and Appendix B for the Common Ownership Confirmation Form. Both the Questionnaire and the Form must be completed and submitted to Underwriting with any application for coverage under a single group plan for an organization of multiple distinct employers. Labor Unions A group policy may be issued in the name of a union to cover union members, employees and officers. Coverage will be available to union members and eligible management actively engaged in their occupation or on layoff and self-pay, as defined in the constitution, bylaws, trust agreement and/or labor agreement. A copy of a document that defines eligibility must be submitted to WPS along with the quote request. Classing Out Employees WPS will allow classing out of established classes of employees provided (1) classes are established in a non-discriminatory manner and (2) coverage is uniformly available to all similarly situated individuals. Proof of coverage for waiving classes, may be required. ASO groups are prohibited by federal nondiscrimination laws from establishing classes that favor highly compensated employees. The ACA extends the prohibition to fully-insured groups, pending issuance of clarifying regulations. WPS does not apply a nondiscrimination test to employer groups. It is the responsibility of the employer group to determine whether established classes of employees are compliant with federal nondiscrimination laws. January

7 Health and Welfare Trust Funds These groups are usually created as a result of collective bargaining agreements. Health and Welfare Funds are eligible groups when a group policy is issued to trustees of a fund established by one or more employers and/or one or more labor unions to cover employees or members of the union. Coverage will only be available to union members actively engaged in their occupation, as defined in the constitution, bylaws, trust agreement and/or labor agreement and eligible management. A copy of the document that defines eligibility and a description of the method to be used to maintain records and remit premium must be submitted to WPS. All Groups - Eligibility Rules Eligible Employee Eligible Person(s) An employee who has met the eligibility requirements for insurance set forth in the group policy. Employees must work 30 hours per week and must be actively at work for groups with 2-50 enrolled employees and 80 hours or more per month for groups with 51 or more enrolled employees. (The employee is actively at work on: each day of a paid vacation; or a regularly scheduled non-working day, provided that, in either case, he/she was at work on his/her last regular working day prior to such date), unless otherwise specified by a group contract agreement. Spouse The person to whom the customer is legally married to, including status of legal separation. A legal spouse may be of the same or opposite sex. A customer who is responsible for providing health insurance to a former spouse under a court order cannot include any former spouse on his or her insurance as a dependent because he or she is not a legal spouse. However, coverage may be provided separately to a former spouse under Wisconsin and Federal (COBRA) Continuation provisions, if applicable. Child(ren) Natural Children - The plan will provide coverage for a single covered employee s/individual s newborn natural child from the moment of that child s birth and for the next 60 days of that child s life immediately following that child s date of birth. The covered employee/individual must change from single to family coverage to provide coverage for the newborn beyond the first 60 days. To do this, he/she must apply for coverage using our application form and either: (a) pay the required premium within the first 60 days after the birth of his/her natural child; or (b) pay all required past-due premium within one year after the birth of his/her natural child and in addition pay interest of such January

8 premium payments at a rate of 5 1/2% per year. - WPS will provide coverage for a covered employee s/individual s child or step-child, who is less than 26 years of age. - WPS will provide coverage for a covered employee's/individual s child or step-child who is a full-time student and meets all of the following criteria: 1. The child was called to federal duty in the national guard or in a reserve component of the U.S. armed forces while the child was attending, on a full-time basis, an institution of higher education; and 2. The child was under the age of 26 when called to federal active duty; and 3. Within 12 months after returning from federal active duty, the child returned to an institution of higher education on a full-time basis, regardless of age. Adopted Children - Wisconsin Statutes and require coverage for adopted children and children placed for adoption with a customer under the same terms and conditions for other dependent children, with these exceptions: Coverage for an adopted child begins on the date a court makes a final order granting adoption, or on the date the child is placed for adoption with the customer, whichever is earlier. Coverage for a child placed for adoption is required whether or not a final order granting adoption occurs. When the child s adoptive placement with the customer ends, the child s coverage will be terminated. The customer is required to notify WPS that a child has been adopted or placed for adoption, and the insured (customer) must pay any premium or fees necessary to cover the child (if applicable). Application for coverage of adopted children must be submitted within 60 days of the final court order granting adoption, or placement in the home, whichever is earlier. If the customer fails to notify WPS or make payment within 60 days, WPS will treat the adoptive child as any other dependent who seeks coverage at other than the time when they are first eligible. Stepchildren - Eligible if the step-child(ren) resides with the customer or is supported by the customer and/or is the child of the customer s legal spouse, subject to all other dependent child eligibility requirements. Legal Guardianship - Eligible for coverage when legal guardianship of a dependent child is obtained by the customer (includes customer and spouse). Children who are not the natural children of the customer and for whom the customer is not legally responsible are not eligible dependents. Relatives of the customer are not eligible dependents unless legal guardianship is obtained. January

9 Foster Children For small group plans only, foster children are eligible for coverage upon placement in foster care, and for the duration of the placement. For large group plans, foster children are not eligible for dependent coverage. Grandchildren - A child of a customer s covered eligible dependent is eligible for coverage until the covered eligible dependent reaches age 18. Overage Handicapped Children eligible if (1) resides with the (insured) customer (2) is solely dependent on/supported by the insured or the insured s legal spouse and (3) was a covered dependent on the date he/she reached the limiting age for dependent coverage under the policy. Documentation such as Social Security eligibility and recent tax documents showing the handicapped child (ren) are solely dependent on their natural or adopted parent. Domestic Partners on all Risk Groups Domestic partners are only eligible for coverage if the group chooses to include this type of coverage upon initial enrollment. If not chosen upon initial enrollment, this coverage can be added by submitting an Employer s Group Application indicating this change along with all applications for those domestic partners who are eligible. This change will become effective first of month following receipt of change application and will be subject to underwriting requirements (please note: this could result in a change in your rates due to the additional risk). The domestic partner must meet the following definition in order to be eligible for coverage: Domestic partners are defined as two individuals: Who are in a committed relationship of mutual support, caring and commitment with the intention to remain in such a relationship in the immediate future; Who are financially responsible for each other s well-being and debts to third parties; Who are not married or legally separated in marriage, and who have not been a party to an action or proceeding for divorce or annulment within six months of registration, or if one has been married, at least six months have elapsed since the date of the judgment terminating the marriage; Who are not currently registered in another designated partnership, and if one party has been in such a registered relationship, at least six months have lapsed since the effective date of termination of that registered relationship before the registration of the current domestic partnership; Who are each 18 years of age or older and competent to contract; Who are not related by blood closer than would bar marriage in the state of their residence; January

10 Who live together in the same dwelling unit as a single non-profit housekeeping unit and have a relationship that is of a permanent and domestic character; Whose relationship is not temporary, social, political, commercial, or economic in nature; Whose relationship has existed for at least six months; Who are not registered with any other domestic partnership; Who, for at least the six-month period immediately preceding the date of this Declaration, have either: - Obtained a domestic partnership certificate from the city, county or state of residence or from any other city, count or state offering the ability to register a domestic partnership; or - Any three of the following with respect to the domestic partner: -- joint lease, mortgage or deed; -- joint ownership of a vehicle -- joint ownership of a checking account or credit account -- designation of the domestic partner as a beneficiary of the covered employee s will -- designation of the domestic partner as a beneficiary for the covered employee s life insurance or retirement benefits; -- designation of the domestic partner as holding power of attorney for health care; or -- shared household expenses If eligible, the domestic partner form (See Forms in Appendix A) must be completed and submitted along with each Employee Application. Same-Sex Marriage As a result of the U.S. Supreme Court ruling, effective October 6, 2014, each spouse in a same-sex marriage is eligible to enroll the other as a dependent spouse on his/her health insurance plan, subject to the terms of the enrollee s certificate of coverage. Generally, spouses must apply at initial enrollment or within 31 days following the date of marriage, with coverage effective on the date of marriage. A same-sex spouse is not considered as a domestic partner; rather, he/she is considered a dependent spouse. January

11 1099 Employees The following guidelines apply to groups with less than 51 full-time equivalent employees. Groups with more than 50 full-time equivalent employees will determine eligibility of their 1099 employees in accordance with the Affordable Care Act Shared Responsibility requirements. A wage and tax statement must be provided listing the average hours worked for each listed employee. Leased employees and independent contractors are not eligible for coverage unless all of the following criteria are met employees must meet the WPS definition of a full-time employee employees must work year round and exclusively for the group. If offering to one eligible 1099 employee, the group must offer coverage to all eligible 1099 employees. Taxed employee for the purpose of this guideline refers to those employees listed on the State Quarterly wage & tax statement. The group must meet all underwriting requirement on their own, before they can add 1099 employees. Participation will then be measured on all eligible taxed employees and eligible 1099 employees. Employer must contribute the same amount of money toward the 1099 employee s premium as the taxed employees. Employer must be eligible for coverage prior to adding the 1099 employee(s). There must be a minimum of two taxed employees at all times. A minimum of 50% of the insured s must be taxed employees. Employer application must indicate that 1099 employees are eligible for plan at time of enrollment employees must be effective at original enrollment, at open enrollment or special enrollment or they will be considered late entrants. Employer must provide copies of all 1099 statements including individuals not electing coverage. January

12 1099 employees that are eligible and not electing coverage must complete a waiver application employees will not be eligible for ancillary coverage Employees are only eligible for coverage if the group chooses to include this type of coverage upon initial enrollment. If not chosen upon initial enrollment, this coverage can be added by submitting an Employer s Group Application indicating this change along with applications for all 1099 employees who are eligible. This change will become effective first of month following receipt of change application and will be subject to underwriting requirements (please note: this could result in a change in your rates due to the additional risk). If eligible, the 1099 form attached must be completed and submitted along with the enrollment or change application. (See 1099 Form on page 73 ) Groups with more than 50 full-time equivalent employees will determine eligibility of their 1099 employees in accordance with the Affordable Care Act Shared Responsibility requirements. January

13 Ineligible Person(s) Overage Dependents A dependent child or step-child ceases to be eligible the day immediately following the last day of the calendar month in which the dependent child or step-child reaches age 26. New Hires New hires and their dependent(s) are guaranteed coverage if an application is submitted in accordance with the group s new hire enrollment requirements. The effective date is the date eligible shown in accordance with the group s waiting period (the waiting period may not exceed 90 days). If application is made after the group s initial enrollment period as stated above, the new hire/dependent is considered a late enrollee. Any requests to waive all or part of the probationary period for a new hire who is a key employee must be submitted in writing to WPS Underwriting. A key employee is someone in an occupation critical to the specific type of business the employer is engaged in, generally in a management or highly specialized position. For Large group Risk, the request must include the employee s title, salary and completed health questionnaire on the application. This request must be made prior to the individual s requested effective date of coverage. Approval of any requests for such an exception is at the sole discretion of WPS Underwriting. For ASO, nondiscrimination rules prevent acting in favor of highly compensated employees. Therefore, the probationary periods will not be waived. Waivers: When an employee, spouse, or dependent waives the WPS coverage because of other creditable coverage, a waiver must be signed by the eligible employee. This waiver will be secured on behalf of the spouse or dependent that declines coverage under the WPS policy during the initial enrollment period or as a new entrant, or as an underwritten individual. Anyone waiving coverage because of other creditable coverage must complete the applicable section of the Employee Application identifying the type of coverage they currently have. For groups of 51 or more enrollees, the group must maintain in its files proof of waiver for each individual choosing to waive coverage and provide WPS a list of employees waiving coverage. January

14 PPACA Special Enrollment Reasons If you fail to make a positive election during the open enrollment period you will be excluded from purchasing coverage until the next open enrollment in the subsequent year. The only exception to these rules occurs if there is a qualifying life event. Birth The effective date of coverage will be the date of event. The application must be submitted within 60 days following the event, unless within 12 months of birth of the child the insured submits all past due premium plus interest at a rate of 5.5% per year). a. No special documentation needed Adoption The effective date of coverage will be the date of event. (Submission of the application must be within 60 days following the event) a. Submit legal documentation of adoption which includes placement, date, child s name and adoptive parent s name Marriage First day of the following the month in which the application was received by WPS (Submission of application must be within 60 days following the event) a. Submit a copy of applicant s Marriage Certificate Loss of Coverage First Day of the following, the month in which the application was received by WPS (Submission of application must be within 60 days of loss of other coverage) a. Submit Certificate of Creditable Coverage or other proof of involuntary loss of coverage For all other reasons: Permanent Move, Gain US Citizenship If applying between the 1 st and 15 th of the month, the effective date will be the 1 st of the following month. If applying between the 16 th and end of the month, the effective date will be the 1 st of the second following month. Late Enrollees A late enrollee is an eligible employee or dependent who did not request coverage during a group s initial enrollment period, did not apply within 30 days of the end of his/her probationary period or does not qualify for the Special Enrollment Reasons listed above. January

15 All Groups - Loss of Eligibility Coverage for all covered members ends based on language in the policy issued. All Groups - Regaining Eligibility An employee that loses eligibility for group coverage and later regains eligibility may be reissued coverage as long as it is reasonable under the circumstances. A group can require the new hire to meet the plan s eligibility criteria, including a maximum 90-day waiting period. For groups subject to Shared responsibility, if an employee regains eligibility within 26 weeks otherwise 90 days following the end of the month he or she became ineligible, the previously held coverage will be re-issued effective on the first day of the calendar month following the date he or she regains eligible status if application is submitted within 30 days of rehire (unless a particular group has other specific requirements that supersede this). Benefits will not exceed those available if the employee had been continuously insured, except to the extent the employee would, if continuously insured, have been eligible to enroll dependents based on a special enrollment circumstance. For group s subject to Shared responsibility, if an employee s return to eligible status is more than 26 weeks, otherwise 90 days following the date coverage terminates, the employee will be considered a new hire (i.e., he or she will need to meet the probationary period). Benefits will not exceed those available if the employee had been continuously insured (i.e. single coverage at time of ineligibility will be reinstated as single coverage upon return) The following applies if a reservist is discharged from a branch of the Armed Services. Employee Military Leave Under the federal Uniformed Services Employment and Re-employment Rights Act (USERRA), employees and their dependents are entitled to immediate reinstatement of their civilian insurance coverage upon return to employment, as long as the guidelines below are followed 1. For Active Duty of less than 30 days, the employee must return to work on the next regularly scheduled workday after receiving adequate time for travel and rest. 2. For Active Duty of 30 to 180 days, the employee must return to work within 14 days after completion of service. January

16 3. For Active Duty of more than 180 days, the employee must return to work within 90 days after completion of service. Subject to the above guidelines, group coverage would be reinstated on the date the employee returns to work. TRICARE coverage eligibility may continue between the date the Service Member is discharged from Active Duty and the date he/she returns to work; a TRICARE Benefits Counselor should be consulted for details if applicable. Dependent Child(ren) Discharged When a dependent child is discharged from the service, coverage will be reinstated under the group plan, provided he/she meets all other eligibility requirements, including limiting age and full-time student status, if applicable. Leave of Absence due to Military Leave Coverage shall end on the date the covered employee or covered dependent enters into military service, other than for duty of less than 30 days. All Groups - Group Quotes Census Information To avoid rate adjustments at the time of enrollment on either an age-rated or composite basis, the quote must be premised on an accurate census. Census information should include: Single/family participation (not marital status). Dates of birth or age (as of the requested effective date) and gender for all employees. Effective Date Group Size 2-50 Total Employees WPS will follow the on-marketplace requirements for enrollments. The cut-off date will be the 15 th of each month for an effective date beginning the first of the following month. For enrollments received after the 15 th of the month, the effective date will be the first date of the second following month. For example, an enrollment received on January 16 will have an effective date of March 1 st. January

17 Group Size 51+ Total Employees An effective date within a proposal means that, if WPS quotes rates for a group with an October 1st effective date, the proposal becomes invalid after October 1st. Only Underwriting can agree to extend the effective date and/or modify the rates or terms of the contract. Guidelines for Quoting Groups with Out-of-State Residents All groups to be quoted must be based in Wisconsin. Guidelines for groups with 51+ total employees. - A maximum of 75% of the group can be out-of-state residents. Please contact WPS Underwriting regarding any such groups which do not meet this guideline. Only Underwriting may grant an exception to this guideline. No more than 25% of the group can be in any one state outside of Wisconsin. Special rule for Minnesota: For any size group with employees residing in Minnesota, the group may be quoted if fewer than 25 employees are Minnesota residents and the employees who are Minnesota residents represent less than 25% of all covered employees. Please contact Underwriting regarding any groups that do not meet this guideline. For any groups not meeting the above guidelines, please contact WPS Underwriting prior to requesting a quote. Carve Out Rates Small Groups on ACA Metal Tier Plans may not receive carve out rates. Guidelines below apply to Non-ACA Groups Carve Out rates are available to eligible employee(s) and/or the spouse/dependent of an eligible employee who(m) are Medicare eligible for Part A & B and their WPS coverage is secondary to Medicare Part A & B under Medicare rules. The applicant(s) must receive the same benefits as the rest of the group. WPS is secondary to Medicare in the following situations, thus Carve Out rates are available: January

18 Medicare eligible due to age (65 and over) For groups under 20 employees (an employer that employs fewer than 20 persons, including part-time employees, for a minimum of 20 weeks during the current or preceding calendar year) - Active employees. - Continuation contracts. For groups with 100+ employees - Retirees (Classes must be approved by Underwriting). - Continuation contracts. Association, Trust, Union - If the group is part of a multi-employer plan that has at least one group with more than 20 employees, such as a union, sponsored trust, Chamber of Commerce sponsored plan or MEWA but the group has less than 20 employees. The Medicare Intermediary must be notified of this situation. Medicare disabled (under 65) employee(s) and/or dependent(s) Under 100 employees (an employer that has under 100 people actively employed 50 percent or more of the regular business days in the preceding calendar year) End-Stage Renal Disease (ESRD) All Groups - after the first 30 months of Medicare eligibility. All Groups Reporting Paid Claim Information Groups with 2-50 enrolled employees. No paid claim information is available unless Self-funded. Groups with enrolled employees. Aggregate paid claim summary information is available on an annual basis from WPS with the group s renewal rates. January

19 Groups with 100 or more enrolled employees and all Administrative Services Only (ASO) groups have access to WPS Data Dashboard. Reports available online include: - Enrollment reports - Financial summary reports - Provider utilization - Health conditions - High cost claims WPS Data Dashboard provides access to a group s health care information at any time through our secure Web site. WPS will appropriately charge the group for any additional requests for paid claim information. All WPS Data Dashboard reports provided to fully insured groups include only de-identified data. WPS Data Dashboard Reporting Package Report Family Enrollment Report Name Enrollment by Age and Employee Plan Enrollment by Age and Member Type Enrollment by Health Plan and Network Enrollment by Subgroup and Class Form 1095 B-C Report Availability Plan Risk ASO X X X X X X X X X X X X X X X X X X X X X X X Financial Summary Claims Matrix Loss Ratio Paid By Claim Type Paid By Claim Type by Subgroup & Class X X X X X X X X X X X X X X X X Health Conditions High Cost Claims Claims by Dignosis and MDC Claims Strata High Cost Patients X X X X X X X X X X X X X Provider Utilization Top Provider X X X January

20 Prognosis Information Fully insured policies do not have the right to access diagnosis or prognosis information on specific individuals. Therefore, WPS will not give claims runs to any employer that indicates the amount and diagnosis or prognosis on the same run. Deductible/Out of Pocket Crediting New groups to WPS/Arise Credit deductible only Existing groups voluntarily moving to an ACA plan credit deductible only Existing groups moved to an ACA plan Calendar year January anniversary groups no credit Non-January anniversary groups Credit deductible & Coinsurance Plan year No credit (if moved on plan year) Groups switching from WPS to Arise or Arise to WPS credit deductible only Please submit deductible credit reports from prior carrier to: WPS Health Insurance Attn: Claims, Deductible Credit Supervisor PO Box 8190 Madison WI This can also be faxed to the attention of Deductible Credit Supervisor at (608) The deductible credit report should also include employee last name, first name and the specific time frame covered in the report. If the group is unable to obtain a deductible credit report from the prior carrier, WPS will accept an Explanation of Benefits (EOB) from the employee. If employees are submitting EOB s, please make sure they are submitted timely in order to prevent WPS from taking deductibles on their claims. Only deductibles will be credited, WPS does not credit coinsurance. Any exceptions to credit coinsurance would have to be submitted in advance for review and approval by WPS Underwriting Management. January

21 All Groups Back Billing & Credit Adjustments Clerical errors Errors by either the group or by WPS will not invalidate coverage otherwise in force nor continue coverage otherwise terminated. Upon discovery of an error, an equitable adjustment will be made in the premium and/or benefit payment. All Groups - Group Changes Small Transitional groups can make a change on their existing policy or move to an ACA compliant plan upon renewal. All transitional relief benefit changes on current policy should be submitted to Underwriting All small group changes to metal tier plans should be submitted to Member Services Benefit Changes Retroactive benefit changes are not permitted. All benefit changes must be submitted to Member Services for approval and rating before the effective date of the change. In unique situations involving union negotiations or other extenuating circumstances, WPS may allow retroactive benefit changes. WPS will, however, charge an appropriate administrative fee to cover the cost of claims processing, re-billing, etc. Customer Network Changes Employees changing network offered by group. Employees can change to a different network offered by the group if he or she has a change during open enrollment or due to a special enrollment reason. If employee does not meet the requirements to change networks, WPS will notify the group. If employee meets requirements to change networks, but the group doesn t offer the requested network, the group can opt to add a network (described below). January

22 If employee meets requirements to change networks and the group offers the network requested, WPS will change the employee to the new network the first of the month following receipt of the request in the WPS Member Services Department. Group Adding Network To add a network, the group leader should submit these forms to WPS Underwriting for Risk groups only: Employer s Group Application with the appropriate Sections completed. A rate quote prepared by WPS Sales or Underwriting and signed by the group leader. A letter on company letterhead indicating which employees should be transferred to the new network. (For both Risk and ASO) Acquisition of a Subsidiary or Buy-out (Common Ownership or Affiliation) An existing group that acquires new employees because of a subsidiary purchase or buy out may add any eligible employee from the subsidiary or buy out within 31 days of the purchase or buy out. Employee additions due to acquisition or buy-out are subject to the following requirements: A Quote Request Form and an Employer s Group Application must be submitted to WPS Underwriting for pre-approval, along with a census for the new employees, medical statement, applications or claims experience for new subsidiary/segment of employees WPS will credit any calendar year deductibles from the prior carrier. WPS must receive the proper enrollment forms, with appropriate medical questions completed. The Prior Carrier s most recent billing statement If a change in rating size occurs, WPS Underwriting may re-rate the entire group on the effective date for the new segment. This process would not change the group s anniversary date. Otherwise, changes in rating size will be implemented on the group s regular anniversary date. If a new business entity is formed as a result of a buy out or merger, employees covered by WPS under the old entity will not be subject to medical underwriting if applying for eligible WPS group coverage. If adding a subsidiary (common ownership or affiliation), this subsidiary must meet all of the eligibility requirements of a new group on their own in order to be eligible to apply with the existing group January

23 All Groups - Group Renewal Renewal Premium Rates Premium rate guarantees are not allowed on groups with 2 50 employees. Premium rate guarantees on groups with 51+ employees must be approved by WPS Senior Management. Change in Group Status WPS will audit groups prior to the anniversary date to determine whether underwriting standards and participation requirements continue to be met. Groups that are below minimum participation will be terminated upon required written notice. Upon request groups that do not meet minimum participation will be given an additional 60 days to meet such requirements. If, after 60 days, the group has not met minimum Participation the group will be terminated. Changes to Group Anniversary Changes to a group s anniversary date must be pre-approved by WPS Underwriting. Without Underwriting s approval; WPS cannot honor renewal rates for a date other than the group s anniversary date, as such a change may not allow ample time for preparation of necessary information to generate renewal rates. All lines of coverage must have a common anniversary date, unless special circumstances apply. All Groups - Group Policy Terminations Reason for Termination There are two main rules for group coverage discontinuance because of non-payment of premium. If coverage terminates for non-payment of premium, WPS is liable for all claims incurred prior to the end of the grace period. Note: The group is responsible for paying the premium during the grace period. WPS will provide the group with a written notice of discontinuance before terminating January

24 coverage for non-payment of premium. The premium must be submitted for the last month of coverage, including the grace period. Reinstatement A group whose coverage terminated due to non-payment of premium may be reinstated back to the termination date at the discretion of WPS. A group reinstatement for non-payment of premium can only occur once and will be on the terms and conditions determined by WPS. All current and past due premiums must be paid in full. All Groups - Group Coverage Discontinuance and Replacement Military Leave Continuation Standard WPS group policies contain exclusions for coverage of health care services for an illness or injury caused by an atomic or thermonuclear explosion or resulting radiation, or any military action, friendly or hostile. In addition, when a covered employee is called to Active Duty for 30 days or more, most of our standard group policies state he/she and his/her dependents can no longer be covered under the group plan as of the first day of Active Duty. Dependents called for Active Duty for 30 or more days are not covered as of the first day of Active Duty; however, the employee and any other dependents may remain on the group plan. In either situation, the Service Member generally has at least one of the following coverage options: COBRA - If the group is a COBRA-eligible employer, COBRA can be elected. Standard COBRA guidelines apply. Uniformed Services Employment and Re-employment Act (USERRA) Continuation - For any size group, the Service Member can elect continuation of group coverage under USERRA for up to 24 months. If this option is chosen, USERRA states that the maximum premium that can be charged is 2% over the regular premium under the plan, to cover administrative costs. For plans that are subject to COBRA, USERRA continuation runs concurrently with COBRA. TRICARE Coverage - TRICARE is the federal group health program available through the U.S. Department of Defense, offered to Service Members and their dependents. Members January

25 entering active military service for more than 30 days are eligible to enroll in TRICARE. Coverage begins for the Service Member and his/her dependents on the first day of Active Duty. If group coverage is continued under USERRA or COBRA, the group coverage is primary and TRICARE is secondary. Crediting Deductibles Liability of Prior and Succeeding Carriers in Group Replacement Situations The succeeding carrier must give credit for deductibles that were satisfied by the customer while he or she was covered under the prior plan. COBRA, Wisconsin Continuation, Extension of Benefits -- In a replacement situation, the succeeding carrier must insure all customers covered under the previous plan, including those covered under COBRA, Wisconsin continuation or an extension of benefits for as long as they are eligible. WPS Underwriting Guide - Groups of 2 to 50 Groups subject to ACA 2 to 50 Groups - Group Size Definition Insured groups with 2-50 total employees, including full-time, part-time and seasonal, for federal and/or state compliance purposes. Note: (If a husband and wife are the only two eligible employees of a group, and there are no other employees including fulltime and/or part time showing on the wage statement, they cannot apply for two single contracts (or one single and one limited family) for the sole purpose of qualifying as a two-person group.) If the actual initial enrollment differs from the group size quoted by WPS, the group will be placed in the correct group size with possible rate and benefit changes. This rule also applies at renewal. It will be based on a 12-month enrollment average. January

26 2 to 50 Groups - Benefits Groups subject to ACA Group Health Available plans, including benefits, cost-sharing, and restrictions, are set on a calendar year basis. Policies are issued for a 12-month plan year. Employer groups may not be renewed or moved to a different available plan before the expiration of their plan year, except at the option of the employer. Group Rate Quotes Quote Guidelines for Groups with 51+Total Employees Non-ACA Group Exceptions to the following quoting guidelines will be reviewed by WPS Underwriting Management on a case-by-case basis. Groups must make full and complete applications to the WPS Underwriting Department upon enrollment before final assessment of risk will be determined, resulting in approved rates (see section on New Group Enrollments below). Internet Quoting Book-rate quoting capability is available on a limited basis in the Agent s Corner section of our website at Please contact your WPS Agency Manager for further details. If you do not currently have this Internet quoting access, the information indicated below must be submitted to WPS to request a quote. Information Needed to Request a Quote The following information is required to request a quote. (Final rates will only be determined upon submission of full enrollment materials and after review of all information, including health information.) Name of Group and Agent/Broker (if applicable) January

27 Address of Group Indicate which employee works at which location (if applicable) Industry Classification (SIC) of Group Census information should include: Election participation i.e. Single/Family (not marital status) Dates of birth or age and gender for each employee Zip Code Benefit selection if multiple plans Benefit Plan(s) and Network(s) requested Quote Guidelines for Groups with 2-50 Total Employees Groups subject to ACA all per-member age rated; family coverage rated based on total permember rates for employee, dependents age 18+, and up to three children age Transitional Non-ACA groups (issued prior to 1/1/2014) All groups of 2-25 will be age rated and groups of 26+ will be composite rated. ACA & Non-ACA Groups All age-band adjustments will be adjusted at time of renewal. Age Adjustments Subject to ACA Effective Date of Quote For groups with 50 or less total employees, rates will be quoted for effective dates no more than 60 days in advance. Non-ACA Group January

28 For groups with 50+ enrolled employees, rates will be quoted for effective dates no more than 90 days in advance. Group quoting beyond the 90 days requires Underwriting s approval. 2 to 50 Employees - New Group Enrollment Groups subject to ACA Required Group Enrollment Material WPS Employer Application WPS Disclosure Notice with 2-50 total employees Employee Applications (those employees still in their probationary period and employees Who are presently on COBRA/State continuation). Most recent Quarterly Wage and Tax Statement (Please see the Required Tax Documents For New Group Sales section below for further detail.) Copy of the sold quote Copy of Sold Quote Age Rate Matrix Grid Initial Monthly Premium Groups that choose the direct billing option should submit their premium with their enrollment. If they choose ACH we will withdraw the first month s premium from the ACH account. Standard grace period will still apply to the first month s premium. The policy will be terminated if payment is not made in a timely manner. Non-ACA Groups WPS Employer Application Employee Medically Underwritten Applications - with appropriate Health Questions completed for each eligible employee and or dependent(s) enrolling for coverage, and also for those employees still in their probationary period and employees who are presently on COBRA/State continuation. Employee Waiver Applications with Waiver Section completed for all eligible employees January

29 waiving coverage with WPS. Copy of COBRA/State Continuation election forms for any terminated employee that has not elected COBRA/State Continuation, but still appears on the prior carrier billing statement. Most recent billing statement from the group s current carrier (if applicable). Most recent Quarterly Wage and Tax Statement. (Please see the Required Tax Documents for New Group Sales section below for further detail.) Copy of the sold proposal/quote given to the agent, broker, and/or the policyholder. Required Tax Documents for New Group All Businesses of two or more eligible employees must supply the following documentation: Most recent Quarterly Contribution/Wage Report, or if not required to file a Quarterly Contribution/Wage Report, we need all of the items listed under the group s specific business type (see subheadings below). C Corporations Articles of Incorporation Form 1120 Payroll S Corporations Articles of Incorporation Form 1120S Payroll Partnership Partnership Agreement Form 1065 Payroll Sole Proprietorship Business license Form 1040/Schedule C Payroll Church Form 941 Payroll January

30 Limited Liability Company (LLC) LLC agreement and documentation for either a C Corporation or a Partnership (see above), depending on how they file with the state. If the business has been in existence less than one year and not filed a Quarterly Contribution/Wage Report, we will accept Corporation or Partnership papers and payroll. Farmers - If not a corporation or partnership, farmers are required to submit Schedule F, itemization of line 24 and copies of W-2 for all employees. 2 to 50 Groups - Medically Underwritten Transitional Non-ACA Groups (issued prior to 1/1/2014) (2-50 enrolled employees but more than 50 total employees) Applications including the Health Information Questionnaire section are required by WPS for groups between 2-50 enrolled employees electing coverage. WPS will not require that employees and dependent(s) who waive coverage complete the Health Information Questionnaire, unless the employee is listed as covered on the prior carrier s bill and who is now waiving coverage during the application process for WPS. If the employee can provide a copy of an ID card with proof of other existing qualifying coverage, the health questions will not be required. Process for Full Underwriting New small employer groups are initially reviewed by WPS Underwriting. WPS Underwriting reviews the information for completeness of forms, eligibility requirements, and medical history that may impact future claims. WPS Underwriting utilizes industry-wide underwriting manuals and other resources to determine a group s risk, including the Attending Physician Statement (APS) which may be requested for specific information. Teleunderwriting services may be utilized by WPS when underwriting group policies. Applicants should be made aware that they may be contacted by telephone if necessary to obtain additional medical information. 51+ groups Non-ACA Group Effective Dates January