Agent Guide for Assurant Health

Transcription

1 Agent Guide for Assurant Health Individual Medical Metallic Plans

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3 What s New in this 09/2014 version? Note: This Agent Guide is updated quarterly. Please refer to the most recent version in the Find a Form section of the Assurant Health sales agent information website (assuranthealthsales.com). Page 9 References to the QLE table (that was displayed in this guide) were removed and replaced with the following: Refer to the Qualified Life Events Guide (J b.pdf) in Find a Form on the Assurant Health sales website for the types of life events and the required documentation. Page 9 The QLE table was removed. Page 9 State-specific QLE information was updated for Colorado. Page 11 The eligibility guidelines were revised to indicate that a paper application is required if any applicants are age 65 or older. Page 12 The Calculating Rates/Quotes section was revised to indicate that premium rates quoted will only be valid through the end of the year. Page 12 The open enrollment effective date guidelines section was revised to indicate the earliest effective dates available. Page 12 Information regarding Colorado was removed from the Qualifying Life Event Effective Date Guidelines section. Page 18 The Premium Modes section was revised with information regarding how January 1 renewals will affect customers billing. Page 23 A Renewals section was added that provides information regarding renewal guidelines for Metallic plans.

4 Why Assurant Health Products for every need and budget Our individual major medical portfolio boasts a medical footprint unrivaled by commercial competitors. Clients can also expect supplemental options to bolster protection. We provide tools that make selling easy for you Technology that allows you to quote, submit and issue business faster Sales support that is unmatched and understands your market, so you can get the help you need navigating the health care reform and the Marketplace Help after the sale so you can focus on selling Feel good about working with a company that s financially secure and experienced Part of Assurant, Inc., a Fortune 500 company Strong A.M. Best rating (November 2013) Efficiently adapt to changes in the Marketplace Overview of our plans Assurant Health continues to offer a robust portfolio with plans in all metal levels. Individual major medical plan names are Assurant Health Bronze, Silver, Gold, Platinum and Catastrophic. Plans are minimum essential coverage under the Affordable Care Act and include required essential health benefits, such as maternity, mental health, preventive care, and pediatric dental and vision. Availability varies by state and distribution channels.

5 About the Agent Guide This version of the Agent Guide contains information about the application submission process. To ensure you are viewing the most updated version of the Agent Guide, go to the Assurant Health sales website. This guide is updated quarterly, but additional updates may occur throughout the year. Refer to the Agent Resources section for additional information. For the purpose of this guide: Applicant refers to applicant and/or enrollee Application is one of the following: Paper application or enrollment form EASE application submission ASC refers to Assurant Supplemental Coverage products Automatic Payment refers to the billing method formerly known as Electronic Funds Transfer (EFT) or Check-o-matic (COM) EASE (Electronic Agent Sales Experience) is the name of our online quoting and submission process. We ll refer to this process as EASE throughout this guide. Policy refers to policy and/or certificate QLE refers to a qualifying life event This guide was developed to assist you in marketing our products. It provides answers to many of your questions and directs you to the proper departments within Assurant Health to obtain information that may not be in this guide. This guide contains new business guidelines, as well as information about plan administration, billing and coverage changes. This guide does not provide product information, but does include some state-specific information. Information can be found in state variations and/or the Assurant Health sales website. Refer to the Agent Resources section of this guide for additional information. Not all of our guidelines are specifically stated in this guide; our practice is to publish only the most common guidelines. If you have specific enrollment questions not answered here, please contact your New Business service team. The guidelines listed are merely illustrative of probable action based on our practices and procedures. Assurant Health retains the right to deviate from these guidelines based on individual case information.

6 Table of Contents Agent Resources Assurant Health sales website Ordering printed materials and forms...7 Manage your business with MyBook TM...7 Contact information...7 Health Care Reform...7 Licensing/Application Requirements...7 Application guidelines...8 Open enrollment...8 Qualifying life events...9 State-specific life events...9 California...9 Colorado Kansas...10 Nebraska...10 North Carolina Oregon South Dakota Utah...11 Washington...11 Eligibility guidelines...11 Persons eligible for coverage and issue ages..11 Adding an applicant to an existing pending application Replacement guidelines...12 Calculating rates/quotes Important information for you and your client..12 Effective Date Guidelines...12 Open enrollment effective date guidelines...12 Qualifying life event effective date guidelines...12 Application Submission Guidelines...13 EASE application submissions...14 Paper application submissions Key sections of the application...15 Agent/agency information...15 Type of activity Application signatures...15 Billing information Interpreters...15 Enrollment Practices...16 Enrollment outcomes...16 Not taken policies...16 Reissues...16 Electronic Delivery of Policy/Contract..16 Legal Requirements...17 Outline of coverage requirements Abbreviated Notice of Insurance information practices...17 Fraud notice (notice text may vary by state)..17 Privacy Health Insurance Portability and Accountability Act (HIPAA)...17 State health insurance plans...18 Billing First premium Payment methods...18 Payment schedule Premium modes...18 Automatic payment...19 Credit card Direct billing...19 List billing...19 Multiple automatic payments...19 Payment method and premium mode changes Policy Changes and Administrative Guidelines...20 Guaranteed conversion Internal replacements...20 Inforce enrollment requests...21 Addition of spouse, dependents or newborns...21 Removal of tobacco rates...21 Submissions for inforce requests...21 Dependent guidelines Address changes...22 State residency changes Non-sufficient funds (NSF)...22 Bank changes for automatic payment...22 Renewals...23 Lapses, Reinstatements and Terminations Lapses Reinstatements Terminations...23 Backdating termination dates...24 Agent Guide for individual major medical plans 6

7 Agent resources Assurant Health sales website To log on to the website, first you will need to register using your agent number, creating a user ID and password. If you do not have an agent number, please contact Assurant Health Agent Appointment and Contract Support at ext Access the Assurant Health sales website at assuranthealthsales.com for information including: Marketing materials and sales literature Applications Forms State approval listings The most updated version of the Agent Guide State variations Underwriting and Administrative Guidelines Product-specific agent guides for Assurant Health Access, Assurant Supplemental Coverage, individual major medical policies issued prior to 01/01/14, and Washington individual medical policies issued prior to 01/01/14. Ordering printed materials and forms Printed sales literature, forms, applications and other items for use in the sale of Metallic products are available from your usual supply channel. All forms referenced in this guide can be found in Find a Form on assuranthealthsales.com. Manage your business with MyBook MyBook provides you with quick and convenient online access to member, plan and billing information for inforce policies (or policies that have lapsed/terminated). In addition, MyBook keeps you up to date on the status of your business through alert notices. To receive alerts, make sure your address is updated periodically in the Assurant Health sales website. You can easily search for a particular client or sort and view business according to your needs. To learn more about MyBook, view the brief training module located in the agent library or through assuranthealthsales.com. Contact information Correspondence addresses For regular delivery: Assurant Health P.O. Box 2948 Milwaukee, WI For overnight or express delivery: Assurant Health 501 West Michigan Milwaukee, WI Office phone numbers: Customer Care Center Individual Enrollment Department Fax Commissions ext Fax Agent Appointment and Contract Support ext Fax Health Care Reform Plans with effective dates 1/1/14 and later must comply with the provisions of the Affordable Care Act, which include: Guaranteed issue Elimination of pre-existing condition coverage restrictions Elimination of rating for health status and gender Dependents covered up to age 26, regardless of school enrollment Preventive services, including women s health Unlimited lifetime maximum Licensing/Application Requirements Each state s rules and regulations dictate under what circumstances an agent may solicit and an insurer may accept business. At a minimum, you must have an active license issued by the states in which your customers reside and you conduct business. Most states also require a company appointment prior to or in conjunction with the solicitation of your first piece of business. State requirements for Internet (ecommerce) sales also vary. We require the soliciting or writing agents to have resident or nonresident licenses and appointments in the resident state of any applicants. Agent Guide for individual major medical plans 7

8 As a licensed agent, you are expected to know the solicitation rules for each state in which you are licensed to sell. If you have any questions regarding resident or non-resident state requirements, please contact your Assurant sale support service team prior to taking your first application. Assurant Health follows a practice of strict compliance with state regulations regarding licensing and appointing agents as it relates to accepting business and paying compensation. We regularly reconcile information in our agent database with the licensing information available from all states in which we conduct business. Your failure to comply with these requirements may result in our inability to accept applications. Assurant Health only accepts applications that are: Completed, signed and/or authorized by a currently licensed and appointed agent in the state in which the applicant is a legal resident For a product type that the company has authorized the agent to solicit For a policy form approved by the state in which the applicant is a resident Legally signed (wet or electronic signature) and/ or authorized by the applicant (through the online verification system [OVS] and any other acceptance methods) on or after the effective date of the agent s current license/approved appointment Submitted with a new agent appointment in a state that allows this practice Not altered or corrected with regard to the signature of the proposed policyholder, the date signed, the city and state or the licensed resident agent s signature Actually or electronically signed by a licensed and appointed agent; stamped signatures or signatures by unlicensed sales staff are not acceptable Note: License duration requirements vary by state. Applications taken by unlicensed staff but countersigned by another licensed agent are not acceptable. In applicable states, a copy of a renewed license must be on file with Assurant Health Agent Appointment and Contract Support for us to accept business. Call Agent Appointment and Contract Support with questions about specific state requirements. In states where allowed, the Application for Insurance/Enrollment form and agent appointment should be submitted together and sent to Agent Appointment and Contract Support. General agents, district agents/managers and managing general agents are authorized to recruit and nominate writing agents in the states and for the products designated by the company. They must ensure that every writing agent who solicits insurance for Assurant Health is: Duly licensed by the state in which he/she solicits; and Properly appointed through the company; and Authorized by the company to submit applications for each type of product Submission of business that does not meet these requirements shall be grounds for termination of the general agent s sales agreement and forfeiture of all rights. Most states no longer require an appointment for general agents, district agents/managers or managing general agents who only receive commission overrides and do not directly engage in selling, soliciting or negotiating insurance. In these states, Assurant Health will not require an appointment unless you notify us that the business activities of your agency require it to be licensed and appointed. This notification must be signed by the principal agent we show on our records and submitted in writing. We suggest you use the Request for General Agency Appointment form at assuranthealthsales.com to notify us. Please check with your sales support service team if you have a question on the rule for a specific state. Application Guidelines Open enrollment Open enrollment dates for 2015 plans are 11/15/14 to 02/15/15. An application with a signed date outside of open enrollment will require a qualifying life event (QLE) to be considered for coverage. Note: In Nevada, applications without a QLE can be submitted outside of open enrollment, but the effective date will be the first of the month following 90 days from the application signed date. Example: For an application signed on 04/01/14, the effective date would be 07/01/14. Several states have open enrollment periods for primary insureds under the age of 19 (under age 21 in Colorado). The states and their open enrollment periods are: Colorado, Illinois, and North Carolina: January and July Missouri and Ohio: March Oklahoma: June 1 through July 31 Agent Guide for individual major medical plans 8

9 Submit a paper application for primary applicants under 19 (under age 21 in Colorado). Paper applications and any required forms can be downloaded from the Find a Form section of assuranthealthsales.com. Effective dates vary by state. Check with your sales support service team if you have questions regarding the application guidelines for a specific state. Qualifying Life Events When a qualifying life event (QLE) occurs, an applicant is eligible to enroll or change their health insurance within 60 days of the event. The application will not be accepted if it is signed more than 60 days after the life event date. Applications can be accepted up to 60 days prior to the life event date. Documentation of the QLE will be required before coverage can be considered. Refer to the Qualified Life Events Guide (J b.pdf) in Find a Form on the Assurant Health sales website for the types of life events and the required documentation. State-specific life events appear below. Once the eligibility review is completed by the Individual Enrollment department, the plan will be delivered and the customer will be billed, even if the QLE hasn t occurred yet. It s important to let customers know so they understand when to expect their first premium to be drafted, as well as when they will receive their plan documents and ID cards. Plan documents for QLE applications for a pending birth will not be available until after the birth occurs. For all QLEs, you must complete a Qualifying Life Event attestation, which you will find in the: Online application process. The attestation will be submitted automatically with the online application. Paper application packet. Please submit the application, including the Qualifying Life Event form (Form 35020). Life event documentation can be faxed to Assurant Health at ; mailed to Assurant Health, Attn.: Enrollment Dept., 501 W. Michigan, P.O. Box 624, Milwaukee, WI, 53201; or ed to mke.uwtechs@assurant.com. If the specific life event is not listed on the online or paper Qualifying Life Event form, the Individual Enrollment department will contact you for the required documentation. When an application is submitted for a birth QLE prior to the birth date, include the baby on the application as follows: Document baby for name Select a gender Document the anticipated due date for the birth After the birth, contact the Individual Enrollment department to provide the baby s name, gender, and date of birth. State-specific life events In addition to the life events listed in the Qualified Life Events Guide, some states have unique life events. Documentation required for state-specific life events will generally be the same as noted in the Qualified Life Events Guide. The Individual Enrollment department will contact you for the required documentation, as well as any state-specific life event proof. California 1. A qualified individual is mandated to be covered as a dependent pursuant to a valid state or federal court order. 2. A qualified individual was receiving services from a contracting provider under another health benefit plan for a particular condition and that provider is no longer participating in the health benefit plan. 3. A qualified individual is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service. 4. A qualified individual s health coverage issuer substantially violated a material provision of the health coverage contract. 5. An individual experienced an error in enrollment. 6. An individual becomes newly eligible or newly ineligible for advance payments of the premium tax credit or experienced a change in eligibility for cost sharing reductions. Colorado 1. Involuntarily losing existing creditable coverage for any reason other than fraud, misrepresentation, or failure to pay a premium. 2. Gaining a dependent or becoming a dependent through marriage, civil union, birth, adoption, placement for adoption, or placement in foster care, or by entering into a designated beneficiary agreement. Agent Guide for individual major medical plans 9

10 3. Enrolling or non-enrolling in a plan unintentionally, inadvertently, or erroneously and is the result of an error, misrepresentation, or inaction of the carrier, producer, or Exchange. 4. Demonstrating to the Commissioner that the health benefit plan in which the individual is enrolled has substantially violated a material provision of its contract in relation to the individual. 5. An Exchange enrollee becoming newly eligible or ineligible for the federal advance payment tax credit or cost-sharing reductions available through the Marketplace. 6. A parent or legal guardian dis-enrolling a dependent, or a dependent becoming ineligible for the Children s Basic Health Plan. 7. An individual becoming ineligible under the Colorado Medical Assistance Act. 8. An Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a qualified health plan or change from one qualified health plan to another one time per month. Kansas 1. An individual gains a dependent or becomes a dependent through marriage, civil union, birth, adoption, or placement for adoption or by entering into a designated beneficiary agreement 2. An individual s enrollment or non-enrollment in a health benefit plan is unintentional, inadvertent, or erroneous and is the result of an error, misrepresentation, or inaction by Us, a producer, or the Marketplace. 3. An individual adequately demonstrates to the commissioner that the health benefit plan in which the individual is enrolled has substantially violated a material provision of its contract in relation to the individual. 4. The Marketplace determines an individual to be newly eligible or newly ineligible for the federal advance payment tax credit or cost-sharing reductions available through the Marketplace pursuant to federal law. 5. The loss of eligibility for Medicaid or a public program providing health benefits. Nebraska 1. The loss of eligibility for Medicaid or a public program providing health benefits. 2. A change in residence, work, or living situation where the health plan does not provide coverage in that person s new service area. 3. A situation in which a plan no longer offers any benefits to the class of similarly situated individuals that includes the individual. North Carolina 1. An individual gains a dependent or becomes a dependent through marriage, civil union, birth, adoption, or placement for adoption or by entering into a designated beneficiary agreement. 2. An individual s enrollment or non-enrollment in a health benefit plan is unintentional, inadvertent, or erroneous and is the result of an error, misrepresentation, or inaction by Assurant Health, a producer, or the Marketplace. 3. An individual adequately demonstrates to the commissioner that the health benefit plan in which the individual is enrolled has substantially violated a material provision of its contract in relation to the individual. 4. The Marketplace determines an individual to be newly eligible or newly ineligible for the federal advance payment tax credit or cost-sharing reductions available through the Marketplace pursuant to federal law. 5. The loss of eligibility for Medicaid or a public program providing health benefits. Oregon 1. Gains a dependent or becomes a dependent through marriage, birth, adoption or placement for adoption or foster care. 2. If the qualified individual s or his or her dependent s, enrollment or non-enrollment in a qualified health plan (QHP) is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Marketplace or United States Department of Health and Human Services, or its instrumentalities as evaluated and determined by the Marketplace. 3. If the enrollee or, his or her dependent adequately demonstrates that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee. 4. If the enrollee is newly eligible or ineligible for advance payments of the premium tax credit, or experiences a change in eligibility for cost-sharing reductions. 5. Loses eligibility for coverage under a Medicaid plan under Title XIX of the Social Security Act or a state child health plan under Title XXI of the Social Security Act. Agent Guide for individual major medical plans 10

11 South Dakota Utah 1. Individual becomes eligible for Social Security. 2. Employer or former employer bankruptcy. A proceeding in a case under Title 11, United States Code, commencing on or after July 1, 1986, with respect to the employer from whose employment the covered individual retired at any time. 1. An Individual or dependent s enrollment or non-enrollment is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee or agent of the Marketplace or the United States Department of Health and Human Services, or its instrumentalities as evaluated and determined by the Marketplace. 2. An individual adequately demonstrates to the individual carrier that the health benefit plan in which he or she is previously enrolled substantially violated a material provision of its contract in relation to the enrollee. Washington 1. The loss of eligibility for Medicaid or a public program providing health benefits. 2. A permanent change in residence, work, or living situation, whether or not within the choice of the individual, where the health plan under which they were covered does not provide coverage in that person s new service area. 3. A situation in which a plan no longer offers ANY benefits to the class of similarly situated individuals that includes the individual. 4. Coverage is discontinued in a QHP by the Health Benefit Exchange (HBE) and the three-month grace period for continuation of coverage has expired. 5. Exhaustion of COBRA coverage due to failure of the employer to remit premium; OR Loss of COBRA coverage where the individual has exceeded the lifetime limit in the plan and no other COBRA coverage is available. 6. If the person discontinues coverage under Washington state health insurance pool coverage [i.e., a health plan offered/issued under Chapter (Health Insurance Coverage Access Act). Eligibility guidelines Refer to the state variations for details on state differences. These documents can be found at assuranthealthsales.com. All submissions of applications, forms and correspondence must be in English. Persons eligible for coverage and issue ages All Assurant Health plans are based on the actual age of the applicant as of the effective date. Assurant Health Bronze, Silver, Gold and Platinum plans Primary and spouse/domestic partner Through age 64. Age 65 and older if the applicant is not eligible for Medicare. (A paper application is required if any applicants are age 65 or older.) Note: Oregon applicants age 65 or older, who are eligible for Medicare, can be considered for coverage unless they are covered by Medicare Part A or Part B, or a Medicare Choice plan or Medicare Advantage plan. Dependents Children through age 25 (may vary by state) who have an eligible dependent relationship to the primary applicant Sibling only applications will also be accepted. A minor child can be the primary policyholder if the parent/legal guardian provides a signature on the application. Assurant Health Catastrophic plans Applicants through age 29 are eligible. Applicants 30 or older are accepted if they are financially eligible and can provide an approved hardship exemption from the IRS. For 2014, applicants age 30 and older are also eligible if their existing coverage is being discontinued due to the introduction of the Marketplace. For these applicants, the hardship exemption application and supporting documentation regarding the loss of coverage should be submitted to us for consideration. A paper application is required if any applicants are age 30 or older. The following age guidelines apply to the 2014 plans: Primary ages Spouse through age 29 Dependents unmarried children through age 25 (may vary by state) Agent Guide for individual major medical plans 11

12 Adding an applicant to an existing pending application If a new applicant wants to be considered as part of an existing pending application, the options for consideration are: 1. Withdraw the pending application and reapply with all applicants included; or 2. Allow the pending application to be issued without the new applicant and apply to add the new applicant via an Inforce enrollment application. Inforce enrollment applications can only be submitted after the policy effective date. Note: In order to add a new applicant to an inforce plan outside of open enrollment, the new applicant must have had a QLE. Replacement guidelines If existing coverage is being replaced, some states require a replacement form be completed and submitted with the application. A copy of the completed replacement form should be left with the applicant. It is your responsibility to provide the form to the applicant. Calculating rates/quotes You can run quotes on our EASE online system from assuranthealthsales.com. You must include a software illustration/quote with all applications. Make certain that if premium is submitted with the application, it matches the software illustration. Premium rates quoted will only be valid through the end of the year. Example The rates for a quote run on 10/10/14 for an effective date of 11/15/14 would only be good from 11/15/14 through 12/31/14. The policy will renew on 01/01/15, and the rates may change at that time. Non-tobacco user discount To qualify for a non-tobacco user discount, each person who is age 21 or older must attest during the application process that he/she has not used tobacco products four or more times per week on average within the past six months. Religious or ceremonial use by American Indians or Alaska natives is excluded. State variations exist for tobacco use. Refer to the state-specific applications for further information. Important information for you and your client Assurant Health relies on your client s answers to application questions, and these answers have a significant impact on eligibility for a plan. If your client provided you with information related to eligibility, you are required to disclose that information to us. If you or your client has questions about eligibility, please contact Assurant Health. Obtaining all the required authorizations at the time of application submissions is critical to beginning the enrollment process. Effective Date Guidelines Open enrollment effective date guidelines The earliest effective date will be determined based on the application signature date: For an application signed 11/15/14-12/15/14, the earliest effective date is 01/01/15. For an application signed 12/16/14-01/15/15, the earliest effective date is 02/01/15. For an application signed 01/16/15-02/15/14, the effective date is 03/01/15. (The last day to apply during open enrollment is 02/15/14, and 03/01/15 is the last available effective date during open enrollment.) Qualifying life event effective date guidelines Customers experiencing a QLE have a 60-day special enrollment period in which they can apply. Applications can be submitted 60 days prior to the life event date (electronically in most states; by paper in all states) and customers must apply no later than 60 days after their life event. Agent Guide for individual major medical plans 12

13 Effective dates of the first and 15th of the month will be available during the 60-day special enrollment period following the life event date, subject to the application submission date rules below. Additional effective date options may be available, beyond those shown on the online application (EASE). The Individual Enrollment department will make available any additional effective date options. If the effective date is not available in EASE, you can the requested date to the Individual Enrollment department In the event of a renewal of a grandfathered or nongrandfathered plan: The qualified life event date is the renewal date. Customers effective date can be as early as 30 days prior to the renewal date. All states All life events except birth, adoption, placement for adoption, and guardianship: Effective date is determined based on the application sign date and the life event date The effective date will not be prior to the life event date The effective date will either be the first or the 15th of the month. The next available effective date will be allowed, as long as it is after the application signed date and on or after the life event date. The effective date cannot be the same as the application signed date. The last available effective date is determined by the date the 60-day special enrollment period ends: - If the 60th day of the special enrollment period is the first through the 15th of the month, then the first of the following month is the last available effective date. - If the 60th day of the special enrollment period is the 16th through the last day of the month, then the first of the month after the following month is the last available effective date. For example, if the life event date is 6/1 and the application signed date is 7/30, the last available effective date is 9/1. The effective date will be the date requested on the application, if that date is available. However, an alternate date can be requested through the Individual Enrollment department. All states Birth, adoption, placement for adoption, and guardianship: The earliest available effective date is the date of birth, date of adoption, date of placement for adoption, or date of guardianship. The 29th, 30th, and 31st are not available effective dates. If the date of birth, etc., is on the 29th, 30th, or 31st, we will allow an effective date of the 28th. Nevada Plans available year round: For customers with a QLE, refer to the rules for all states for birth, adoption, placement for adoption, guardianship, and all other life events. If there is no QLE, the first available effective date is the first of the month following a 90-day waiting period. Example: Application signed: 6/15 End of 90-day wait: 9/13 Effective date: 10/1 Refer to the Qualified Life Event Guide (J B) in Find a Form for additional information. Application Submission Guidelines The available application submission methods for the Metallic plans are: EASE online quoting and submission Paper application faxed or mailed to Assurant Health Follow one of the two submission methods above to help you efficiently proceed through the application process. Electronic Agent Sales Experience (EASE) EASE is a set of online resources which are available on the Assurant Health sales website at assuranthealthsales.com. EASE makes selling and managing your individual major medical plans easier than ever before. EASE expedites your overall sales cycle. With EASE, you ll be able to obtain a quote online and submit your business electronically. You will have access to the most current rates with no software to download. EASE has most state requirements/authorizations built into the application process. No need to worry if you have all of the required forms. You ll have the capability to check application status online for all policies you sell. All instructions are available online at assuranthealthsales.com. For more information about EASE, contact your sales manager. Agent Guide for individual major medical plans 13

14 EASE application submissions Plans can be quoted and enrolled directly using EASE in most states. After quoting, you may proceed to completing the application with the applicant. After submitting the application, an application number will be provided. Completing the application in EASE involves providing basic demographic applicant information, current insurance information and billing/payment information. All required information, including most state forms, are completed online. This information should be completed with the primary applicant or parent/legal guardian. After the initial information is completed on EASE, the process will continue depending on the applicant s resident state. If you are writing business in an applicant s resident state where paper applications are not required, you have the following options: 1. Complete the entire application with your applicant in person. This process will allow the applicant to attest to the information right away. Once the application is submitted through EASE, the applicant will receive a confirmation from us. 2. Complete the entire application with your applicant on the phone. Once the application is submitted through EASE, the applicant will receive an directing him or her to our online verification system. This system will allow the applicant to correct and attest that all information is accurate. Once he or she attests to the accuracy, the online verification system will submit all information electronically to Assurant Health. 3. Submit the initial application information from EASE and have the applicant call in for the enrollment interview. Applicants must call to provide information within 10 days of the submission from EASE. The agent should help prepare applicants by letting them know the following: Accident Fixed-Benefit, Accident Medical Expense, and Dental coverage will be reviewed based on the individual major medical paper application. An independent decision will be made on the individual major medical product and the Accident Medical Expense or Dental product. 4. The primary applicant or parent/legal guardian must complete the interview. Your customer will speak directly with an Assurant Health representative. The interview will take approximately 10 minutes to complete. Be sure to print all takeaway documents and provide them to the applicant. EASE integrated online application submissions for ASC For your convenience, Assurant Supplemental Coverage products (Accident Fixed Benefit, Accident Medical Expense, Cancer and Heart/Stroke, Critical Illness/Term Life, and Dental) can also be added directly to your individual major medical application via EASE. Refer to the Assurant Supplemental Coverage Agent Guide for more information. Paper application submissions Paper submissions are available in states for agents who do not choose to submit their business electronically via EASE. The application must be fully completed and accompanied by a quote as well as any required forms. Applications are state-specific and should be used for the following requests: New business submissions. Spouse and dependent conversions from an existing Assurant Health individual major medical plan to a new plan. Refer to the guaranteed conversion section of this guide for further information. Internal replacements from an existing Assurant Health individual major medical plan to a new plan. Refer to the Internal Replacements section of this guide for further information. Note: Replacement applications submitted through EASE may not be identified as internal replacements. Paper applications are required for internal replacements. For changes to existing policies, refer to the Policy Changes and Administrative Guidelines section of this guide for further information. Paper application packets and any required forms can be downloaded from the Find a Form section of assuranthealthsales.com. Paper integrated application submissions for ASC Assurant Supplement Coverage (ASC) products can be sold with an individual major medical application for your convenience. When enrolling an applicant, both the individual major medical application and the ASC application must be completed. Both plans can be quoted together in EASE. We refer to this type of enrollment as an integrated application submission. When submitting an integrated application via paper along with an individual major medical plan, include an EASE integrated quote, along with the completed applications and necessary forms. Agent Guide for individual major medical plans 14

15 After the integrated applications are submitted, each product applied for will be assigned a separate application number. Any requests or correspondence related to the integrated application should reference all of the associated application numbers. Integrated applications for Term Life/Critical Illness and Cancer and Heart/Stroke coverage are not available with paper applications for the individual major medical products. A standalone Term Life/Critical Illness or Cancer and Heart/Stroke application and quote should be submitted to apply for these products. Refer to the Assurant Supplemental Coverage Agent Guide for more information. It s available on Find a Form at assuranthealthsales.com. Completing the application You must fully complete the Application/Enrollment form so that it can be processed without delays. Incomplete applications may not only result in delays, but can also result in the termination of the enrollment process. Please use black or blue ink when completing the application. Key sections of the application Below are some key sections of the application and information on how to complete these sections. Note: Since applications vary by state, you may notice state-specific differences. Agent/agency information Fill in the writing agent s name, writing agent s number, key agency contact, fax number, phone number, address and agency name and number. We will contact the agent at these numbers if we need additional information. Type of activity Check the appropriate box for an initial enrollment or a life event. If an existing customer is requesting changes to a policy, select the appropriate change. Application signatures The signature of the primary applicant is required. In the case of insurance requested for a minor (under age 18), the signature of a custodial parent or legal guardian is required in lieu of the person to be policyholder. For sibling-only applications, the parent or legal guardian should sign the application, regardless of the applicant s age. Signatures of the spouse or dependents are not required and will not be accepted in lieu of the primary applicant s signature. Some state-specific applications may require additional signatures. The application s signed date and time are legal requirements. In most states, the agent s signature is not required. Refer to the state specific application to determine if an agent s signature is required. If the application is received more than 30 days after the date signed, a new application will be required. Billing information Billing information is not included on the application and is completed on the Billing Selection worksheet. This form must be completed and submitted with the application, and is available on Find a Form at assuranthealthsales.com. Interpreters We will allow interpreters based on the following guidelines: An agent cannot act as an interpreter A spouse, a child age 12 or older or family friend may interpret for the primary policyholder when completing the application The interpreter should not answer the questions for the applicant The applicant should answer with the translation following the applicant s answer Person(s) to be insured Please refer to the Application Submission Guidelines section of this guide before completing this portion of the application. The following information is required: Name, gender, date of birth, relationship and social security number for each applicant. Note: When an application is submitted for a birth QLE prior to the birth date, include the baby on the application as follows: Document baby for name Select a gender Document the anticipated due date for the date of birth. Once the birth has occurred, contact the Individual Enrollment department to provide the baby s name, gender and date of birth. Complete resident address (address where the applicant files state income taxes for those with multiple residences) including county. A PO Box is not acceptable. Relationship to the primary applicant for all dependents. address. Telephone numbers. We may contact the applicant to verify or obtain information. The tobacco use question must be completed for all applicants age 21 or older, including dependents. Agent Guide for individual major medical plans 15

16 Other coverage inforce or applied for If this policy is replacing other coverage, or if other coverage has been applied for, we need to know the following information: The name of the other carrier Whether it is group or individual coverage The type of coverage The effective date and termination date of the other coverage All questions pertaining to other coverage inforce need to be answered. Some states may require a Replacement form when coverage is being replaced. Refer to Find a Form at assuranthealthsales.com for further information. Enrollment Practices Enrollment outcomes Submission of the application will produce one of the following outcomes: Standard issue You or the applicant will receive the policy in the mail, or the customer will receive the policy via e-delivery through the member portal. Requests for additional information and/or forms You will receive notification on your EASE status report of any additional information required to complete the application review. Counteroffer Posted on EASE before the policy is issued when one or more, but not all, applicants are ineligible for coverage; or when the applicant was submitted as a nonsmoker, but will be issued as a smoker. Review the offer with your customer and contact us to respond to the offer. If the counteroffer is not accepted, the application will be marked incomplete. Ineligible applicant notification You will receive notification via mail or EASE if any applicants are ineligible for coverage. The applicant will also receive a letter from us that explains the reason(s) why he or she is ineligible for coverage. Applicants who do not meet the eligibility requirements for a spouse or dependent may be eligible to reapply and submit their own application. Incompletes The application will be marked incomplete when all applicants are ineligible for coverage or when outstanding application information has not been received in the required timeframe. Not taken policies A 10-Day Right to Examine is provided on all policies (timeframe may vary by state). Applicants who decide the policy does not meet their needs within this time period may return the policy and request, in writing or by phone, to have the policy marked NOT TAKEN. All paid premium will be refunded. Not taken requests will be granted prior to the policy effective date or within 10 days of the policy delivery date. Requests received beyond these timeframes will be handled as a request to terminate a policy as of the request date, and any refunds would be calculated to that date. Reissues Reissue requests are subject to approval. We will consider requests to reissue inforce policies for plan selection and effective date if we receive the request prior to the policy effective date or within 30 days of the policy issue date. If we receive a policy change request outside of these timeframes, it will be processed as a policy change rather than a reissue of the policy. Refer to the Policy Changes and Administrative Guidelines section of this guide for further information. If a new applicant wants to be added to an active policy prior to the policy effective date, there are two options: 1) mark the policy not taken and reapply with all applicants included; or 2) apply to add the new applicant via an Inforce enrollment application. Inforce enrollment applications can only be submitted after the policy effective date. Electronic Delivery of Policy/ Contract Policyholders have access to view policies and contracts electronically at members.assuranthealth.com. During the application process, customers can choose to receive their policies electronically versus paper. If a customer opts into electronic delivery (edelivery), once the policy is issued, an will alert them that their policy is ready for viewing. The will list their policy plan type, policy number and a link to the customer website. First-time customers will need to register and create a unique user ID and password. Agents are notified via the EASE Application Status Detail if customers opted into edelivery. The message in EASE will read: Upon approval, policy will be edelivered (except if policy is conditionally or HIPAA issued). It is important to note that a customer s address is vital to the success of edelivery. Please do not use your agent/agency address or a false address for your customer. Agent Guide for individual major medical plans 16

17 Legal Requirements Outline of coverage requirements Some states have a legal requirement to provide the state-approved outline of coverage to the applicant at the point of sale. Refer to the appropriate state variations to determine if an outline of coverage is required. State-specific outlines of coverage define mandates and other differences in coverage specific to those states. Please make sure you deliver the correct outline of coverage to the applicant. Abbreviated Notice of Insurance information practices To issue an insurance policy or certificate, Assurant Health needs to obtain information about persons proposed for insurance. Some of this information will come from the application and some will come from other sources. All information collected by Assurant Health may, in certain circumstances, be disclosed to third parties without the proposed policyholder s specific authorization. The proposed policyholder does have the right to access and correct the information collected. The Abbreviated Notice of Insurance Information Practices is part of the Application/Enrollment form for insurance. Refer to Find a Form at assuranthealthsales.com for further information. Fraud notice (notice text may vary by state) It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the appropriate regulatory agency in the appropriate state. We restrict access to nonpublic personal information about applicants to those employees who need to know that information to provide products or services. We maintain physical, electronic and procedural safeguards that comply with federal standards to guard nonpublic personal information. We may disclose nonpublic personal information to non-affiliated third parties as permitted by law. Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act (HIPAA) sets forth minimum standards for the availability of individual medical policies on a guaranteed issue basis with no pre-existing condition limitation for qualifying eligible individuals. If you have a customer who wishes to obtain coverage on a guaranteed issue basis with no pre-existing limitations, please contact the Individual Enrollment department. Note: Coverage under the Metallic plans is a guarantee issue health plan without a pre-existing exclusion or any riders excluding specific conditions. HIPAA requires that this notice be provided. You may contact us in regard to applicants requesting a HIPAA plan; however, it will have similar benefits and premium to the individual major medical plans available for purchase. HIPAA privacy As a business associate of Assurant Health and as a representative working on behalf of each applicant, it is your responsibility to protect the confidential information you collect. HIPAA privacy and security regulations require that you, as a business associate, have the physical, administrative, and technical safeguards in place to protect this information. Please refer to the Assurant Health privacy policy at assuranthealth.com to understand how protected information is handled at Assurant Health and how policyholders can exercise their individual rights under HIPAA. Please contact the Assurant Health Privacy Office immediately if you are aware of any breach of protected health information. Privacy We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted by law. We collect nonpublic information about applicants from the following sources: (1) information we receive on the enrollment/application forms or other information related thereto or as part of policy administration, and (2) information about the applicant s transactions with our affiliates, others or us. Agent Guide for individual major medical plans 17

18 State health insurance plans In order to provide coverage for people who are unable to purchase satisfactory medical insurance through private insurers, states have enacted State Risk Pool plans. For details regarding these types of plans, please refer to the Underwriting and Administrative Guidelines at assuranthealthsales.com. Generally, people who have been declined, charged an extra premium or issued coverage with a special exception rider are eligible to obtain coverage through these plans. Many states also require insurers to notify applicants of their eligibility to apply for coverage under these plans. People who wish to obtain coverage through a State Risk Pool plan usually must submit evidence that they have been unable to acquire coverage through private insurers or unable to obtain coverage without special exception riders. Assurant Health will assist an applicant in this regard. In order to do so, we require that a fully completed paper application be submitted to our office. (EASE submissions cannot be used for this request). Please advise us by a separate memo or note, directly on the Application/Enrollment form, stating that the application is being submitted for purposes of qualifying for coverage under a State Risk Pool plan. If the State Risk Pool plan is the state s guaranteed issue plan for HIPAA eligibles, a letter of declination from a private insurer is not required. Note: Coverage under the Metallic plans is a guarantee issue health plan without a pre-existing exclusion or any riders excluding specific conditions. Many state health plans require that we provide notification about those plans. Billing First premium If the policyholder requests payment method of automatic payment or credit card, the first full premium will be drafted on the date the policy is issued, not on the policy effective date or requested draft date. For direct bill, the first bill will be sent with the policy. If a check or money order is submitted, it should be made payable to Assurant Health. Checks and/or money orders made payable to an agency will be returned. In cases where the full premium is not paid at the time of application, a tolerance of 80% of the premium due (not to exceed $100) will be applied. This means that if the payment falls within this tolerance, the premium will be applied to the policy, the agent s commission will be paid on the total amount due and the balance will be billed to the policyholder at the next billing cycle. If no premium or less than the tolerance amount is received, we will mail a bill along with the policy to the policyholder. For list bill, we will include the premium due on the next list bill. No commissions will be paid until the premium is received. Payment methods Automatic payment Credit card Direct billing/paper bill List billing Payment schedule To alleviate confusion regarding when bank accounts and credit cards will be charged for plan premiums, we now send a payment schedule to new policyholders who choose to pay by automatic payment bank draft or credit card. The schedule displays withdrawal dates, coverage periods the withdrawals correspond to and debit amounts for the next year of premiums. Premium modes Note: Regardless of selected premium mode, plans are subject to calendar year billing due to the mandatory January 1 renewals. Because of this, customers may receive a prorated year-end bill, depending on their policy effective date, selected billing mode, and any mid-year billing mode changes. Example If a customer chooses to change to quarterly billing effective August 1, the customer will receive a quarterly bill for August through October, and a prorated year-end bill for November and December premiums. The policy will resume billing as of January 1, and the customer will receive a full quarterly bill for January through March premiums. Policies on credit card or automatic payment billing will draft for their January quarterly premium on the customer s selected draft day, in January. See the Renewals topic for more information on January renewals and calendar-year billing. The following premium modes are available: Monthly: with automatic payment and list bill payment methods Monthly: with credit card payment in Arizona, Connecticut, Kansas, North Carolina, and Ohio Quarterly: with direct bill and credit card payment methods Semi-annual: with direct bill and credit card payment methods Annual: with direct bill and credit card payment methods Agent Guide for individual major medical plans 18

19 Automatic payment Automatic payment is a convenient payment method by which premiums are automatically drawn from the payer s checking account. Premiums can be drawn on any day except the 29th, 30th and 31st. Policies on automatic payment will automatically draft as soon as the policies are issued by the Individual Enrollment department. If automatic payment is requested, be sure to complete a Bank Draft authorization, including routing, transit and account numbers. The authorization gives Assurant Health the authority to draft the premium payer s account for premium due. A copy of a voided check is helpful in verifying the appropriate information. Automatic payment draft date The automatic payment draft date and the policy effective date should coincide, if possible. This ensures that the premium is drafted on the same day of the month that the policy was effective. Premium to pay the policy to a current date will be drawn from the payer s checking account. Automatic payment premium payments Even if the applicant s policy is not yet issued, the agent should encourage the payer to record regular debits from his/her checking account each month. This will help to reduce non-sufficient funds NSF checks since the first automatic payment withdrawal will cover all due premiums other than the first. Credit card Payment by MasterCard and VISA credit card is available to applicants for recurrent premium payments. To set up credit card billing, we require the credit card information and authorization by the cardholder to draft their account. Required credit card information includes: Card type: Visa or MasterCard Expiration date Name of cardholder as it appears on the credit card Signature/authorization of the cardholder Credit cardholder address, if different than the policyholder address Note: Premium to pay the policy to a current date will be charged to the credit card as soon as the policy is activated. Direct billing Quarterly, semi-annual and annual premium modes are available with the direct billing method. Monthly direct bill is not available. On direct bill policies, premium notices are mailed as early as 35 days prior to the due date and include adjustments for past due premiums, underpayments and overpayments, as well as additional charges or credits due to a policy change. List billing Refer to the List Bill Agent Administrative Guide in Find a Form for additional details (Form 29240). List bill enables an employer to payroll deduct premium for individual medical coverage purchased by employees. Employers do not contribute any monies toward the payment of these individual medical plans. Employees pay 100% of the medical premiums. The following are features of the list bill option: List bill accounts are billed monthly to the list bill account holder (employer) on a combined bill. Employers select their billing due date, between the first and the 28th of the month. Employers submit one check that incorporates all employees premiums due. The employer must complete a List Bill Account Agreement form to establish a list bill account. This form is available on Find a Form at assuranthealthsales.com. The availability of the list bill option is based on the physical location of the employer. Multiple automatic payments The capability exists in many states to debit multiple individual policies on one automatic payment account, with a maximum of 18 policies per automatic payment account. This will help facilitate the administration of payment of individual policies where the employer is collecting the premium from the employee through payroll deduction. The employer should have one common draft date for all policies, even though the effective dates differ. Multiple automatic payments can occur only in those states that allow payroll deduction. In addition, the multiple automatic payment group must qualify per the state s Employer Sponsored Business (ESB) Requirements. Payment method and premium mode changes Requests to change payment methods and premium modes following the issue of the policy should be directed to the Customer Care Center. Refer to the contact information section of this guide. Agent Guide for individual major medical plans 19

20 Policy Changes and Administrative Guidelines Guaranteed conversion An eligible person may request a conversion of coverage if he or she is no longer eligible for coverage due to: Divorce Death of the primary insured Dependent who no longer meets eligibility requirements A spouse or dependent child no longer eligible for coverage may obtain an equal or similar plan. Conversions are given a new plan number. An Assurant Health paper application is required within 60 days of spouse or dependent status termination. Conversion should be selected in the Type of Activity section on the application. The application can be found in our Metallic plans enrollment packet. Guidelines for completing the application: Complete the demographics information, including name, address/county, etc. Only the tobacco use question needs to be answered The primary applicant age 18 and older must sign the application. A parent/legal guardian should sign the application if multiple siblings are applying or if the primary applicant is not capable due to mental or physical disability Select the billing mode and provide required billing information on the Billing Selection worksheet A quote/proposal is required. All required new business forms, such as replacement forms, should be submitted with the application. What you can expect: The plan will be dated with the termination date of the original plan. Assurant will not allow a gap in coverage or an overlap of coverage. A modified commission rate will be paid. If the applicant submits an application for a conversion without agent information included, no agent will receive commission on the conversion plan. We cannot process add-on dependents with a conversion due to different dating rules. We will process the conversion application first, then an inforce request can be submitted to consider the addition of the dependent. Internal replacements An internal replacement is a request to replace an existing active Metallic, individual medical or Assurant Health Access policy. Outside of open enrollment, a qualifying life event will be required to apply for an internal replacement. A fully completed Assurant Health EASE or paper application is required, along with a quote and all required new business forms, such as replacement forms. For EASE application submissions, provide all of the current insurance information to ensure that the application is identified as an internal replacement. Contact your sales support Assurant Health team for additional information. For paper applications, Internal Replacement should be selected in the Type of Activity section on the application. The application can be found in our Metallic Series enrollment packet. Submission of a paper application for internal replacements is recommended to ensure that the replacement application is properly identified and processed. Guidelines for completing the application: Complete the demographics information, including name, address/county, etc. Responses to all questions are required The primary applicant age 18 or older must sign the application. A parent/legal guardian should sign the application if multiple siblings are applying or if the primary applicant is not capable due to mental or physical disability Agent information is required Select the billing mode and provide required billing information on the Billing Selection worksheet A quote/proposal is required All required new business forms, such as replacement forms, should be submitted with the application For all qualifying life events, you must provide any necessary documentation and complete a Qualifying Life Event attestation, which you will find in the: Online application process. The attestation will be submitted automatically with the online application Paper application packet. Please submit the application, including the attestation (Form 35020) Agent Guide for individual major medical plans 20