Florida underwriting brochure

Transcription

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

2 Underwriting guidelines 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 ACA, take precedence over any and all underwriting rules. Exceptions to underwriting rules require approval of the Regional Underwriting Director except where Senior Director of Underwriting approval is indicated. 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 Groups may be written standalone or with ancillary coverage Only non-occupational injuries and disease will be covered Dental 2 eligible employees Contributory (nonvoluntary) dental available with medical Voluntary dental not available 3 to 100 eligible employees Contributory (nonvoluntary) and voluntary dental plans are available with or without medical Standalone available. Standalone dental has ineligible Industries Retirees (51 to 100 eligible employees) Contributory (nonvoluntary) plans can comprise no more than 10 percent of the group Voluntary plans not eligible Orthodontic coverage Available with 10 or more eligible employees with a minimum of five enrolled employees for dependent children only for both contributory (nonvoluntary) and voluntary plans Adult and child orthodontic coverage is available for certain plans; see footnotes in the Plan Guide dental plan section for plan availability Vision Single option only (dual option, triple option not available) Vision only is allowed; or can be sold with medical and ancillary products Life and Disability 2 to 9 eligible employees if packaged with medical 10 to 50 eligible employees if packaged with medical or dental 26 to 50 eligible employees on a standalone basis 51 to 100 eligible employees contact your Aetna sales executive Packaged life and disability 2 to 50 eligible employees if packaged with medical 10 to 50 eligible employees on a standalone basis 51 to 100 eligible employees contact your Aetna sales executive Health/dental benefits plans, health/dental insurance plans, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Health Inc., and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products. 2

3 Product Availability (continued) Life and packaged life A plan sponsor cannot purchase both life and packaged life and disability plans. COBRA/State continuation enrollees and retirees are not eligible. Product packaging rule is a group level requirement. Employees will be able to individually elect life, disability or packaged life & disability insurance even if they do not elect medical coverage. 51 to 100 eligible employees contact your Aetna sales executive. Disability 2 to 50 eligible employees groups are ineligible for coverage if 60 percent or more of eligible employees, or 60 percent or more of eligible payroll are 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. 51 to 100 eligible employees contact your Aetna sales executive. Case Submission Dates Census Data Groups with three or fewer enrolled must have all completed paperwork into Aetna Underwriting 45 calendar days before the requested effective date. If not received by this date, the effective date will be moved to the next available effective date. Groups with four or more enrolled must have all completed paperwork into Aetna Underwriting five business days before the requested effective date. If not received by this date, the effective date may be moved to the next available effective date. Any case 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. Member-level census is required and must include first name, last name, date of birth, gender, residence ZIP Codes for all employees and dependents, physical work ZIP code for employees, medical tier and dental tier. The census must also include all waivers and COBRA/Mini-COBRA enrollees employees include the date of birth for each employee, spouse and child 51 to 100 employees The census must be provided in Excel format. Life and disability: additional census information is required. Please contact your Aetna sales executive. Sold groups may the above via EList. Include first and last name, date of birth (for each employee, spouse and child), date of hire, gender, dependent status, residence ZIP code and the physical work location for each enrolling employee, medical tier and dental tier. This must be provided in Excel format. Sold groups may submit this via e-list. If both husband and wife work for the same company, they may enroll together or separately. COBRA/Mini-COBRA enrollees should be included on the census and noted as COBRA/Mini-COBRA. Rates are based on final enrollment. 3

4 COBRA/Mini-COBRA Enrollees Consumer Flex Choice (Medical only) COBRA and Mini-COBRA eligible enrollees are required to be included on the census for medical and dental (not eligible for life, disability or voluntary dental). COBRA/mini-COBRA qualifying event, length, start and end date must be provided. COBRA enrollees are not billed separately and are included with the group bill. Mini-COBRA is billed separately, 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 or urgent/emergency care. Note: COBRA/mini-COBRA enrollees are not to be included for purposes of counting employees to determine the size of the group. Once the size of the group has been determined and it is determined that the law is applicable to the group, COBRA/mini-COBRA enrollees can be included for coverage, subject to normal underwriting guidelines. Consumer Flex Choice (all plans) allows employers to select an unlimited number of plan options within the current product portfolio. New Business Available to groups with 4 to 100 eligible employees. Employer contribution 50 percent of the employee-only cost of the lowest cost plan in the portfolio (even if the employer does not select that plan). Participation noncontributory plans: 100 percent participation is required, excluding valid waivers. Participation contributory plans: 70 percent participation is required, excluding valid waivers. Each plan chosen must have a minimum of one employee enrolled for the plan to be offered and available for newly hired employees, until the employer s next renewal. Renewing Business Employer may select Consumer Flex Choice at renewal. Same rules apply as new business. Counting Employees to Determine Group Size Average total number of employees (ATNE) will be the method used in counting employees for determination of group size eligibility. Once the segment size is determined (1 to 50 or 51 to 100), we will use eligible/enrolled for all other guidelines product availability, participation, contribution, etc. To calculate the annual average total number of employees: 1. Count any employee receiving a W-2. This includes full-time, part-time, and seasonal workers who may or may not have been eligible for your medical coverage (this does not include 1099 independent contractors). 2. When calculating the average, consider all months of the previous calendar year regardless of whether the group has coverage with Aetna, or another carrier, or no coverage at all. 3. Add each month s number to get an annual total, and then divide by 12. (Example: = 21). 4. Use whole numbers only (no decimals, fractions, or ranges). Round up or down to the nearest whole number. (Example: 24.6 = 25) 5. Newly formed business calculate the prior year average using only those months the group was in business; or use reasonable expected total employees if the group was not in business the prior year. Illustrative Quote include ATNE at time of quote request. New business submission complete the Affordable Care Act (ACA) Medical Loss Ratio Requirement field on the employer application. Groups with 50 or fewer total employees are rated as a small employer. Groups with 51 or more total employees are rated as a large employer. 4

5 Continuing Employees to Determine Group Size (continued) Examples 2014 ATNE Example 1 Example 2 Example 3 Example 4 Full-time Part-time Seasonal Total ATNE Eligibles ACA Size Small group 1 50 Large group Large group Large group Examples Group A requests February 2015 effective date ATNE 2014 = 48 employees Group is considered small group At time of quote request group has 55 total employees If submitted as large group, we will confirm the group is small and rate as small because the prior year the group had 48 total employees. Group B requests March 2015 effective date ATNE 2014 = 80 employees Group is considered large group At time of quote request group has 40 total employees If submitted as large group, we will confirm the group is large and rate as large because the prior year the group had 80 total employees. Group C requests January 2015 effective date ATNE 2014 = 60 employees Group is considered large group At time of quote request group has 105 total employees If submitted as large group, we will confirm the group is large and rate as large because the prior year the group had 60 total employees. Example A Participation Small employer with 50 or fewer total employees 30 total employees receiving W-2 = 1 to 50 segment (rated as small group) 26 employees work 25 hours or more, 26 is the number of eligible used to calculate participation 8 have spousal group 5 have IVL = 13 x 70 percent = 9.1 = 9 must enroll 4 work 10 hours and are part-time = not eligible to enroll Example B Participation Large employer with 51 to 100 total employees 60 total employees receiving W-2 = 51+ segment (rated as large group) 30 eligible employees work 25 hours or more, 30 is the number of eligible used to calculate participation 8 have spousal group 5 have IVL = 17 enrolling (a rating adjustment may apply) 30 work 10 hours and are part-time = not eligible to enroll 5

6 Deductible Credit Dependent Eligibility Deductible credit applies to group-to-group takeover for individuals on the prior group plan. Employees who are eligible and want to receive credit for any amounts paid toward the deductible with their prior carrier should submit a copy of the Explanation of Benefits (EOBs) no later than 90 days after the effective date. Be sure the member s Social Security number (SSN) is on the EOB and/or handwrite the SSN on the form to avoid delay. EOBs may be submitted with the initial submission, with the first claim, or can be faxed to claims at no later than 90 days after the effective date. If you choose to fax, please include ECHS Category: SFRE in the subject line with the group/control number in order to direct the information to the correct area for processing. Deductible carryover not allowed. Deductible credit and out of pocket credit applies to calendar-year plans. Deductible credit reports may be submitted. Be sure it includes Social Security numbers. Eligible dependents include: An employee s spouse if both employee and spouse/partner work for the same company, they may enroll together or separately. Domestic partners may be covered as eligible dependents if the employer elects this designation at contract effective date or renewal date. An affidavit is not required. Coverage is available to eligible dependents who are same sex or opposite sex partners. Dependent children: Medical and dental: Children are eligible as defined in plan documents in accordance with state and federal law, are eligible for medical and dental coverage up 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 are eligible to the end of the month turning age 26. Children eligible for coverage through both parents cannot be covered by both parents under the same plan. 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 papers must be submitted. At the election of an employer offering group medical coverage or the subscriber, a dependent child between the ages of 26 and 30 may request to continue medical coverage as a dependent on his or her parent s group coverage even after the child reaches the limiting age under the terms of the policy if he or she: is not yet 30 years of age; is unmarried; has no dependents of his or her own; is a resident of FL, or if not a resident of FL, is a full-time or part-time student; is not eligible for Medicare; and is not actually covered under another group, blanket or individual health plan. Dependent life: 2 to 50 eligible employees 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. 51 to 100 eligible employees contact your Aetna account executive. Other eligibility guidelines: Individuals cannot be covered as an employee and dependent under the same plan, nor may children be eligible for coverage through both parents and be covered by both under the same plan. Dependents are not eligible for AD&D or disability coverage. For medical and dental, dependents must enroll in the same benefits as the employee (participation is not required). Employees may select coverage for eligible dependents under the dental plan even if they select single coverage under the medical plan. 6

7 Effective Date Employee Eligibility (1 to 50 employees) The effective date must be the 1 st or the 15 th of the month. The effective date requested by the employer may be up to 90 days in advance. The term employee means any individual employed by an employer. Eligible employee means an employee who works full time, having a normal work week of 25 or more hours, and who has met any applicable waiting-period requirements or other requirements of this act. Independent contractors (1099) are eligible as long as there is at least one enrolled W-2 employee who is not the owner and not the owner s spouse. Part-time, temporary, or substitute employees are not eligible. 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. While they must be included in the count in determining whether or not the group meets the definition of a small employer and is subject to Small Group Reform (SGR) rules, the employer may carve out union employees as an excluded class. Employees are eligible to enroll in the dental plan even if they do not select medical coverage. Likewise, employees may enroll in the medical plan even if they do not elect dental. Retirees Retiree coverage is not available except for any county, municipality, community college or district school board that requires the provision of coverage to retirees and their dependents. Retirees are not eligible for life, disability or voluntary dental coverage. Employee Eligibility (51 to 100 employees) Eligible employees are those employees who are permanent and work on a full-time basis with a normal work week of at least 25 hours, and who have met any authorized waiting period requirements. Ineligible employees include 1099 contractors, directors, stockholders, partners or other outside consultants who are not active, permanent full-time employees. Retirees Medical retirees are eligible. Groups with more than five percent early/non-medicare retirees will have an additional factor applied. Dental retirees cannot comprise more than 10 percent of the group. Retirees are not eligible for life, disability or voluntary dental coverage. The retiree must be currently covered with present carrier (must be shown on the bill roster or provide a copy of the ID card). If there were no retirees covered by the prior carrier the employee must be covered as an employee on the bill roster. Census required for retirees, split by over and under age 65. Retirees are not included in the count to determine the case size. 7

8 Employer Contribution (monthly) Medical 1 to 3 eligible employees 100 percent employer contribution of employee only cost. 4 to 100 eligible employees 50 percent of the employee cost of the lowest cost plan in the portfolio (even if the employer does not select that plan). 51 to 100 eligible employees the employer cannot fund the deductible in excess of 50 percent annually whether through a HRA, HSA or any other arrangement, or will be subject to a rating adjustment. 1 to 50 eligible employees groups that do not meet contribution are eligible to enroll during open enrollment, November 15 through December 15, for a January 1 effective date. Dental 2 to 50 eligible employees 25 percent of the total cost or 50 percent of the cost of employee only coverage for dental plans. If the employer contributes less than the above guideline, or if the coverage is 100 percent paid by the employee coverage is deemed voluntary. 51 to 100 eligible employees Contributory (nonvoluntary) employer must contribute. Excludes employee-pay-all plans. Voluntary plans percent employee paid. If the employer pays 100 percent the group is not eligible for a voluntary plan and would get a contributory (nonvoluntary) plan. Life 2 to 9 eligible employees 100 percent of the total cost of the life and disability plans. 10 to 50 eligible employees at least 50 percent of the total cost of the plans excluding optional dependent term life. 51 to 100 eligible employees contact your Aetna sales executive. Coverage can be denied based on inadequate contributions. Employer Eligibility 1 to 50 employees Any employer that has its principal place of business in this state, employed an average of at least one but not more than 50 employees on business days during the preceding calendar year, and employs at least one employee on the first day of the plan year. Group applicants that do not meet the above definition of a small employer are not eligible for coverage. Sole proprietors, owners of corporations, and partners in a partnership qualify for coverage if there is at least one enrolled W-2 employee other than the owner(s) or owner(s) spouse. 1 to 100 employees Medical plans can be offered to sole proprietors, partnerships or corporations. Organizations must not be formed solely for the purpose of obtaining health coverage. Associations, Taft Hartley groups, professional employers 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, packaged life/disability or disability-only have ineligible industries. The dental ineligible industry list does not apply when dental is sold in combination with medical. 8

9 Excluded Class/ Carve Outs Medical Union employees are the only class of employees that may be excluded. However, union employees are included in the total count of eligible employees in determining the case size. Management carve outs: 2 to 50 eligible employees are not allowed. 51 to 100 eligible employees may be permitted with underwriting management approval. Groups that carve out a specific class of employees for coverage may have an additional factor applied even if standard participation requirements are met. Dental Union employees may be carved out if packaged/sold with medical. Life Union employees may be carved out if packaged/sold with medical. Initial Premium Late Applicants The initial premium should be the total of the first month s premium for all products (medical, life, disability, dental, vision) and may be in the form of a check or electronic funds transfer (EFT). Electronic Funds Transfer (EFT) option is available for the initial premium payment. 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. Submit a copy of the initial premium check payable to Aetna Inc. or complete the ACH/EFT form and include with the new business group enrollment applications. If you provide a copy of the check, 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, the initial premium will be withdrawn 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, the premium will be returned to the employer. If the initial premium payment is returned by the bank for nonsufficient funds the standard termination process will be followed. If the plan sponsor is currently with Aetna and adding another product (medical, dental, life and/or disability, vision) coverage, no premium payment is required at the time of enrollment. 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, loss of eligibility for coverage as a result of legal separation, divorce, cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan), death of an employee, termination of employment, reduction in the number of hours of employment, and any loss of eligibility for coverage after a period that is measured by reference to any of the foregoing) 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. 9

10 Late Applicants (continued) 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 five years of age. 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. Example Group has $50,000 life with $20,000 guarantee issue limit. Late enrollee enrolling for $50,000 would not automatically get the $20,000. Since the applicant is late they must medically qualify for the entire $50,000. Licensed, Appointed Producers Medical Underwriting (51 to 100 employees) Medicare (MSP) for CMS Reporting 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 employer group being submitted. To become appointed with Aetna go to and click Start working with Aetna. Groups of 25 or more enrolled subscribers must complete a group medical questionnaire (GMQ). These cases may be rated up. Groups of 24 or less enrolled members must complete individual health statements. These cases may be rated up. Groups seeking coverage for the first time with no group medical coverage may be required to provide individual health statements. These cases may be rated up. Medical claims may be reviewed for any individuals who had prior Aetna coverage and used along with the health information included on the employee application(s) and/or group medical questionnaire, and included in the overall medical assessment of the group. Medical conditions of COBRA enrollees are included in this rating calculation. 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 10

11 Municipalities and Townships (1 to 50 employees) Newly Formed Business (in operation less than 3 months) 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. In most counties a municipality is the smallest administrative subdivision to have its own democratically elected officials. Underwriting requirements: Quarterly Wage and Tax Statement (QWTS) W-2 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, obtain 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 and participation will be maintained. Newly formed businesses must provide the following: 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 A copy of the articles of organization and the operating agreement to include the signature page(s) of all officers. Corporation 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 ID number; and QWTS. If not available, when will one be filed; and The most recent two consecutive weeks of payroll records that includes hours worked, taxes withheld, check number and wages earned; or A letter from the employer, officer of the company or 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 6. When a QWTS UC018/UC020 will be filed 51 to 100 employees will be rated accordingly. 11

12 Out-of-State (OOS) Employees Medical Out-of-state employees must be enrolled in an OAMC/PPO plan if available, otherwise an indemnity plan. Hawaii and Vermont have no health products available. North Dakota PPO is not available. Louisiana residents 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 completion of Louisiana employer and employee applications. Dental Members who reside out of state (OOS) will receive the same plan as in-state members (based on state rules and network availability). This applies to DMO, PPO and FOC dental plans. If an OOS member resides in a state that does not allow the in-state plan those members will be placed into an available PPO or indemnity plan. Life Employees are eligible for the same life plan selected by the employer. Participation Medical Noncontributory plans (employer pays all) 100 percent must enroll, excluding valid waivers. Contributory plans 1 to 3 employees 100 percent must enroll, excluding valid waivers. 4 to 100 employees 70 percent must enroll, excluding valid waivers, rounding down to the nearest whole number. Value Pick plans 50 percent participation, with a minimum of four enrolled employees. Valid waivers Spousal/parental group coverage Individual coverage on and off exchange Medicare/Medicaid Champus/ChampVA Military coverage Retiree coverage Association coverage (for doctors/lawyers covered under an association who want to cover their employees). Group coverage through a second full-time job Surviving spouse COBRA enrollees 2 to 50 eligible employees Groups that do not meet participation are eligible to enroll during open enrollment, November 15 through December 15, for a January 1 effective date. 51 to 100 eligible employees Groups that do not meet participation may have an additional factor applied to 100 eligible employees Dependent participation is not required. Limited liability plans are not valid waivers. All employees waiving coverage must complete the waiver section of the employee application.

13 Participation Dental Noncontributory plans (employer pays all) 100 percent participation is required, excluding valid waivers. Contributory plans with medical or standalone (round to the nearest) Contributory (nonvoluntary) plans 2 to 3 eligible employees 100 percent excluding valid waivers with a minimum of two enrolled. 4 to 50 eligible employees 70 percent excluding valid waivers. A minimum of 2 and 50 percent of total eligible employees must enroll in the dental plan. 51 to 100 eligible employees 30 percent excluding valid waivers. Voluntary plans 3 to 100 eligible employees 30 percent excluding valid waivers. Minimum of three must enroll. If a group does not qualify for a contributory (nonvoluntary) plan and has 30 percent or more participation then group qualifies for voluntary. Contributory (nonvoluntary) 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. 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 coverage (widow) Association coverage COBRA enrollees 13

14 Participation Life 2 to 9 eligible employees 100 percent participation is required 10 to 50 eligible employees Noncontributory (employer pays all) 100 percent participation is required Contributory 70 percent participation is required 51 to 100 eligible employees Contact your Aetna sales executive. Standalone life 70 percent participation is required 51 to 100 eligible employees contact your Aetna sales executive. 2 to 50 eligible employees COBRA and state enrollees are not eligible. Retirees are not eligible. Coverage can be denied based on inadequate participation. Employees may elect life insurance even if they do not elect medical coverage and the group must meet the required participation percentage. If not, the plan will be declined for the group. Example 9 employees 3 waiving medical 9 must enroll for life 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). Dental Freedom-of-Choice may change from DMO to PPO and vice versa at any time but must be received in Aetna underwriting by the 15 th to be effective the next month. Life and Disability 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 Changes allowed on plan anniversary date only. Dental Dental plans must be requested 30 days before the desired effective date. The future renewal date of the change will be the same as the medical plan anniversary date. Life and disability Packaged life/disability must be requested 30 days before the desired effective date. Nonpackaged 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. 14

15 Professional Employer Organization (PEO) Groups Covered Under a PEO Prior Aetna Coverage Rates Replacing Other Group Coverage Signature Dates Groups currently with a PEO may be eligible, subject to underwriting approval, as long as the PEO provides payroll specific for the group, the group has their own separate tax ID number, and we can determine it is a 1 to 100 life group, even though the group may be reported under the PEO tax ID number. A letter of intent is not needed. 51 to 100 employees groups currently with an Aetna PEO should provide members Social Security numbers with the quote request so claims can be reviewed. Groups that have been terminated for nonpayment by Aetna must pay all premiums owed before a new plan will be issued. 51 to 100 employees medical claims may be reviewed for any individuals who had prior Aetna coverage and used along with the health information included on the employee application(s) and/ or group medical questionnaire, and included in the overall medical assessment of the group. Rates are based on final enrollment. 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. 1 to 9 eligible employees use tabular rating based on each member s age. 10+ eligible employees are composite rated. 51 to 100 employees new business rating may be re-rated if enrollment changes by more than +/- 10 percent from the initial quote enrollment projection. Current and renewal rates are required at initial time of proposal. All rates will be quoted on a four-tier structure: single, couple, employee plus child(ren), family. No portion of the member s cost sharing, including but not limited to, copayments, deductibles and/or coinsurance balances will be subsidized or funded by the employer, with the exception of a federally-qualified health reimbursement arrangement (HRA), or health savings account (HSA), whether insured or self-funded, including but not limited to a partially self-funded Section 105 wrap around, now or in the future; and The employer cannot fund the deductible in excess of 50 percent annually whether through a HRA, HSA or any other arrangement, or an additional factor will be applied. Do not cancel any existing medical coverage until notified of approval from the Aetna Underwriting unit. Dental, provide a copy of the benefit summary to verify: Major and orthodontic coverage for contributory (nonvoluntary) 2 to 9 and voluntary 3 to 100 eligible employees; and Preventive and basic coverage for voluntary plans. 51 to 100 employees: Claims experience is required unless the prior carrier is known not to release claims experience. Medical underwriting is required; known high-cost or emergent conditions must be provided. Current rates are required from the current carrier and renewal rates should also be provided on incumbent s letter head. Provide a copy of the current billing statement that includes the account summary of subscribers enrolled, and summary of benefits. 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. 15

16 Spin Off Groups (current Aetna customers leaving an Aetna group only) Standard Industrial Classification (SIC) Codes (Medical) Tax Documents 1 to 9 Enrolled Employees and 10 to 50 Enrolled Employees with NO Prior Coverage We will consider the group with the following: A letter from the group or agent indicating the group is enrolling as a spin off. Letter needs to include the name of the group they are spinning off from. Ownership documents showing that the spin-off 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. 51 to 100 employees current Aetna customers spinning-off or otherwise separating from an existing Aetna group will have medical claims reviewed along with the health information provided on the employee application and included in the overall medical assessment of the group. 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 plans. 51 to 100 eligible employees the employer should provide the SIC code and/or nature of business. Groups must provide a copy of the most recent Quarterly Wage and Tax Statement (QWTS): Containing the names and wages of all employees of the employer group New hires, terminated and 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 payroll in questionable situations. 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. 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 provide any other documentation the Underwriter deems acceptable to establish eligibility. Sole Proprietor Franchise Limited Liability Company (operating as a sole proprietor) Partner Partnership Limited Liability Partnership Corporate Officer S-Corporation Personal Service Corporation 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 eligible partners must be listed on agreement Any other documentation the owner would like to provide to determine eligibility IRS Form 1120 S Schedule K1 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) W2 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 16

17 Tax Documents 1 to 9 Enrolled Employees and 10 to 50 Enrolled Employees with NO Prior Coverage (continued) Corporate Officer C-Corporation Limited Liability Company (LLC) operating as C Corp If the officers/owners are on the quarterly wage and tax statement, no additional documents are needed (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 Two or More Companies Affiliated, Associated or Multiple Companies, Common Ownership Value Pick Vision No documentation is required a QWTS or prior carrier bill is not needed. Upon request, the underwriter will contact the broker if a QWTS is necessary. 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 51 percent or more ownership in all associated companies The owner files (or is eligible to file) an Affiliations Schedule, IRS Form 851, 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. 51 to 100 eligible employees the two or more groups may have multiple standard industrial classification (SIC) codes; however, rates will be based on the SIC Code for the group with the majority of employees. A completed Common Ownership form is submitted. Value Pick is the Aetna plan designed specifically for small businesses. Offers reduced minimum participation and employer contribution requirements May select up to three plans Minimum of four enrolled employees Available to groups with two or more eligible employees with 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 by , Word doc, Excel spreadsheet, EList. Or, vision can be marked 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. License and appointment - there is no special license. Once the broker is licensed and appointed to sell ALIC, they can sell all products that fall under that umbrella. 17

18 Waiting Period At initial submission of the group, the benefit waiting period (BWP) may be waived upon the employer s request. This should be checked on the employer application. The BWP for future employees may be 1 st or 15 th of the month following: 0 days, 30 days, 60 days, or exactly 90 days after the date of hire. Date of hire BWP is not available. One or two BWPs 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. A change to the BWP may only be made on the plan anniversary date. No retroactive changes will be allowed. BWPs must be consistently applied to all employees, including newly hired key employees. New hires: the eligibility date will be the first day of the policy month following the waiting period, not to exceed 90 calendar days from the date of hire. 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 Exactly 90 Days is selected the enrollment eligibility date will begin 90 calendar days from 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 after the BWP 15 th of the month after 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 90 days exact Date of hire: 4/18 Effective date: 7/16 not 8/1 exactly 90 days from the date of hire 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 Date of hire: 4/18 Effective date: 7/16 not 8/15 exactly 90 days from the date of hire 18

19 Dental Coverage Waiting Period Contributory (nonvoluntary) 2 to 9 eligible employees and voluntary 3 to 100 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. DMO there is no waiting period. 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. For 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 prior, 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. Contributory (nonvoluntary) 10 to 100 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. 19

20 Dental Ineligible Industries All industries are eligible if sold with medical. Standalone dental or dental packaged with life only have ineligible industries 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. Contributory (nonvoluntary) plans with medical or standalone 2 to 9 eligible employees there is no open enrollment. 10 to 100 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 100 eligible employees there is no open enrollment. 20

21 Dental Option Sales Product Packaging Rein-statement (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. DMO cannot be sold as standalone and must be packaged with any PPO option as dual option. Refer to the plan guide dental footnotes page for plan availability. Members once enrolled who have 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. 21