Group Dental and Vision Insurance Producer Guide

Transcription

1 Group Dental and Vision Insurance Producer Guide Not for consumer distribution or solicitation. DentalVisionsPG 0512

2 Producer Appointment & Commissions Carrier appointment and IHC Health Solutions producer agreement In order to begin selling products available through IHC Health Solutions, you must be recommended through a general agent or IHC sales representative. In addition to becoming your point of contact for sales, service and training, this individual will assist you in determining contracting and appointment rules for the state(s) in which you do business. If requesting appointment, you must have a current life/health license for each state in which you do business, be in good standing with the Department of Insurance and not have been convicted of a felony involving moral turpitude. If commissions are paid to an agency, some states require that the agency be licensed as well as the individual agent. Upon submission of your first case, provide your general agent or sales representative with the following properly completed, signed and dated documents: A legible photocopy of your current life/health insurance license(s) and, if applicable, a legible photocopy of your current life/health agency insurance license(s) for each state in which you do business An IHC Health Solutions Requisition for Agent Appointment form An IHC Health Solutions Producer s Agreement Compensation Schedule to Producer Agreement A Hierarchy Form If you have requested an appointment without the submission of new business, we will not process your appointment request until new business is submitted. Please be advised that we will keep your appointment paperwork on file for 90 days from date of submission so we encourage you to submit new business as soon as possible to finalize the appointment process. You will be notified when the insurance carrier appointment is completed and will be sent a copy of your executed Producer s Agreement. Until the insurance company completes your appointment, IHC Health Solutions may hold any commissions that are due. Appointment /Administration fees Resident and non-resident appointment fees, if applicable, for SSL and/or MNL will not be required when accompanied by new business. A $20 administration fee will be assessed annually. Commissions You will receive monthly commissions, as earned, subject to the terms and conditions of the IHC Health Solutions Producer s Agreement. Commissions are paid on the 5th of the month for premium that has been received, posted and earned by the last day of the previous month, providing that the amount is greater than $25. Commission amounts less than $25 will forward to your next month s commission statement, subject to the same minimums. If, for any reason, the company refunds premium on a policy you have written and been paid commission, you will be required to repay the commission amount received on the refunded premium. Such adjustments will be reflected on your commission statement. To continue to receive commissions, the case must remain inforce, the premiums must be paid and you must actively service the account. Agent of Record Changes (AOR s) If a case has not been inforce for 12 months an agent of record can be requested and processed, but the agent of record will not begin to receive commissions until the renewal of the policy. To grant first year

3 commissions to the agent of record, a release letter from the original agent must be received. The writing agent can be changed on the case but the GA will remain the same for the life of the case. A written request from the Insured is required for an individual case and it needs to contain the following items: Case name and number New agent name Insured s signature Insured s phone number It is recommended that the request be printed or typed A written request from a company is required for a group case and the request must be submitted on the company letterhead and signed by the owner or officer of the company and needs to contain the following items: Case name and number New agent name Owner/officer signature Owner/officer contact information The agent contracting department will contact the insured or group and verify the change request. Once the AOR has been confirmed, agent contracting will send notification to the original agent and the new agent to advise when the change will become effective. The change is effective the 1 st of the month following 30 days of the receipt of all necessary documents. Carriers Madison National Life Insurance Company, Inc. (MNL) Madison National Life Insurance Company, Inc. is one of the insurers for dental and vision insurance benefits described in this guide. Madison National Life, a member of The IHC Group, is rated A- (Excellent) for financial strength by A.M. Best Company, Inc. a widely recognized rating agency that rates insurance companies on their relative financial strength and ability to meet policyholder obligations. (An A++ from A.M. Best is its highest rating). Standard Security Life Insurance Company of New York (SSL) Standard Security Life Insurance Company of New York is the other insurer for dental and vision insurance benefits described in this guide. Standard Security Life, a member of The IHC Group, is also rated A- (Excellent) for financial strength by A.M. Best Company, Inc. a widely recognized rating agency that rates insurance companies on their relative financial strength and ability to meet policyholder obligations. New business requirements Please submit the following to your general agent or IHC Health Solutions representative, who will review the forms for completeness and forward them to underwriting: Employer application signed by the owner or officer of the participating employer. (Please be sure to complete the producer/general agent information portion on the back of the employer application.) Employee application for each employee Sold quote showing the benefits/rates elected by the employer, if applicable New business submission form. Please make sure all applicable items are completed to ensure efficient case processing. Employer s check for the first month s premium. Checks should be made payable to the appropriate carrier. Copy of prior carrier billing if applicable Verification of eligibility form Schedule of benefits for prior carrier plan, if applicable.

4 Employee choice (dental only) Employers can allow their employees to choose different dental benefit plans to fit their needs, based on group size. Groups with 5 or more eligible employees have unlimited plan design options. Groups with 5 or more have the option to offer dual/triple options to their employees. If multiple plans are offered, the optional benefits (such as orthodontia) must be the same on all plans. For example, if you wish to add orthodontia, it must be added to all plans that offer major services. Contact your general agent for quoting information. Note: Takeover groups with 100 or more enrolling lives must be quoted by the home office and must submit the most recent 12 months premium/claims experience and, if requesting customization, must also submit plan specifications. Non-takeover groups up to 250 lives can be quoted using the online rating system. Group eligibility Dental offices and dental-related businesses are ineligible Groups of independent contractors or those with 1099 employees are eligible on an exception basis (specific enrollment materials are required, contact your general agent or IHC Health Solutions representative) Employee and dependent eligibility Employees Employees who are directly employed on a full or part-time basis working the minimum number of hours required may apply for coverage through a participating employer. To be eligible for coverage under the plan, an employee must be engaged in active employment as of the certificate effective date. Dependents Also eligible to apply are the eligible employee s lawful spouse and any unmarried dependent children under age 26. Newborn children The dependent child of an insured person will be insured from birth for a period of at least 31 days. Coverage will terminate at the end of 31 days if the insured does not complete and submit an application to have the newborn dependent added to his/her coverage. Newly adopted children A child who is adopted on or after an insured s effective date of coverage under the dental and vision plan will be insured for a period of at least 31 days from the earlier of: 1) the date of placement in the insured s home for the purpose of adoption; or 2) the entry date of an order granting the insured custody of the child for purpose of adoption. Court-ordered coverage for dependent children To add a dependent for which an insured person is mandated by a court order to provide dental coverage, we must receive notification within 30 days of the issuance of a court order providing for the payment of dental expenses/dental insurance coverage for this dependent. The following documents are required: A copy of the court order providing for payment of dental expenses and/or dental insurance coverage on behalf of the child by the noncustodial parent; or A release signed by the insured permitting us to communicate directly with the custodial parent. Participation requirements When at least 5 employees enroll for coverage, IHC Health Solutions requires no participation percentage unless the employer is paying 100 percent of the employee premium in which case all employees must enroll. Groups with 2 to 4 employees require 100 percent participation of both employees and dependents. Dependent participation is not required for groups of five or more. This applies to both dental and vision cases.

5 Changes to group size Group size is determined at case issue and is not recalculated until renewal. Add-on employees that will affect participation requirements or waiting periods will count toward group size at renewal. Refer to the Verification of Eligibility form for calculating employee participation. Continuous open enrollment (COE) Continuous open enrollment is available for voluntary dental plans for all group sizes. Employees are eligible to enroll anytime on or after the open enrollment date without reduced benefits or late enrollee penalties. Requirements for COE: Plan must have a 12 month waiting period on major services Plan must include endodontics and periodontics on major services Oral surgery can be moved to Basic only on groups with 10 or more employees COE will apply only after employee enrollment constraints have been met Requests to decline coverage, or waivers of coverage For plans where the employer is contributing a portion of the premium, any eligible employee who is not applying for dental and/or vision coverage must complete a Waiver of Coverage. For groups with five or more eligible employees, employees who have alternate group dental and/or vision coverage and waive coverage under the group dental and/or vision plan will not be counted against participation requirements. Waivers are not required for employee-paid plans. Effective date of coverage Employers may request a coverage effective date of the 1st or the 15th of the month. Groups must have a 15th of the month effective date on a prior plan to qualify. However, the premium due date will always be the 1st of the month. All applications must be signed and dated on or before the requested effective date. Any application received after the requested effective date, if approved, will be made effective the next available date. Newly hired employees added to the dental plan will have their coverage made effective the 1st of the month following completion of their benefit waiting periods. Applications that are more than 60 days old upon receipt will be returned unprocessed. Benefit waiting period and prior carrier credit Waiting period is defined as the number of consecutive months a person must be covered under the plan before benefits are payable. Employees are eligible immediately for benefits if they are enrolled on the employer s prior group dental plan at the time of takeover. No waiting period credit is granted for employees added after the initial effective date. To receive prior carrier credit, submit the following: A copy of the prior carrier s Schedule of Benefits The prior carrier s billing for the month in which coverage is requested under the new plan Prior carrier credit is only applicable for applicants moving from a prior group dental plan to a new group dental plan. Coming from a prior individual dental plan or from a point of service discount plan is not applicable for prior carrier credit. Dental deductible credit and calendar year maximum reduction Deductible credit and calendar year maximum reduction is available. There is no rate up for this option but it must be indicated on the employer application if the group is interested. A report showing each person s deductible and/or calendar year maximum met since January 1st of the same year the plan was sold must be provided at the time of new business submission in order to receive this reduction. Deductible only credit is available for an additional cost. This credit can be applied to plans that had a calendar year or lifetime deductible on the previous plan. This is not an automatic credit. This will only apply for the first year the group is inforce. Any deductible or annual maximum met on the previous plan will be deducted from your dental plan with IHC Health Solutions.

6 A report showing each person s deductible met since January 1 st of the same year the plan was sold must be provided at the time of new business submission in order to receive this credit. Dental orthodontia waiting period and takeover credit Orthodontia is available to dependents under age 19 for groups with five or more employee s. The orthodontia waiting periods offered are 12 or 24 months. However, if orthodontia is a covered service with the employer s prior plan, each covered person will receive credit for the orthodontia waiting period and annual maximum, not to exceed the new policy s lifetime maximum. Patients already in orthodontia treatment upon the effective date of the new policy should submit the following information with their claim: Banding date Number of months of treatment Assignment of benefits information ADA code Total case fee Primary insurance provider explanation of benefits (if coordination of benefits is necessary) Prior insurance carrier information, including deductible, coinsurance/copay, maximum and amount paid to date To reiterate the statement above, benefits between what was paid by the prior carrier and the new carrier cannot exceed the new policy lifetime maximum. Usual, Reasonable and Customary The Usual, Reasonable and Customary amount is the most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the geographic area in which the charge is incurred. The most common charge means the lesser of: The actual amount charged by the provider; The negotiated rate; or The usual charge which would have been made by a provider (dentist, hospital, etc.) for the same or comparable professional services, drugs, procedures, devices, supplies or treatment within the same geographic area, as determined by us. A geographic area is a three-digit ZIP code in which the service, treatment, procedure, drug or supply is provided, or a greater area if necessary to obtain a representative cross-section of the charge for a like treatment, service, procedure, device drug or supply. IHC Health Solutions Usual, Reasonable and Customary levels are determined using a proprietary blending of data provided through its own claims data and the data provided by a professional service. IHC Health Solutions has a standard allowance level and for some products the policy holder has the ability to choose alternate allowance levels for an applicable premium change. Coordination of benefits If a person covered under this plan is also covered under one or more other eligible plans, benefits will be coordinated with the benefits payable under those plans. For purposes of applying the coordination of benefits provision, an eligible plan is defined as: a) any group insurance or group-type coverage, whether insured or uninsured, including prepayment, group practice or individual practice coverage; and b) any governmental program, or coverage required by or provided by law, except Medicaid. Premium payments and grace period Premiums are due on the 1st day of the month and should be received at IHC Health Solutions no later than the 10th of the month for which the premium is due. A grace period of 31 days is allowed for any premium after the first premium. However, claims reimbursement will be pended for non-payment during the grace period.

7 DENTAL Benefit enhancements All groups with 5 or more employees have the option to elect benefit enhancements when using the quoting system. These include: Office visit copays (subject to state availability) Increased number of cleanings Graded annual maximums (MaxGrow) that increase by either $250 or $500 each year regardless of how much was used the year before. This is only available on plan year plans and is not subject to any prior coverage credit benefits or provisions Veneers Multiple options for deductible and annual maximums are also available Preferred provider option (PPO) plans Employers that select a preferred provider plan can choose to have non-network claims reimbursed either at the network reimbursement level or on an incentive basis. Selection of the network reimbursement level or incentive is not available for all plans. Groups with over five eligible employees have the option to customize PPO plans on the rating system. Maximum allowable charge (MAC) In-network: Services received from an in-network dentist are subject to the MAC. The MAC for each covered procedure is the amount agreed to by the dentist. Insured s are not responsible for amounts charged above the MAC. Out-of-network: Services received from an out-of-network dentist, are also subject to the MAC. However, if the out-of-network dentist charges more than the MAC, the insured is responsible for the balance. MAC PPO plans have the same in and out of network coinsurance. Incentive In-network: Services received from an in-network dentist are subject to the applicable in-network coinsurance for that plan. The coinsurance is applied based on the selected plan fee schedule. Out-of-network: Services received from an out-of-network dentist are subject to the applicable out-of-network coinsurance for that plan. The coinsurance is applied subject to the Usual, Reasonable and Customary amount. Incentive PPO plans can have the same or reduced out-of-network coinsurance. Preferred* PPO network coverage for dental products Aetna** AL, AR, AZ, CA, CO, CT,DC, DE, GA,HI, IA, IL,, KS, KY, LA,MA,MD,MI, MN, MO, MS, MT, ND,NE, NM,NV, OH, OR, OK, RI, SC, SD,TN, TX, UT, VA, VT, WI, WV DenteMax AK, ID, ME, NC, NH, NJ, NY, ND,WA, PA, WY Maverest Dental Alliance: IN only Prestige (Argus): FL only *Networks and their state availability are subject to change. Contact IHC Health Solutions for more information. All networks can be accessed on our website by clicking on Providers. ** Groups must have under 100 eligible employees to utilize the Aetna Dental Access network. A Flexident plan quoted with the Aetna Dental Access network cannot replace an existing plan utilizing the Aetna Dental Access network.

8 VISION Vision can be sold in conjunction with dental or on a stand alone basis. There are multiple plans available to choose from. Quotes can be obtained by requesting a rating tool from your GA or an IHC Health Solutions sales representative. Agents can quote vision up to 500 lives without claims experience. All groups over 500 lives must be sent to home office for quoting. We automatically include a free Davis Vision discount plan with all dental plans. Groups have the option to upgrade to a fully insured plan. Vision benefits are paid on an in-network and out-of-network basis according to the schedule of benefits. Outof-network benefits are based on a reimbursement up to a specified dollar amount per service. Wal-Mart & Sam s Club are two of our biggest vision providers. For a full list of providers, you can access the provider directory at select Find a Provider and enter control code Please check with IHC Health Solutions for an updated list of states in which these products are available. Important addresses and inforce administration IHC Health Solutions Department Address Phone Fax Address New business processing Dental and Vision [email protected] IHC Health Solutions Policy Services PO Box Loves Park, IL Agent contracting [email protected] IHC Health Solutions Agent Contracting PO Box Phoenix, AZ Commissions [email protected] IHC Health Solutions Commissions PO Box Phoenix, AZ Policyholder services Inforce dental business [email protected] IHC Health Solutions Customer Service PO Box Phoenix, AZ Claims Dental [email protected] Automated benefits: Claims and members services Clear Vision Claims and members services Avesis Vision IHC Health Solutions Claims Customer Service PO Box Eagan, MN Davis Vision 711 Troy Schenectady Road Latham, NY Avesis Vision Claims Department PO Box 777 Phoenix, AZ Additional information For more information about IHC Health Solutions dental and vision programs, please contact your general agent or an IHC Health Solutions sales representative.