Common Qualifying Events* Aetna Individual Policies- 2014

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Common Qualifying Events* Aetna Individual Policies Qualifying Event Definition Supporting Documentation Application Submission: Effective Date** Loss of employer coverage Loss of employer coverage due to termination of employment, reduction in hours or coverage no longer offered to individual's employment class - Termination letter from employer if you have been terminated, or - Pay stubs both current & previous hours if hours have been reduced, or of coverage loss - Letter from employer stating no longer paying for insurance. No longer a dependent Loss of employer or individual coverage because no longer eligible as a dependent Carrier letter documenting loss of coverage due to loss of dependent status, for example: - dependent age maximum reached, of loss of dependent eligibility event -death of policy holder, etc. Divorce from policyholder Loss of coverage due to a Divorce Copy of the divorce decree or custody agreement of divorce Loss of Medicaid or CHIP Loss of Medicaid or CHIP coverage Termination letter of loss of Medicaid or CHIP coverage from the Insurance carrier including the date of the loss of coverage. of loss of Medicaid or CHIP coverage. 1st-15th of mo:. 16th-last date: First day of 2nd following mo. Birth or adoption Addition of new dependent as a result of birth, adoption or placement for adoption -Birth certificate, or -Adoption papers Date of birth, adoption or placement for adoption Marriage Addition of new dependent as a result of marriage Marriage license or domestic partner certificate * The above list is not intended to be comprehensive of all qualifying events. Nevada allows a customer without a qualifying event to be enrolled for coverage, subject to a 90 day waiting period between date of application and effective date. ** Will not occur before the Qualifying Event.

2 Common Qualifying Events* continued Aetna Individual Policies Qualifying Event Definition Supporting Documentation Application Submission: Effective Date** Loss of eligibility for health insurance exchange subsidies Loss of eligibility for health insurance exchange subsidies Documentation showing that you are no longer eligible for a health insurance exchange subsidy. 1st-15th of mo: 1st day of mo. following app receipt. 16th-last date: First day of 2nd following mo. Renewal of a pre-aca plan during 2014 The pre-aca plan renewal or cancellation occurs in 2014 Carrier letter communicating that current pre-aca coverage will end on a certain date. Within 30 days of loss of coverage. 1st-15th of mo:. 16th-last date: First day of 2nd following mo. Minimum Essential Coverage Existing policy no longer provides Essential Minimum Coverage Letter documenting Loss of Minimum Essential Coverage Move Permanent move to a new area that offers different plan options Proof of move such as utility bill or rental/lease agreement. COBRA Expiration COBRA coverage ends Documentation showing the date that COBRA coverage ends and the people covered by the COBRA coverage. Return from active military service Newly eligible due to return from active military service Supporting paperwork confirming departure date from active military service Release from Incarceration Newly eligible due to release from incarceration Copy of certified letter documenting release date from incarceration Court Order or Chapter 11 Coverage directed by Court Order or resulting from Chapter 11 filing Copy of legal supporting documentation requiring health coverage * The above list is not intended to be comprehensive of all qualifying events. Nevada allows a customer without a qualifying event to be enrolled for coverage, subject to a 90 day waiting period between date of application and effective date. ** Will not occur before the Qualifying Event. THIS INFORMATION IS INTENDED FOR BROKERS ONLY. Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company. Aetna Health Plans (HMO/HNO) are underwritten by Aetna Health Inc. ( Aetna refers to Aetna Life and/or Aetna Health Inc.). In some states, individuals may qualify as a business group of one and may be eligible for guaranteed issue, small group health plans Aetna Inc (3/14)

3 Frequently Asked Questions For 2014 Plans Q: What is different in 2014? A: With the introduction of the Affordable Care act effective January 1st 2014, individuals and families can shop and apply on or off-exchange for coverage. Coverage is mandated for most individuals. Q: What is an exchange? A: Public exchanges are online market places where individuals and small group employers can shop for health insurance. It can be operated by the state or federal government. Consumers will be able to compare health plans from multiple carriers and purchase plans online. Q: Does everyone have to apply for coverage on-exchange? A: No, applicants can apply on or off exchange. In order to qualify for subsidies or tax credits you have to apply on-exchange. Q: What are the types of plan offerings? A: Plans are divided into metallic levels and must offer essential health benefits: Bronze (60% coverage) Silver (70% coverage) Gold (80% coverage) Platinum (90% coverage) Catastrophic Plan Not all metallic levels are offered in each state. Q: What are essential health benefits? A: Plans must offer a standard package of coverage known as essential health benefits. They are to include at least the following: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services (including oral and vision care). Q: What are Catastrophic Plans? A: Applicants are eligible to select a catastrophic plan if: Applicant is under age 30 OR Applicant is age 30 or over and their pre-aca plan was cancelled OR Applicant is age 30 and over and has a certificate of exemption from the Secretary of Health and Human Services to confirm applicant is eligible for a Catastrophic Plan due to hardship or lack of affordable coverage. A certification is awarded making them eligible for this plan. If multiple individuals are on the application, all individuals must meet the eligibility criteria for the catastrophic plan. Q: What extra documentation is required for a Catastrophic Plan A: Applicant under age 30 submits a 2014 application Applicant whose pre-aca plan was cancelled: application - Copy of the Carrier s Cancellation Letter - Application for Exemption from Shared Responsibility Payment for Individual who Experience Hardship Applicant is age 30 and over and has hardship or lack of affordable coverage: application - Certificate of Exemption from HHS. Applications should be submitted using standard processes. Documents confirming the Qualifying Event can be sent to AetnaIndivAppDocs@Aetna.com Q: Are there Lifetime Limits on these plans? A: No; there is no lifetime limit on any of the ACA plans. Q: Are there pre-existing condition restrictions or rating increases on these plans? A: For plan years beginning in 2014, Aetna can t decline or charge additional premium because of health conditions. Same rates for women and men. The only exceptions are: grandfathered individual health insurance plans and tobacco use in the past six months.

4 Q: What s the definition of tobacco use? A: Regularly used tobacco products (cigarettes, pipe, cigars, snuff, or chewing tobacco) within the last 6 months. Regular use means an average of four or more times per week. Q: Who is eligible for coverage? A: U.S. citizens or nationals, legal residents, resident of the state and zip code where Aetna offers products. Q: Who is not eligible for coverage? A: Undocumented residents Applicants who do not live in the U.S. People who are incarcerated Applicants who live in a state or zip code Aetna does not offer coverage Applicants that are enrolled in or have Medicare benefits. Q: What proof is required for non-citizens to provide for eligibility? A: Provide proof of U.S. residency can be faxed to (866) or ed to: AetnaIndivAppDocs@Aetna.com: Alien Registration Receipt Card with photograph (INS Form or 1-551) US passport (updated or expired) Certificate of US Citizenship (INS Form N-560 or N-561) Certificate of Naturalization (INS Form N-550 or N-570) Updated foreign passport with I-551 stamp or INS Form I-94 indicating unexpired employment authorization Updated Temporary Resident Card (INS Form I-688) Updated Employment Authorization Card (INS Form I-766 or I-688B) Updated Reentry Permit (INS Form 1-327) Updated Refugee Travel Documents (INS Form I-571) Updated Employment Authorization Document issued by the INS containing a photograph (INS Form I-688B) - L-1 Visa - L-2 Visa - H1B Visa (H4 visa for their spouse and children is acceptable for the same expiration date as the H1B visa. Both are required as proof of eligibility) Q: Who can be on a family plan? A: Applicant, spouse or domestic partner, children, legal guardianship or ward. Children can be added or kept on the health insurance policy until they turn 26* years old. Children can join or remain on a plan even if they are: Married Not living with their parents Attending School Not financially dependent on their parents Eligible to enroll in their employer s plan * 28 in OH, 30 in FL and in NY parents may purchase additional coverage to age 30. Q: When is open enrollment? A: The open enrollment period is October 1, 2013 to March 31, 2104 for the first year. The next open enrollment period will be November 15, 2014 January 15, 2015 Q: What is the first available effective date? A: January 1st (Applications with signature date of December 23rd or earlier) January 1, 2015 for the next open enrollment period. Q: What is the effective date off-exchange? A: 1st of the month. Q: What is the first available effective date if I apply Jan 1st off-exchange? A: February 1st (you will be assigned the first of the following month). Q: What is the first available effective date if I apply Jan 16th off-exchange? A: March 1st. (if you apply between the 16 and the end of the month you will be assigned the first of the second following month.) Q: If I apply: 1/16-1/31; I get a 3/1 effective date 2/16-2/28; I get a 4/1 effective date 3/15-3/31; I get a 5/1 effective date Q: What if there is information missing from the application? A: Aetna will notify the applicant of the required information.

5 Q: What if the information is received months after my requested date? A: Aetna will honor the requested effective date as long as the missing information is received prior to April 10th. Example: An applicant applies on December 15th requesting a January 1st effective date. The applicant is notified of missing eligibility requirements and returns that information to Aetna on March 1st. Aetna will assign the original effective date of January 1st. as requested. Q: What happens if information is missing from a family application? A: There is no SOE (Statement of enrollment) on the new application. We will notify the primary applicant of the missing information. At the end of 10 business days we will enroll the applicants with complete information and close the applicant(s) with missing information. Q: Can the premium rate be appealed? A: If a higher premium is given due to tobacco usage, there is no appeal and the tobacco use rate will apply for the full year. Q: What happens if the SOA (statement of accountability) is not completed? A: Aetna requires the person translating to complete the SOA in full. The same applies if someone is filling out the application for someone who is incapacitated. Q: Who must sign the application? A: Primary applicant, spouse/domestic partner and any dependents age 18 and older. Each of these applicants must attest they have read the application and the information is true and complete. Q: Will Aetna accept a paper check or money order for the initial payment? A: Yes, we will accept either with the paper application. Q: Does the PHI section of the application need to be completed? A: Primary applicant, spouse/domestic partner and any dependents age 18 and older. Each of these applicants must give permission for personal health information to be used. Q: Can the application be declined? A: No. If Aetna cannot confirm the applicant s eligibility (such as age or dependent status) the application will be closed. Q: Will Aetna accept a paper application after March 31st for open enrolment? A: The application must be received by April 15th (allowing 10 business days for delivery.) Applications received after April 15th will be closed as ineligible. Q: What if I don t apply for coverage during open enrollment? A: You are not eligible for coverage until January 2015 unless you have a qualifying event. Q: What is a qualifying event? A: Loss of employer coverage due to termination, reduction in hours or coverage no longer offered by employer Loss of employer or individual coverage because no longer eligible as a dependent Marriage Birth Adoption Divorce Loss of Medicaid or CHIP coverage Loss of eligibility for health insurance exchange subsidies Loss of coverage due to a permanent move US residency Death of insured Loss of coverage due to unintentional enrollment error or decertification of existing health plan Return from active military duty Release from incarceration Court order or chapter 11 filing Your current plan renews in 2014 (must apply 30 days prior to plan renewing). Q: How long do I have to apply for a qualifying event? A: Applicant must apply within 60 days of the qualifying event to be eligible and proof of the qualifying event will be required. Q: What documentation is required as proof of a qualifying event? A: Applicant must provide: Loss of employer coverage. (Through termination of employment, reduction in hours, or benefits no longer offered by an employer). Termination - Request from the applicant a termination letter from their employer. Reduction in Hours - Request from the applicant a current and prior paystub showing reduction in hours. Benefits no longer being offered by an employer - Request from the applicant a letter from their employer stating they are no longer paying for insurance.

6 No longer eligible as a dependent. - Request from the applicant a copy of the termination letter from the insurance carrier stating loss of benefits due to age. Marriage - Request a copy of the marriage license or domestic partner certificate. Birth Adoption - Request a copy of the adoption paperwork. Divorce - Request a copy of the divorce decree. Loss of Medicaid or CHIP coverage. - Request from the applicant a copy of the termination letter from the insurance carrier with the date of the loss of coverage. Loss of eligibility for health insurance exchange subsidies. - Request from the applicant a copy of the termination letter from the insurance carrier. Loss of coverage due to a permanent move. - Request a copy of a utility bill or a rental/lease agreement. US residency - Request a copy of a visa or other documentation. Please note the US residency requirements have not changed. An applicant must be a US resident for 6 months and submit a copy of an accepted Visa (L1, L2 or H1B). Loss of coverage due to unintentional enrollment error or decertification of existing health plan - Request a copy of a letter from the insurance carrier from the applicant. Return from active military duty. - Request a certified letter documenting discharge from service. Release from incarceration. - Request a certified letter documenting release from custody. Court order or chapter 11 filing. - Request legal documentation. Q: What effective date is given for a qualifying event? A: Most applicants will receive the first of the following month. The exceptions are: Newborn (covered from DOB) Adoptee (covered from date of placement) Loss of Medicaid/CHIP or subsidies (follow the open enrollment rules) New US resident or citizen (follow the open enrollment rules) Q: What about applications submitted on exchange through healthcare.gov or state exchanges? A: The exchange will validate the qualifying event and will only pass the application to Aetna if valid. Death of insured - Request a copy of the termination letter from the insurance carrier or a copy of the death certificate from the applicant. THIS INFORMATION IS INTENDED FOR BROKERS ONLY. Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company. Aetna Health Plans (HMO/HNO) are underwritten by Aetna Health Inc. ( Aetna refers to Aetna Life and/or Aetna Health Inc.). In some states, individuals may qualify as a business group of one and may be eligible for guaranteed issue, small group health plans Aetna Inc (3/14)