Delaware underwriting brochure

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Delaware underwriting brochure Plans effective January 1, 2015 For businesses with 1 50 eligible employees DE (9/14)

2 Underwriting guidelines For businesses with 50 or fewer employees This material is for informational purposes only and is not intended to be all inclusive. Other policies and guidelines may apply. Note: State and federal legislation/regulations, including small group reform and HIPAA, and ACA, take precedence over any and all underwriting rules. Exceptions to underwriting rules require approval of the Director of Underwriting, except where Executive Director of Underwriting approval is required. This information is the property of Aetna and its affiliates ( Aetna ), and may only be used or transmitted with respect to Aetna products and procedures, as specifically authorized by Aetna, in writing. All underwriting guidelines are subject to change without notice. Product Availability Medical May be written stand-alone or with ancillary coverage Dental 1 life --Not available 2 eligible employees --Standard plans available with or without medical coverage --Voluntary plans not available --Orthodontic coverage not available 3 to 50 eligible employees --Standard and voluntary plans are available with or without medical coverage --Stand-alone available --Stand-alone dental has ineligible industries Orthodontic coverage --Available with 10 or more eligible employees with a minimum of five enrolled employees for dependent children only Vision Available to groups with two or more eligible employees Single option only (dual option, triple option not available) Vision only is allowed; or can be sold with medical and ancillary products Life and/or disability 1 life not available 2 to 9 eligible employees available if packaged with medical 10 to 50 eligible employees available if packaged with medical or dental 26 to 50 eligible available on a stand-alone basis Health benefits, health/dental insurance and life and disability insurance plans/policies are offered, underwritten and/or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products. 2

3 Product Availability (continued) Packaged life and disability 2 to 50 eligible employees available if packaged with medical. 10 to 50 eligible employees available on a stand-alone basis. A plan sponsor cannot purchase both life and packaged life and disability plans. Product packaging rule is a group level requirement. Employees will be able to individually elect life, disability or packaged life and disability insurance even if they do not elect medical coverage. Disability Groups are ineligible for coverage if 60 percent or more of eligible employees; or 60 percent or more of eligible payroll are for employees over 50 years old. Conversion options are not available. Available to employees only; dependents are not eligible. Employees may elect disability coverage even if they do not elect medical coverage. Case Submission Dates COBRA/Mini-COBRA All new business case submissions must be received by Aetna Underwriting the 25 th of the prior month for 1 st of the month effective dates; 10 th of the month for 15 th of the month effective dates. Any cases received after the cut-off date will be considered on an exception basis only, as approved by the underwriting unit manager. If not approved, the effective date will be moved to the next available effective date, with potential rate impact. Employers with less than 20 employees (full- and part time) are eligible to offer mini-cobra. This law gives covered employees and/or eligible dependents who lose their coverage because of a qualifying event the option to extend their coverage for up to nine months. Employers with more than 20 employees full and part time are eligible to offer COBRA. Companies under common ownership are included in the count. COBRA is not billed separately and is included with the group bill. Mini-COBRA is billed directly to the individual. If the COBRA enrollee does not reside in an Aetna service area, they are only eligible for out-of-network benefits if applicable or urgent/emergency care. Life, disability and/or voluntary dental COBRA/Mini-COBRA enrollees are not eligible. Eligible enrollees are required to be included on the census. Provide the qualifying event, length, start date and end date. Note: COBRA/Mini-COBRA enrollees are not to be included for the purpose of counting employees to determine the size of the group. Once the size of the group has been determined according to the law applicable to the group, COBRA Mini/COBRA enrollees can be included for coverage subject to normal underwriting guidelines. 3

4 Dependent Eligibility Effective Date Electronic Funds Transfer (EFT)/ACH Employee Eligibility Spouse/civil union partner of employee. If both employee and spouse/civil union partner work for the same company, they may enroll together or separately. A domestic partner may be covered as an eligible dependent if the employer elects this designation at contract effective or renewal date. Children: --Medical and dental: --Children are eligible as defined in plan documents in accordance with applicable state and federal laws up to the end of the month turning to age 26, regardless of financial dependency, employment, eligibility of other coverage, student status, marital status, tax dependency or residency. This requirement applies to natural and adopted children, stepchildren, and children subject to legal guardianship. --Children can only be covered under one parent s plan when both parents work for the same company. --When the child works for the same company as the parent, the child may enroll separately as an employee OR as a dependent under the parent s plan. --Grandchildren are eligible if court ordered. A copy of the court order must be submitted. --Incapacitated child attainment of limiting age will not terminate the coverage of the child while the child is and continues to be both incapable of self-sustaining employment by reason of mental retardation or physical handicap and chiefly dependent on the employee or member for support and maintenance. Employees or members must send proof of incapacity and dependency to us within 31 days of the child reaching the limiting age and subsequently as we require it, but not more frequently than annually after the two-year period after the child reaches the limiting age. --Dependent life packaged life insurance 2 to 50 eligible employees and basic life insurance 10 to 50 eligible employees dependent children are eligible from 14 days up to their 19 th birthday or to their 26 th birthday, if in school on a regular basis and dependent solely on the employee for support. --Individuals cannot be covered as an employee and dependent under the same plan. --Dependents must enroll in the same benefit option as the employee. --AD&D and disability dependents are not eligible. --Employee must elect life to purchase dependent life. The effective date must be the 1 st or the 15 th of the month. The effective date requested by the employer must be within 60 days of the submission date. The first month s premium for new business can be processed via an electronic funds transfer/ach. Once the group is issued, customers can pay their monthly premiums online or by calling an automated phone number, , using their checking account and routing number. There is no extra charge for this service. Eligible employees are those employees and active owners who are permanent, work on a full time basis and have a normal work week of 30 hours or more. This includes a sole proprietor, partner of a partnership or an independent contractor (1099 employee), if included as an employee in the health benefits plan of employer. Coverage must be extended to all employees meeting the above conditions, unless they belong to a union class excluded as the result of a collective bargaining arrangement. Employees/individuals not eligible for coverage include part time, temporary, seasonal, substitute or uncompensated employees, employees making less than equivalent minimum wage, volunteers, retirees, inactive owners, shareholders, officers or managing members who are not active, investors or silent partners. Early retiree coverage is not available. 4

5 Employer Contribution Medical Minimum of 50 percent of the employee-only cost. The employer may elect a defined-contribution strategy by defining the amount to contribute, which can be no less than 50 percent of the employee-only cost. For example, a minimum of $150 per employee. Groups that do not meet the contribution requirement are eligible to enroll during open enrollment, November 15 through December 15, for a January 1 effective date. Dental 25 percent of the total cost or 50 percent of the cost of employee-only coverage. If the employer contributes less than the above guideline, or if the coverage is 100 percent paid by the employee coverage is deemed voluntary. Life Groups with 2 to 9 eligible employees 100 percent of the cost of the basic term life plan. Groups with 10 to 50 eligible employees at least 50 percent of the cost of the plan (excluding optional dependent life). Coverage may be denied based on inadequate contributions. Employer Definition Employer Eligibility Small employer means any person, firm, corporation, partnership or association that is actively engaged in business that, on at least 50 percent of its working days during the preceding calendar quarter, employed no more than 50 eligible employees, the majority of whom were employed in Delaware. In determining the number of eligible employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of state taxation, shall be considered one employer. Group applicants that do not meet the above definition of a small employer are not eligible for coverage. Sole proprietor and partners are eligible even if there are no W-2 employees as long as they are full time and provide the necessary documentation. Medical plans can be offered to sole proprietorships, partnerships or corporations. Organizations must not be formed solely for the purpose of obtaining health coverage. Associations, Taft Hartley groups, professional employer organizations (PEO)/employee leasing firms and closed groups (groups that restrict eligibility through criteria other than employment) and groups where no employer/employee relationship exists are not eligible. Dental, life and disability have ineligible industries. The dental ineligible industry list does not apply when dental is sold in combination with medical. 5

6 Excluded Class/ Carve Outs Medical We will allow an employer to consider certain distinct classes of employees as ineligible for health care benefits (management versus non-management, salary versus hourly, union versus non-union). A key provision is that the ineligible class must not be offered any other group coverage through this employer. The class being offered coverage would be subject to our participation requirements. Union employees are included in the total count of eligible employees in determining the case size while other excluded classes are not included. Management carve-outs are not permitted. Groups that do not meet participation guidelines are eligible to enroll during open enrollment, November 15 through December 15, for a January 1 effective date. Dental Union employees, if packaged with medical. Life Union employees, if packaged with medical. Initial Premium The initial premium payment should be the total amount of the first month s premium for all products (medical, dental, vision, life, disability), and may be in the form of a check or electronic funds transfer. Submit a copy of the initial premium check payable to Aetna or complete the ACH/EFT form (Aetna form) and include with the new business group enrollment applications. If a copy of the check is provided, once coverage is approved you will be advised where to mail the initial premium check. If the check is not submitted, coverage will terminate retroactive to the case effective date. If the EFT method is selected, we will withdraw the initial premium from the checking account when the group is approved. This is a one-time authorization for the first month s premium only. The initial premium is not a binder check and does not bind Aetna to provide coverage. If the request for coverage is withdrawn or denied due to business ineligibility, participation and/or contributions not met, the premium payment will not be processed. If the initial premium is returned by the bank for nonsufficient funds, the standard termination process will be followed. If the group is currently with Aetna and adding another product medical, dental, vision, life, disability no premium check is required. 6

7 Late Applicants An employee or dependent enrolling for coverage more than 31 days from the date first eligible or 31 days of the qualifying event is considered a late enrollee. Applicants without a qualifying life event (that is, marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are subject to the late entrant guidelines as noted below. Voluntary cancellation of coverage is NOT a qualifying event unless it is done at open enrollment. For example, if a spouse is covered through his/her employer and voluntarily cancels the coverage, it is not a qualifying event to be added to the other spouse s plan. The spouse who cancelled the coverage must wait until the next open enrollment to be eligible to enroll. However, if each spouse has different open enrollment dates and drops coverage during their annual open enrollment period, we would allow them to be enrolled. Medical Late applicants will be deferred to the next plan anniversary date of the group and may reapply for coverage 30 days before the anniversary date. Dental An employee or dependent may enroll at any time; however, coverage is limited to preventive and diagnostic services for the first 12 months. No coverage for most basic and major services for first 12 months (24 months for orthodontics). Late entrant provision does not apply to enrollees under age five. Life Late applicants will be deferred to the next plan anniversary date of the group and may reapply for coverage 30 days before the anniversary date. The applicant will be required to complete an individual health statement/questionnaire and provide evidence of insurability (EOI). Example Group has $50,000 life with $20,000 guaranteed issue limit Late enrollee enrolling for $50,000 would not automatically get the $20,000 Since the applicant is late, he/she must medically qualify for the entire $50,000 Licensed, Appointed Producers Live/Work Situs Only appropriately licensed agents/producers appointed by Aetna may market, present, sell and be paid commission on the sale of Aetna products. License and appointment requirements vary by state and are based on the contract state of the small employer group being submitted. To become appointed with Aetna go to and click Start working with Aetna. Medical Eligible employees who live or work in PA, NJ, DE, MD, DC, VA, NY and CT (the situs region) will receive the same rates and benefits as the headquarters location. Dental Eligible employees who live or work in PA, NJ, DE, MD, DC, VA, NY and CT (the situs region) will receive the same rates and benefits as the headquarters location. Life Not applicable. 7

8 Medicare (MSP) for CMS Reporting Multi-Option Plans (Medical) Municipalities and Townships Newly Formed Business (in operation less than 3 months) Each year, all carriers must report to CMS (Centers for Medicare & Medicaid Services) the number of Medicare secondary payer (MSP) groups and the number of employees, based on the number of employees provided by the employer. MSP is the term used by Medicare when Medicare is not responsible for paying first. This is generally when the Aetna plan would pay primary to Medicare for active employees and would pay first when there are 20 or more total employees full and part time for 20 or more weeks during this calendar year or prior calendar year. --Include: full time, part time, seasonal, temporary, union, owners, partners, officers --Exclude: self-employed persons, independent contractors (1099), directors, leased employees Groups may offer up five medical plans, provided the five plans have different medical features. A township is generally a small unit that has the status and powers of local government. A municipality is an administrative entity composed of a clearly defined territory and its population, and commonly denotes a city, town or village. A municipality is typically governed by a mayor and city council, or municipal council. Underwriting requirements --Quarterly wage and tax statement (QWTS) --Elected or appointed officials and trustees may be eligible for group coverage based on the charter or legislation. If so, they may not be on the QWTS; rather, they may be paid via W 2. In that case, provide a copy of their prior year W 2. --If elected officials are to be covered, provide a copy of the charter or contract indicating which classes or employees are to be covered, the minimum hours required to work per week to be eligible for coverage, and confirmation that coverage will be offered to all employees meeting the minimum number of required hours and that minimum participation will be maintained. The following documentation must be provided for consideration: Sole proprietor Partnership or limited liability partnership A copy of the business license (not a professional license). A copy of the partnership agreement. Limited liability company Corporation A copy of the articles of organization and the operating agreement to include the signature page(s) of all officers. A copy of the articles of incorporation that includes the signature page(s) of all officers (must be followed up with a copy of the statement of information within 30 days of filing with the state). Each newly formed business must also provide: Proof of employer identification number/federal tax identification number; and QWTS. If not available, when will one be filed; and The most recent two consecutive weeks of payroll records, which includes hours worked, taxes withheld, check number and wages earned; or A letter from the group or a CPA with the following information: 1. A list of all employees, to include owners, partners, officers (full time and part time) 2. Number of hours worked by each employee 3. Weekly salary for each employee 4. Date of hire for each employee 5. Whether payroll records have been established 8

9 Open Enrollment for Groups Not Meeting Standard Participation or Contribution Requirements Out-of-Area within Delaware Groups that do not meet our standard participation or contribution requirements are eligible to enroll during an annual open enrollment period. Groups must be submitted between November 15 and December 15 of each year for a January 1 effective date. Groups that don t meet our standard participation or contribution requirements will be denied coverage outside of this open enrollment period. Medical Out-of-area employees must be enrolled in a PPO plan if available; otherwise, an indemnity plan. Dental Out-of-area employees must be enrolled in a PPO plan if available; otherwise, an indemnity plan. Life Employees are eligible for the same life plan selected by the employer. Out-of-Situs Employees Medical Any active employee who lives and works outside of PA, NJ, DE, MD, DC, VA, NY and CT are considered outside the situs region. Out-of-situs employees can enroll in a Delaware PPO plan (or indemnity plan if PPO network is not available). Louisiana out-of-state employees residing in Louisiana are required to have a separate plan quoted and sold based on Louisiana rates and benefits. These employees are still underwritten as part of the group; however, the plans and rates for the Louisiana members will not be based on where the employer is located. This will require Louisiana employer and employee applications to be completed. Hawaii and Vermont health coverage is not available. North Dakota PPO is not available. Massachusetts employees if the employee/group proceeds with a plan that does not meet Massachusetts credibility, the Massachusetts employee(s) could be subject to fines/penalties associated with Massachusetts credibility. For more information on Massachusetts credibility, please contact your CPA or financial advisor. Dental Any active employee who lives and works outside of PA, NJ, DE, MD, DC, VA, NY and CT are considered outside the situs region. Out-of-situs employees will be offered one of the dental PPO plans. Employees who fall outside a dental PPO network area will default to a comparable indemnity plan. Life Employees are eligible for the same life plan selected by the employer. 9

10 Participation Medical Noncontributory plans (employer pay all) 100 percent of eligible employees excluding valid waivers Contributory plans 1 to 9 eligible employees 100 percent excluding valid waivers 10 to 50 eligible employees 75 percent excluding valid waivers, rounding down Example 20 eligible employees 2 covered under spouse 20 2 = 18 x 75% = 13.5 = 13 (rounded down) must enroll Valid waivers Spousal group coverage Parental group coverage Individual coverage Medicare, Medicaid TRICARE/CHAMPUS/CHAMPVA - military coverage Religious reasons Retiree coverage through a previous employer Group coverage though a second full time job Surviving spouse Association coverage COBRA enrollees (active eligible employee waiving coverage based on current COBRA coverage through prior employer once they waive coverage under our plan they are not eligible to enroll until open enrollment OR they exhaust the entire continuation period). All plans Any eligible employees waiving coverage must complete the waiver section of the employee application. Groups that do not meet participation requirements are eligible to enroll during open enrollment, November 15 through December 15, for a January 1 effective date. 10

11 Participation Dental Noncontributory plans (employer pay all) 100 percent excluding valid waivers with a minimum of two enrolled Contributory plans with medical or standalone (round to the nearest) Standard plans 1 life not available 2 to 3 eligible employees 100 percent excluding valid waivers and a minimum of two enrolled Example 3 eligibles 1 spousal dental 3 minus 1 = 2 x 100% = 2 must enroll 4 to 50 eligible employees 75 percent excluding valid waivers. A minimum of two and 50 percent of total eligible employees must enroll in the dental plan. Voluntary plans 3 to 50 eligible employees 30 percent excluding valid waivers with a minimum of three enrollees If a group does not qualify for a standard plan and has 30 percent or more participation then group qualifies for voluntary Valid waivers Spousal group coverage Parental group coverage TRICARE/CHAMPUS/CHAMPVA - military coverage Retiree coverage through a previous employer Group coverage through a second full time job Surviving spouse Association coverage (for doctors/lawyers covered under an association who want to cover their employees) COBRA enrollees Standard and voluntary Employees may select coverage for eligible dependents under the dental plan, even if they elected single coverage on the medical plan, or vice versa. Coverage can be denied based on inadequate participation. Quoting and Renewal System (QRS) quoting Select contributory or voluntary don t select both or rates will be identical as QRS can only calculate one participation. Select 75 percent participation if not known to get an idea of rates. 11

12 Participation Life 1 life Not available 2 to 9 eligible employees 100 percent participation 10 to 50 eligible employees Noncontributory (employer pay all) 100 percent participation Contributory 75 percent participation Stand-alone life 75 percent participation All plans COBRA and state continues are not eligible Retirees are not eligible Employees may elect life insurance even if they do not elect medical coverage, and the group must meet the required participation percentage If not, then life will be declined for the group Example 9 employees 3 waiving medical 9 must enroll for life Coverage can be denied based on inadequate participation Plan Change Employee Level Medical Employees are not eligible to change plans until the group s open enrollment period, which is upon their annual renewal (except for qualified special enrollment events). Life Employees are not eligible to change plans until the group s open enrollment period, which is upon their annual renewal (except for qualified special enrollment events). Plan Change Group Level Medical Groups may change plans on the anniversary date only. Dental Dental plans must be requested five days before the desired effective date. The future renewal date of the change will be the same as the medical plan anniversary date. Life Packaged life/disability must be requested 30 days before the desired effective date. Non-packaged plans are only available on the plan anniversary date. The future renewal date of the change will be the same as the medical plan anniversary date. Professional Employer Organization (PEO) Groups Covered Under a PEO Prior Aetna Coverage Groups currently with a PEO may be eligible as long as the PEO provides payroll specific for the group and we can determine it is a small group, even though the group may be reported under the PEO tax ID number, the group may be considered subject to underwriting approval. A letter of intent is not needed. Groups that we have terminated for nonpayment must pay all premiums owed before a new plan will be issued. 12

13 Rating Information Replacing Other Group Coverage Signature Dates Spinoff Groups (current Aetna customers leaving an Aetna group only) Standard Industrial Classification (SIC) Codes Tax Documents 1 to 9 ENROLLED Employees AND 10 to 50 ENROLLED Employees With NO Prior Coverage Process illustrative quotes using the quoting tools in Producer World. All quotes are subject to change based on additional information that becomes available in the quoting process and during case submission/installation, including any change in census. If any of the information we receive is determined to be incomplete or incorrect, we reserve the right to adjust rates. Do not cancel any existing coverage until the employer has been notified of approval from the Aetna Underwriting unit. Dental - provide a copy of the benefit summary to receive credit for: --Major and orthodontic coverage for standard 2 to 9 and voluntary 3 to 50 eligible employees; and --Preventive and basic coverage for voluntary plans. The Aetna employer application and all employee applications must be signed and dated before and within 90 days of the requested effective date. All employee applications must be completed by the employee himself/herself. We will consider the group with the following: A letter from the group or broker indicating the group is enrolling as a spinoff. Letter needs to include the name of the group they are spinning off from and the name of the new spinoff group. Ownership documents showing that the spinoff company is a newly formed separate entity. A minimum of two weeks payroll. If the group that is spinning off has been in business longer than two weeks, payroll will be required for the amount of time in business, up to a maximum of six consecutive weeks. Underwriting will use a variety of tools, including Dun & Bradstreet, to verify a group s industry code and classify the business correctly. All industries are eligible for medical coverage. Groups must provide a copy of the most recent quarterly wage and tax statement (QWTS): --Containing the names, salaries, etc., of all employees of the employer group --Newly hired employees should be written in on the QWTS --Terminated or work part time employees should be noted accordingly on the QWTS --Reconciled QWTS should be signed and dated by the employer --If a QWTS is not available, explain why and provide a copy of payroll records --The underwriter may request additional documentation, if necessary. Seasonal industries, such as lawn and garden services, construction, concrete and paving, golf courses, farm laborers, etc., must provide four consecutive quarters of wage and tax reports to verify consistent, continuous employment of eligible employees. Churches must provide Form 941, including a copy of the payroll records with employee names, wages and hours, which must match the totals on Form 941. Sole proprietors, partners and officers not listed on the QWTS are still required to submit tax documents. Sole proprietors, partners or officers of the business who do not appear on the QWTS should submit one of the following identified documents. This list is not all-inclusive. The employer may also provide any additional documentation to establish eligibility. 13

14 Tax Documents 1 to 9 ENROLLED Employees AND 10 to 50 ENROLLED Employees With NO Prior Coverage (continued) Sole Proprietor Franchise Limited liability company (operating as a sole proprietor) Partner Partnership Limited liability partnership Corporate Officer S-Corporation Personal service corporation Corporate Officer C-Corporation Limited liability company (LLC) operating as C-corp IRS Form 1040 along with Schedule C (Form 1040) IRS Form 1040 along with Schedule SE (Form 1040) IRS Form 1040 along with Schedule F (Form 1040) IRS Form 1040 along with Schedule K-1 (Form 1065) Any other documentation the owner would like to provide to help determine eligibility IRS Form 1065 (Schedule K-1) IRS Form 1120 S (Schedule K-1) along with Schedule E (Form 1040) Partnership agreement if established within two years listing eligible partners Any other documentation the owner would like to provide to help determine eligibility IRS Form 1120 S Schedule K-1 along with Schedule E (Form 1040) IRS Form 1120 W (Personal Service Corp) IRS Form 1040 ES (Estimated Tax) (S-Corp) IRS Form 8832 (Entity classification as a corporation) W-2 Form Articles of Incorporation if established within two years listing corporate officers Any other documentation the owner would like to provide to help determine eligibility If the officers/owners are on the quarterly wage and tax statement, no additional documents are needed 1120 (Corporation Income Tax Return) 1120A (Corporation Short-Form Income Tax Return) Articles of Incorporation if established within two years - corporate officers must be listed Any other documentation the owners would like to provide to help determine eligibility Tax Documents 10 to 50 ENROLLED Employees with Prior Coverage Tobacco Rates No documentation is required QWTS or prior carrier bill is not needed. Upon request, the underwriter will contact the broker if a QWTS is necessary. Tobacco rates for medical plans apply to any person age 18 and older (as of the effective date), who has used tobacco products (cigarettes, pipe, cigars, snuff or chewing tobacco) an average of four or more times per week within the past six months. This only applies to enrolling person(s) that meets or exceeds the state-defined legal tobacco age. Tobacco rates do not apply to: --Individuals who are participating in a cessation program; --Religious or ceremonial uses of tobacco (for example, by American Indians and Alaska Natives). 14

15 Two or More Companies Affiliated, Associated or Multiple Companies, Common Ownership Employers who have more than one business with different tax identification numbers (TINs) may be eligible to enroll as one group if the following are met: One owner has controlling interest of all businesses to be included; or The owner files (or is eligible to file) an Affiliations Schedule, IRS Form 851 and a combined tax return for all companies to be included. If they are eligible but choose not to file Form 851, please indicate as such. A copy of the latest filed tax return must be provided; and All businesses filed under one combined tax return must be enrolled as one group. For example, if the employer has three businesses and files all three under one combined tax return, then all three businesses must be enrolled for coverage. If the request is for only two of the three businesses to be enrolled, the group will be considered a carve-out. There are 50 or fewer eligible employees in the combined employer groups. Businesses with equal controlling interest may be considered, if the owners of the company designate an individual to act on behalf of all the groups. Underwriting reserves the right to final underwriting review, and may consider common ownership on a case-by-case basis. Example One owner has controlling interest of all companies to be included: Company 1 Jim owns 75 percent and Jack owns 25 percent Company 2 Jim owns 55 percent and Jack owns 45 percent Both companies can be written as one group since Jim has controlling interest in both Vision Available to groups with two or more eligible employees. No minimum participation or contribution. The employer may only offer one vision plan to all employees. To enroll, submit a list of employees and dependents with vision plan indicated. The list can be sent via , Word doc, Excel, EList. Or, you can mark vision on the employee application. The initial premium can be included with payment for medical, dental or life, or can be separate. Waivers are not needed as participation is not required. 15

16 Waiting Period At initial submission of the group, the benefit waiting period (BWP) may be waived for current employees upon the employer s request. This should be checked on the employer application. The BWP for future employees may be the 1 st or 15 th of the policy month following 0 days, 30 days or 60 days following the employee s date of hire. Date of hire BWP is not available. A change to the BWP may only be made on the plan anniversary date. No retroactive changes will be allowed. One or two BWP may be selected and must be consistently applied within a class of employees as defined by the employer, such as management versus non-management, hourly versus salaried, etc. For new hires, the eligibility date will be the first day of the policy month following the waiting period, not to exceed 60 calendar days. Policy month refers to the contract effective date of the 1 st or 15 th. --If 0 days is selected and the employee is hired on the 1 st of the month, the effective date will be the date of hire. --If the group has a 15 th of the month bill cycle, the new hire will be effective on the 15 th of the month following date of hire. Examples 1 st of the month following the BWP 15 th of the month following the BWP 0 days Date of hire: 4/1 Effective date: 4/1 0 days Date of hire: 4/18 Effective date: 5/1 30 days Date of hire: 4/18 Effective date: 6/1 60 days Date of hire: 4/18 Effective date: 7/1 Date of hire: 4/1 Effective date: 4/15 Date of hire: 4/18 Effective date: 5/15 Date of hire: 4/18 Effective date: 6/15 Date of hire: 4/18 Effective date: 7/15 16

17 Dental Coverage Waiting Period Standard 2 to 9 and voluntary 3 to 50 eligible employees PPO and indemnity plans for major and orthodontic services employees must be an enrolled member of the employer s plan for one year before becoming eligible. Ortho is only available to groups with 10 or more employees. Discount plans do not qualify as previous coverage. Future hires waiting period applies regardless if takeover for voluntary. Virgin group (no prior coverage) the waiting periods apply to employees at case inception as well as any future hires. Takeover/replacement cases (prior coverage) you must provide a copy of the last billing statement and schedule of benefits in order to provide credit. If a group s prior coverage did not lapse more than 90 days, the waiting periods are waived. In order for the waiting period to be waived, the group must have had a dental plan in place that covered major (and orthodontic, if applicable) immediately preceding our takeover of the business. Example Prior major coverage but no orthodontic coverage Aetna plan has coverage for both major and orthodontic The waiting period is waived for major services but not for orthodontic services Standard 10 to 50 eligible employees No waiting period. Creditable Prior Coverage Voluntary plans Plans that cover preventive and basic services will satisfy our requirements for having prior creditable coverage as long as the subscriber was covered for 12 months under a dental plan within the last 90 days that included both preventive and basic coverage. You must provide a copy of the schedule of benefits to receive credit. Preventive only or discount plans do not meet the requirements for having prior creditable coverage. These groups will continue to be written has having no prior coverage. 17

18 Dental Ineligible Industries All industries are eligible if sold with medical. The following industries are not eligible when dental is sold stand-alone or packaged only with life Advertising, Miscellaneous Miscellaneous Repair Amusement, Recreation & Entertainment Miscellaneous Services Associations & Trusts Mobile Home Dealers Auto Dealerships Passenger Transportation Beauty & Barber Shops Photo Studios Direct Mailing, Secretarial Photofinishing Labs Employment Agencies Real Estate Engineering & Mgmt Services Repairs, Cleaning, Personal Services International Affairs Restaurants Jewelry Manufacturing Schools, Libraries, Education Legal Seasonal Employees Medical Groups Security Sys, Armored Cars Medical Groups Service Private Households Miscellaneous Business Services Social Services Museums, Art Galleries Botanical Gardens Miscellaneous Computer Services Watch, Clock & Jewelry Repair Open Enrollment An open enrollment is a period when any employee can elect to join the dental plan without penalty, regardless if they previously declined coverage during the first 31 days of initial eligibility. Standard plans with medical or standalone 2 to 9 eligible employees no open enrollment. 10 to 50 eligible employees employees/dependents who do not enroll when initially eligible are now eligible to enroll during a subsequent open enrollment period without being subject to the late entrant provision. Voluntary plans with medical or standalone 2 to 50 eligible employees no open enrollment. Option Sales Reinstatement (applies to voluntary plans only) Option sales alongside another dental carrier are not allowed. All dental plans must be sold on a full replacement basis. Members once enrolled who previously terminated their coverage by discontinuing their contributions may not re-enroll for a period of 24 months. All coverage rules will apply from the new effective date including, but not limited to, the coverage waiting period. 18

19 Life and disability Actively-at-Work Continuity of Coverage (no loss/no gain) Evidence of Insurability (EOI) Employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full time work one full day. The employee will not lose coverage due to a change in carriers. This protects employees who are not actively at work during a change in insurance carriers. If an employee is not actively at work, we will waive the actively-at-work requirement and provide coverage for a maximum of 12 months from the policy effective date, except no benefits are payable if the prior plan is liable. If the employee has not returned to active work before the end of the 12-month period, conversion must be offered. Evidence of insurability (EOI) means the person must complete an individual health statement and may have to submit to medical evidence via medical records at their expense. EOI is required when one or more of the following conditions exist: 1. Life insurance coverage amounts requested are above the guaranteed issue limit. 2. Late entrant coverage is not requested within 31 days of eligibility for contributory coverage. 3. New coverage is requested during the anniversary period. 4. Coverage is requested outside of the employer s anniversary period due to qualifying life event (that is, marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.). 5. Reinstatement or restoration of coverage is requested. 6. Dependent coverage option was initially refused by employee but requested later. The dependent would be considered a late entrant and subject to EOI, and may be declined for medical reasons. 7. Requesting life or disability at the individual level and is a late enrollee even if enrolling on the case anniversary date. Late enrollees are not eligible for the guaranteed issue limit. Example Group has $50,000 life with $20,000 guaranteed issue limit Late enrollee enrolling for $50,000 would not automatically get the $20,000 Since the applicant is late, he or she must medically qualify for the entire $50,000 Guaranteed Issue Coverage We provide certain amounts of life insurance to all timely entrants without requiring an employee to answer any medical questions. These insurance amounts are called guaranteed issue. Employees wishing to obtain increased insurance amounts will be required to submit evidence of insurability, which means they must complete a medical questionnaire and may be required to provide medical records. On-time enrollees who do not meet the requirements of evidence of insurability will receive the guaranteed issue life amount. Late enrollees must qualify for the entire amount and are not guaranteed any coverage. 19

20 Life and disability Job Classification (Position) Schedules Varying levels of coverage based on job classifications are available for groups with 10 or more lives. Up to three separate classes are allowed (with a minimum requirement of three employees in each class). Items such as probationary periods must be applied consistently within a class of employee. The benefit for the class with the richest benefit must not be greater than five times the benefit of the class with the lowest benefit, even if only two classes are offered. For example, a schedule may be structured as follows: Position/Job Class Basic Term Life Amount Packaged Life & Disability Executives $50,000 High Option Managers, supervisors $20,000 Medium Option All other employees $10,000 Low Option Ineligible Industries Packaged life/disability ineligible industries 2 50 eligible employees Description SIC code(s) Description SIC code(s) Asbestos Products Motion Picture/Amusement & Recreation Automotive Repairs/Services Nonclassifiable Establishments 9999 Doctor s Offices Clinics Primary Metal Industries Explosives, Bombs & Pyrotechnics Real Estate Agents 6531 Fire Arms & Ammunition Security Brokers 6211 Liquor Stores 5921 Service Detective Services 7381 Membership Associations Service Private Household Mining

21 Life and disability Ineligible Industries (continued) Life Simplified plans eligible employees Description SIC code(s) Description SIC code(s) Hunting, Trapping & Game Propagation 971 Fire Arms & Ammunition Mining Metal Trucking & Courier Services, except Air Mining Coal Transportation Water/Air Mining Oil and Gas Detective, Guard & Armored Car Service 7381 Mining Nonmetallic Minerals, Except Fuels Amusement Parks 7996 Manufacturing Logging & Sawmills Memberships Sports and Recreation Clubs 7997 Manufacturing Industrial Inorganic Chemicals Manufacturing Fertilizers/ Pesticides/Explosives Manufacturing Lime/Gypsum/ Stone Products County/Cities/Municipalities Public Order and Safety National Security 9711 Asbestos Products Nonclassified Establishments

22 Life and disability Ineligible Industries (continued) Short-term and long-term disability simplified plans eligible employees Description SIC code(s) Description SIC code(s) Agriculture, Forestry, Fishing Transportation Water/Air Mining Transportation Services General Building Contractors - Residential Sanitary Services Highway & Street Construction 1611 Automotive Dealers & Gasoline Stations Bridge Tunnel & Elevated Highway Liquor Stores 5921 Roofing, Siding, Sheet Metal 1761 Fuel Dealers Concrete Work 1771 Security/Commodity Brokers & Dealers Construction Special Trade Contractors 1791 Real Estate Agents and Managers 6531 Excavation Work 1794 Hotels, Rooming Houses, Camps Wrecking and Demolition Work 1795 Laundry, Cleaning & Garment Services Meat Processing Beauty Shops 7231 Manufacturing Tobacco Products Manufacturing Logging & Sawmills Barber Shops Shoe Repair Shops 7251 Pulp Mills 2611 Misc Personal Services 7299 Paper Mills 2621 Services to Dwellings and Other Buildings Paperboard Mills 2631 Detective, Guard & Armored Car Services Alkalies & Chlorine 2812 Automotive Repair & Services Industrial Gases 2813 Motion Pictures Manufacturing Fertilizers/ Pesticides/Explosives Amusement & Recreation Services

23 Life and disability Ineligible Industries (continued) Petroleum Refining Offices & Clinics of Medical Doctors Manufacturing Asbestos Products Skilled Nursing Facilities 8051 Asbestos Products Child Day Care Services 8351 Primary Metal Industries Membership Organizations Nonferrous Foundries Service Private Households 8811 Fire Arms & Ammunition Services NEC 8999 Transportation Railroad County/Cities/Municipalities Transportation Taxicabs/Buses/ Trucking National Security 9711 US Postal Service 4311 Nonclassifiable Establishments

24 This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health benefits, health/dental insurance and life insurance plans/policies contain exclusions and limitations. Not all health, dental and disability services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Aetna Inc DE (9/14)