California Underwriting & Administrative Guidelines for Assurant Supplemental Coverage & Major Medical Insurance for Individuals and Families

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1 California Underwriting & Administrative Guidelines for Assurant Supplemental Coverage & Major Medical Insurance for Individuals and Families These guidelines are in place in order to comply with insurance legislation in California and include the eligibility and underwriting practices and procedures of Assurant Health. For state specific product information, refer to your product brochures and State Variations (if applicable). New Business Enrollment Access EASE through the Assurant Health Sales website at to apply for Assurant Supplemental Coverage (ASC). If not using EASE for submission, application packets, enrollment and ancillary forms can be found on Select the Find A Form option on the grey toolbar. Assurant Supplemental Coverage Select Supplemental category Major Medical Insurance for Individuals and Families (Portfolio) Select Individual Medical category* *Effective February 19, 2011, electronic/ease submissions will be turned off and only the most recent version of the paper enrollment form listed below will be accepted. Distribution Channel Enrollment Form Paper Time Insurance Company CA (Rev. 8/2010) John Alden JI 2300 CA (Rev. 8/2010) California Agent Attestation for Individual Medical: Agents must attest that the application is complete and accurate and that he/she has explained the risk of providing inaccurate information to the applicant. The agent attestation text has been added to Enrollment Forms listed above. Assurant Health 501 West Michigan P. O. Box 624 Milwaukee, WI Assurant Health is the brand name for products underwritten and issued by Time Insurance Company and John Alden Life Insurance Company. Form CA (Rev. 02/2013)

2 Important Information for You and Your Client: Assurant Health relies on your clientʹs answers to the application questions, and their answers have a significant impact on their eligibility for insurance. Your client should respond to the application in a thorough and complete fashion because this information is relied on by Assurant Health. Information that is not completely and accurately disclosed may result in the rescission of coverage. If your client provides you with any health history information, you are required to fully disclose that information with the application. Do not make a determination about the significance of the information. Assurant Health underwriters will determine what information is relevant during the underwriting process. Assurant Health does not automatically order medical records for every case. The client should disclose their full and complete medical information and not assume that medical records will be ordered. Obtaining accurate child height and weight information is very important. The application process will be delayed until the information is received. Obtaining all the required authorizations at the time of application submission is critical to begin the underwriting process. Clients should contact Assurant Health if they think of any additional information that should be disclosed. To assist you and your client with completing the application, an Agent Checklist and Applicant Checklist are available on the Assurant Health Sales Agent Information Site at: Please use the Agent Checklist and provide the Applicant Checklist to your client every time you complete the application process to ensure we obtain all the information needed to process the application

3 Language Assistance Program (LAP) Notice: Pursuant to California law, the following notice has been added to California specific vital documents including, Enrollment forms, Underwriting Authorizations and the Employer Sponsored Business Questionnaire as well as certificates of coverage. IMPORTANT: You can get an interpreter at no cost to talk to your doctor or health insurance company. To get an interpreter or to ask about written information in Spanish, first call your insurance company s phone number at Someone who speaks Spanish can help you. If you need more help, call the Department of Insurance Hotline at IMPORTANTE: Puede obtener la ayuda de un intérprete sin costo alguno para hablar con su médico o con su compañía de seguros. Para obtener la ayuda de un interprete o preguntar sobre información escrita en español, primero llame al número de teléfono de su compañía de seguros al: Alguien que habla español puede ayudarle. Si necesita ayuda adicional, llame a la línea directa del Departamento de seguros al (Spanish) Existing Business Change Requests Please use the packet or application listed below for inforce change requests. Packets and applications are available on Find A Form. Inforce Assurant Supplemental Coverage: ASC Product Dental Accident Packet Form Number CA PKT CA PKT Inforce Individual Medical Plans: Note: If applying for Internal Replacement which is a request to replace an existing active IM plan without a gap in coverage or a change in current benefits of an existing active IM plan refer to the Request for a Change in Benefits guidelines later in this document. Distribution Channel Enrollment Form Paper Time Insurance Company CA (Rev. 8/2010) John Alden JI 2300 CA (Rev. 8/2010) - 3 -

4 Inforce Health Access Plan B or C Enrollment Form: Distribution Channel Time Insurance Company John Alden Inforce Underwriting Change Request Packet for Health Access Plan B or C CA PKT JI 2801 CA PKT Health Replacement Forms: California may have more than one Health Replacement Form. The form that is required varies based on the product applied for and the circumstances of the coverage being replaced. Assurant Supplemental Coverage (ASC) Replacement Forms: Our ASC plans may need replacement forms if an applicant is replacing certain types of prior coverage. The replacement form and the instruction for its use can be found within the application packet. The packet is available under the Supplemental option on Find A Form. Portfolio Health Replacement Form: Not applicable in California. Eligibility and Underwriting Actions Assurant Supplemental Coverage (ASC): Eligibility: In order to be eligible for an ASC plan, an applicant must be a resident of California. Underwriting Actions ASC: Refer to the Agent Guide for Supplemental Coverage, Form (available on Find A Form under the Supplemental Category) for product specific eligibility requirements and underwriting action(s). Major Medical Insurance for Individuals and Families (Portfolio): Eligibility: In order to be eligible for an individual medical plan, an applicant must be a resident of California, must be a member of the Health Advocates Alliance Association and must not have the coverage sponsored by an employer. If an employer is sponsoring coverage, then they are ineligible for this plan. All individuals enrolling for coverage will be medically underwritten

5 Child Only Applications for Portfolio Plans: Applications for primary applicants under the age of 19 will only be accepted if received during the following: Open Enrollment Period: o During the childʹs birth month. Qualifying Events: o When there has been a loss of coverage due to one of the following: Change in employment or change in employerʹs contribution rate for health care. Death. Divorce/separation. Loss of government health care. o When the child is applying outside of an open enrollment period due to one of the following: Adoption or birth. Child becomes a resident of California during a month that is not the childʹs birth month. Child is born as a resident of California but did not enroll in the month of their birth. Child is mandated to be covered pursuant to a valid state or federal court order. o o Applications must be received within 63 days of a qualifying event. The following effective date rules apply for child only applications: Applications received before the 15th of the month will be dated the 1st of the following month. Applications received on or after the 15th of the month will be dated the 1st of the month after the following month

6 Underwriting Actions (Portfolio): Underwriting actions may include the following and coverage may be issued with: preferred non tobacco or preferred tobacco rates. standard non tobacco or standard tobacco rates. a special class premium. or Coverage may be declined based on medical history* Special exception riders will not be applied. *Not applicable to persons under the age of 19 (with effective dates on or after 9/23/2010). Preferred Rating Questionnaire (Portfolio) When submitting a paper Enrollment Form and applying for preferred rates, then the Preferred Rating Questionnaire Form listed below must be completed and submitted. Distribution Channel Preferred Rating Questionnaire Packet Number Time Insurance Company John Alden JI 1614 Employer Sponsorship (Portfolio) We define employer sponsorship as meeting any one of the following criteria: Any portion of the premium or benefits is paid by or on behalf of the small employer. An eligible employee or dependent is reimbursed, whether through wage adjustments or otherwise, by or on behalf of a small employer for any portion of the premium. The health benefit plan is treated by the employer or any of the eligible employees as part of a plan or program for the purposes of Internal Revenue Code sections 106, 125, or 162. Employer Sponsored Business Questionnaire Form: This form is incorporated into the paper enrollment form. It is available as a stand alone employer sponsorship verification tool in the rare event that a separate form is needed

7 Distribution Channel Time Insurance Company John Alden Employer Sponsored Business Questionnaire Form Number CA JI 1589 CA Worksite/List Billing Major Medical Insurance for Individuals and Families (Portfolio): A business payor is acceptable when the application has a billing mode of List Bill. Please refer to the Agent Administrative Guide for List Bill for additional details. Distribution Channel Agent Administrative Guide for List Bill Time Insurance Company John Alden JI 1635 Assurant Supplemental Coverage (ASC): A business payor is acceptable when the application has a billing mode of Worksite Billing. Please refer to the Worksite Billing Administrative Guide, Form for additional details. Preexisting Condition Limitation Refer to the appropriate product brochures and specimen contracts for additional information regarding pre existing condition definitions and limitations. Assurant Supplemental Coverage (ASC): Assurant Supplemental Coverage (ASC) products do not have Pre Existing Condition Limitations for any insured. Major Medical Insurance for Individuals and Families (Portfolio) Insureds over the age of 18 may be subject to a pre existing condition limitation

8 Continuity of Coverage/Credit for Previous Coverage (may be available for Major Medical Insurance plans only): The pre existing condition limitation will be credited with the time an individual was previously covered under creditable coverage, provided there is no more than a 63 day gap in coverage between the termination date of their prior coverage and the effective date of the Assurant Health plan. In order to provide continuity, we require that proof of prior qualifying coverage be submitted. Proof of prior coverage includes one or more of the following: A copy of the declarations, A summary of benefits or schedule page, A letter from the prior carrier indicating dates of coverage, type of coverage and names of those insured. If proof of prior qualifying coverage is provided at a later date, we will provide continuity of coverage. Creditable Coverage: Creditable coverage is defined as coverage under an individual or group policy, contract or program that is written or administered by a disability insurance company, health care service plan, fraternal benefit society, self insured employer plan, or any other entity that provides medical, hospital and surgical coverage not designed to supplement other private or governmental plans, Medicare, Medicaid, a public health plan, TRICARE (formerly CHAMPUS), a medical care program of the Indian Health Service or tribal organization, a state risk pool, a health plan offered to federal employees, a public health plan or a health plan offered under the Peace Corps Act. Existing Customers with Assurant Health Individual Medical Coverage: Request for a Change in Benefits: The first thing to consider when determining how to best serve your client is to determine if the client s benefits are increasing, decreasing or staying the same. This will determine what course of action to take and the forms required. Insureds who wish to increase their benefits or replace/transfer coverage to a plan with greater benefits are subject to medical underwriting. Insureds who wish to reduce their benefits on their existing plan or replace/transfer coverage to another individual policy with equal or lesser benefits may do so without medical underwriting. The various changes to existing plans or replacing their existing plan (other than Health Access Plan B or C) with a new one may require different forms to be filled out. Here is a quick reference to determine what steps to follow and paper work to complete, based on the type of benefit change requested

9 Type of Request Paper Work Needed for Changes to Existing Active Assurant Health IM plan Misc. Add a new dependent Request removal of Special Class Premium or SER Changing Risk Class Smoker to Non Smoker or Standard to Preferred Request to Reinstate Coverage Paper Work Needed for Internal Replacements (Transfers) with Medical History Completed with quote with Medical History Completed with quote JALIC: JI 2300 CA(Rev. 8/2010)*with Medical History Completed with quote N/A Decreasing or Maintaining Benefit Levels Increasing Individual/Family Total Out of Pocket (i.e. deductible & co ins increase) Adding: Dental Insurance or Dental Vision Discount Plan, Suite Solutions Replacing/Transferring existing coverage to a new policy with equal or lesser benefits. Refer to Plan Ranking below to determine equal or lesser benefits. Contact Policyholder Services at Contact Policyholder Services at Contact Policyholder Services at without Medical History Completed with quote without Medical History Completed with quote without Medical History Completed with quote Increasing Benefit Levels Decreasing Individual/Family

10 Total Out of Pocket (i.e. deductible & co ins increase) Replacing/Transferring existing coverage to a new policy with richer benefits. Refer to Plan Ranking below to determine if richer benefits. and quote with Medical History Completed and quote N/A with Medical History Completed and quote *Note: These requests cannot be submitted electronically. They should be completed manually and faxed to The various changes for existing Health Access Plan B or C may require different forms to be filled out. Here is a quick reference to determine what steps to follow and paper work to complete, based on the type of change requested. Type of Request Misc. Add a new dependent Paper Work Needed for Changes to Existing Active Assurant Health IM plan TIC: CA* JALIC: JI 2800 CA* Request to Reinstate Coverage Decreasing or Maintaining Benefit Levels Adding: Dental Insurance or Dental Vision Discount Plan, Suite Solutions TIC: CA* JALIC: JI 2800 CA* Contact Policyholder Services at Increasing Benefit Levels Replacing/Transferring existing coverage to a new policy with richer benefits. N/A Refer to Plan Ranking below to determine if richer benefits

11 *Note: These requests cannot be submitted electronically. They should be completed manually and faxed to If you are making multiple request types (i.e. transferring to a plan with reduced benefits AND adding a new dependent) and one of the requests indicated that medical information is needed, then the entire request is subject to medical underwriting and the medical information should be included in your submission. Plan Ranking: 1. Preferred 2000 Traditional 2. MaxPlan/Elite & Preferred 2000 MDPPO 3. OneDeductible/HSA/ Traditional 4. OneDeductible/HSA/ PPO 5. PPO Xtra/PPO Saver 6. CoreMed & Value/Pac Plan 7. RightStart 8. RightStart HSA/SaveRight HSA 9. HIPAA 10. Health Access Plan C 11. Health Access Plan B These plans are ranked in descending benefit level order. Using the Ranking: First: Identify the plan type that your client is currently enrolled in Second: Identify the plan that your client wishes to move to. Third: Use the Type of Request grid above to determine the correct forms to submit. If your client is moving up, they are increasing their benefits and underwriting would be required. If a client is moving down or staying at the same level they are either reducing their benefits or remaining equal to their current plan and no medical information would be necessary. If you would like additional information regarding a benefit or plan change for your existing customers, please contact the Customer Care Center (CCC) at

12 Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act (HIPAA) set minimum standards for the availability of individual medical plans on a guaranteed issue basis for Eligible Individuals. Eligible Individuals will be guaranteed issue coverage with no exclusion riders or pre existing condition provisions. Special class premiums may be applied based on medical history. The following sections contain information regarding eligibility criteria, underwriting requirements to obtain a HIPAA quote and plan/benefit basics. Eligible Individual: An eligible individual is defined as an individual: For whom, as of the date the individual seeks coverage, has an aggregate period of creditable coverage* of 18 months or more; Whose most recent creditable coverage* was under an employee welfare benefit plan that provides medical care directly or through insurance, an accountable health plan, a governmental plan or church plan; Who is not eligible for coverage under an employee welfare benefit plan, an accountable health plan, Part A or Part B of Medicare or Medicaid, and does not have other health insurance coverage; Who enrolled for coverage within 63 days after their most recent creditable coverage* terminated; Whose most recent coverage was not terminated due to nonpayment of premiums or fraud; Who has been offered and elected the option of state continuation or COBRA and has exhausted such coverage. *Creditable Coverage: Creditable coverage means coverage provided under any of the following: a group health plan; individual plan, including short term limited duration insurance; church plan; accountable health plan; Medicare; Medicaid; TRICARE; Indian Health Service or a tribal organization; state health benefits high risk pool; health plan offered by the Federal Employees Health Benefits Program; public health plan or plan under the Peace Corps Act or foreign coverage. Underwriting Requirements To receive a HIPAA quote or to apply for coverage under HIPAA, please submit all of the following: A completed paper Enrollment Form The other coverage information section of the Enrollment Form will be utilized to verify eligibility requirements. Please fully complete all fields within this section of the enrollment

13 form. In addition, please provide the prior policy number, prior carrier contact number, reason for coverage termination and if replacing group coverage, prior employer name and contact number. HIPAA plan: HIPAA eligible individuals are eligible for our two most popular plans by premium volume. On and after 4/1/2013, the Time Insurance Company plans are: CoreMed Plan with a $5,000 deductible and 50% coinsurance, with $750 Facility Fee or OneDeductible PPO Plan with a $5,000 deductible and 100% coinsurance On and after 4/1/2013, the John Alden Life Insurance Company plans are: CoreMed Plan with a $15,000 deductible and 100% coinsurance, with $750 Facility Fee or CoreMed Plan with a $5,000 deductible and 50% coinsurance with $750 Facility Fee

Medical Coverage Offered To Individuals and Families

(Rev Medical Coverage Offered To Individuals and Families Ohio Underwriting & Administrative Guidelines These guidelines are in place in order to comply with health insurance legislation in Ohio and include