Protect your priorities.

Transcription

1 Protect your priorities. Your future. Agent Field Guide For use with Long-Term Care Insurance Policies and All Related Products LTC-121 (Rev. 4-00)

2 Welcome This Guide is designed to be an all-purpose reference tool for you, the Agent writing long-term care business for CareDirections and related products. This is your Agent Field Guide. We have made every attempt to make the Guide user-friendly to assure your SUCCESS in the sale of OUR long-term care insurance products. We are proud to have you represent us in the field. We want YOU to be proud to represent us. We are continuously working to improve our products and service, and we welcome your suggestions and comments. Please call us and let us know! It s a pleasure to work with you! Your link to Us Agent Services and the Medical Underwriting Hotline Agent Services...especially for You, our Company Representative! Call or Fax to Agent Services for the following needs: * To order supplies - including state-of-the-art proposal software. To inquire about policy benefits. To inquire about the status of an application. * To inquire about commission payments and reports. To inquire about billing and premium rates. For assistance with policy delivery and quotes. To notify us of a client s need for claim. To get the answer to ANY question or concern you may have. *BCBS Florida Agents: Order supplies from Materials Management by calling Ext WE WANT TO HEAR FROM YOU. AGENT SERVICES: 9:00 a.m. to 6:00 p.m. EST (Voice Mail available after hours) FAX: MEDICAL UNDERWRITING HOTLINE: 9:00 a.m. to 5:00 p.m. EST: (Voice Mail available after hours) Select Menu Option 4 FAX:

3 Table of Contents PAGE AGENT S CODE OF ETHICS...1 APPLICATION PROCESSING...2 PHILOSOPHY OF RATE GROUPS...3 QUOTING THE PROPER PREMIUM RATE GROUP...3 AGENT CHECK LIST...4 SUBMITTING THE APPLICATION...6 SUMMARY OF APPLICATION PROCESSING...6 AGENT S ROLE IN THE APPLICATION PROCESSING...6 UNDERWRITING PHILOSOPHY...7 UNDERWRITING TOOLS...7 ADMINISTRATIVE PROCEDURES...8 ABBREVIATIONS AND DEFINITIONS...13 HT/WT CHART...14 MEDICAL CONDITIONS GUIDE...15 THE MEDICATION GUIDE...33

4 Agent s Code of Ethics All Agents are expected to maintain the highest ethical standards, as described in the Agent s Code of Ethics, included in each Agent s Company Contract. The Code is included below for reference. Any person selling long-term care insurance shall: 1. Possess a thorough understanding of the benefits and limitations of each long-term care insurance policy presented. 2. Maintain an effective working knowledge of Medicare and Medicaid as each program pertains to long-term care insurance. 3. Ensure that all medical questions on long-term care applications are answered thoroughly and accurately for optimum underwriting. 4. Clearly identify yourself by using only approved identification badges, and/or letters of introduction or endorsement, and not represent that you are an employee of the company. 5. Obey all laws governing business and professional activities and honestly represent product(s) in an ethical manner without fraud, misrepresentation, exaggeration, coercion, scare tactics or concealment of pertinent facts; and without taking advantage of the customer or potential customer that could lead to the customer s detriment in insurance choices based on need and financial capability. 6. Replace long-term care insurance policies when it is clearly in the policyholder s best interest. (Consider benefits, pricing due to new age, pre-existing condition, penalties, changes in medical history and stability of new carrier.) Make sure new coverage is in effect before canceling old policy. 7. Use only authorized promotional materials, unless prior approval has been obtained, and fairly focus presentation on positive benefit comparisons rather than disparaging remarks about competition. 8. Approach potential customers by appointment only, unless otherwise authorized by the company. 9. Treat a customer or potential customer with due courtesy, respect and priority in accordance with thoughtful, ethical and legal business practices. 1

5 Application Processing Assuring Applicant Eligibility Check the following eligibility list carefully. Memorize it! It will help you write good business. It will help us process your business quickly and successfully. To be eligible to apply for a Care Directions or related product, the applicant MUST meet ALL of the following conditions: Must be >18 and < 85 (generally, but age is product specific) Application must be signed by the applicant. (Power of Attorney is NOT acceptable.) Applicant does NOT have a Power of Attorney in effect for finances or medical purposes. Application must be signed in the state where the application is approved. Applicant must have an available personal or work address for delivery in the state where the application is approved. Applicant is not eligible for OR is not receiving Medicaid. Applicant can accurately answer all of the questions in Part 1 of the Medical Profile on the application as NO. Applicant has no surgery or diagnostic testing planned or recommended. Applicant must meet the stability guidelines in the Medical Conditions Guide. CAUTION: Any surgery or diagnostic testing to be performed should signal the Agent to postpone taking the application for at least three (3) months after recovery from surgery or testing is complete and the diagnosis is made. IF YOU ARE COMFORTABLE THAT THESE CONDITIONS ARE BEING MET, YOU RE READY TO HELP YOUR CLIENT COMPLETE AN APPLICATION. 2

6 Philosophy of Rate Groups Rating products allows the Company to distribute the premium more evenly across insurable risks. At the point of sale, the Agent needs to explain that the quoted rate could be adjusted based on the Underwriting Evaluation. Set the stage at the point of sale that the quoted rate is based only on the information provided at the time of application. Quoting the Proper Premium Rate Group Check each medical condition reported by the client in the Medical Conditions Guide. Total the Points for all of the Conditions reported by the client and listed on the Application. Submit the application with the assigned rate group, based on the following Table: MEDICAL CONDITIONS TOTAL POINT VALUE RATE GROUP 0 I 1, 2, 3 II 4, 5, or 6 III 7 or more Not Insurable - Decline Rate Groups apply to base products, as well as any rider and/or optional benefit premiums. Existing discounts (spousal, list bill) are applicable to each Rate Group. Remember: Medical Underwriting may deliver the policy at the Rate Group submitted or the Rate Group may change based on conditions or risk uncovered during the underwriting process. Prior to Delivery The Agent must check the Policy Acceptance Report for the Rate Group assigned by Medical Underwriting. If there is a higher premium assigned than quoted, the Agent needs to be prepared to resell the policy. If you are unsure of what Rate Group to quote, call the Medical Underwriting Hotline at Menu Option 4. 3

7 Agent Check List Remember, the more accurate and detailed the information on the Application, the better the time service during the underwriting process. It is important that you observe all requirements. Before you submit your client s Application: HAVE YOU DONE ALL of the FOLLOWING? Included ALL REQUIRED FORMS you need in order to submit the Application? Used only BLACK INK? Clearly completed the applicant s name, address, phone number, social security number, date of birth, age, and height and weight? Made sure the product type and all benefits selections are clearly marked? Completed ALL questions in the Insurance Information section, which requires listing of current and past insurance policies and Intent to Replace? Clearly completed the Medical Profile? Included the applicant s PHYSICIAN s name, address and telephone number? Completed information requested for a Lapse Designee including name, address and phone number? Calculated Premium accurately using the proper rate group based on your use of the Medical Conditions Guide? Collected Conditional Premium equivalent to the first billing cycle selected or a minimum of 2 months premium? Reminder: Monthly payment frequency is only allowed with Bank Funds Transfer or Credit Card (if available). Completed the Conditional Receipt and left it with the applicant? Bank Funds Transfer: Did you complete the authorization and attach a voided check? (if available) Credit Card: Did you complete the authorization and include the expiration date? Be sure the Credit Card is Mastercard or Visa. We do not accept Discover Card or American Express. Indicated on the Application the rate group at which you are submitting the Application? Has the applicant SIGNED and DATED the Application? Have you SIGNED and DATED the Application yourself -- AND written in the space provided your CORRECT AGENT/PRODUCER IDENTIFICATION NUMBER? (Commission cannot be paid correctly without it.) 4

8 Check List for the Agent (Cont d.) Did you provide the applicant with the following? Outline of Coverage A Shopper s Guide to Long-Term Care Insurance Conditional Receipt If you are REPLACING an existing long-term care insurance policy, have you completed a Replacement Form and submitted it with the Application? (Mandatory) Have you checked for any other state-specific forms necessary and completed them? Some State-Specific Requirements: Iowa requires a Notification of Non-Duplication for all applicants over age 65. If this applies to your applicant, have you submitted the Non-Duplication form? New York State Partnership Applications require a Consumer Participation Agreement form. If this applies to your applicant, be sure you submit the correct form. To obtain the correct form, please call Agent Services at These states require a Personal Worksheet (or Suitability Form ): Have you completed the form and obtained the applicant s signature? California Montana Colorado New Mexico Delaware North Carolina Hawaii Oklahoma Illinois Rhode Island Lousiana Wisconsin 5

9 Submitting the Application New business Applications should be submitted and received by the Company within fourteen (14) days of the Application sign date. Mail the Application and all accompanying forms to: LTC Operations One Blue Cross Place 165 Court Street Rochester, New York Summary of Application Processing The Agent submits the Application to the Company. Applications are screened for completeness. Medical Underwriting determines the appropriate Medical Underwriting Process to follow for this applicant. Applications are keyed to the system. Phone History Interview or Welcome Call is done by the Medical Underwriting Department. APS/FTF is received, if required. Medical Underwriting makes the underwriting decision. Policy Delivery to the Agent. Agent s Role in the Application Processing What you know and do will increase your success in long-term care insurance sales! Make it your goal to: Always inform your clients of the underwriting process. Improve time service by providing complete information and facilitating the process. Have a strong working knowledge of the information in this Guide to better predict the outcome of your submitted Applications. Assist Medical Underwriting Department in obtaining requirements as requested. Deliver your policies on time! 6

10 Underwriting Philosophy Our goal in underwriting is to issue your business in a timely manner. Underwriting long-term care insurance products requires attention to an applicant s current functional and cognitive ability, past medical history and current medical conditions. Underwriting Tools Welcome Call. Phone History Interview (PHI). Attending Physician Statement (APS) or Medical Records. Face-to-Face Assessment (FTF). Welcome Call A brief interview with applicant generally lasting only 5 minutes to verify the physician s name, address, and phone number and inform the applicant a nurse will be contacting them for a personal interview (Face-to-Face Assessment). Phone History Interview (PHI) Required of most applicants age 74 and younger. This is a fifteen-minute interview conducted by the Company with the applicant. We verify the information on the Application. There are some cognitive questions, and, if the questions are missed, the Company will request a FTF to determine insurability. Attending Physician Statement (APS) = Medical Record We request the last 3 years of medical information from the primary doctor and other specialists if indicated. We pay for the medical records. Medical Records are required in the following situations: - All applicants 75 and older. - If hospitalized due to a disease of unknown cause. - If proper details do not appear in the Medical Profile of the Application. - If a medication is not reasonable for the condition. - If the condition is an automatic APS as listed in the Medical Conditions Guide. - If the information obtained on the PHI does not match the information on the Application. Special Situations Applicants 75 and over who have not seen a physician in 2 years and report no medical conditions will be underwritten with a Face-to-Face Assessment. Applicants with chronic health problems who have not seen a physician in 2 years or have no medical records available are not eligible to apply. Face-to-Face Assessment (FTF) A Face-to-Face Assessment is an in-home evaluation of the applicant s daily functional and cognitive ability. It assists the underwriters to better determine an applicant s individual response to various diseases. FTF is Required: For ALL applicants 75 and over. If the condition is an automatic FTF as listed in the Medical Conditions Guide. To clarify functional or cognitive status after the phone interview to attempt to issue the policy. 7

11 Administrative Procedures ALPHABETICALLY ARRANGED Agent Application Tracking Report Each week the Agent s manager will be provided a summary report of all Applications pending. The report is run by Agent. Each Agent should be provided with a copy of the Applications pending and the current status as of Friday from the previous week. Agent of Record The Company protects the original Agent of Record. If the Agent of Record is an Agent in good standing with the Company, another Agent cannot write business on the client without a signed release from the original writing Agent. Care Management Our philosophy is to be available to assist YOUR clients and our Policyholders at the time of claim. We pride ourselves on providing expert guidance to the Policyholder and family in helping them navigate the health care delivery system and meeting their needs. All inquiries regarding a claim should be directed to our Customer Service Department at Our Care Managers/Benefit Planners/Personal Care Advocates will: Speak with the Policyholder and/or family members to explain benefits, review care needs and initiate the benefit eligibility process. Coordinate with the Policyholder and/or family to design an individualized care plan that includes policy benefits and community referrals as appropriate. Provide direction to the Policyholder regarding submitting claims. Commissions Various Compensation Agreements are available. Please review your statement upon receipt. If your records do not agree, please notify the Company immediately. All inquiries should be directed to Agency Services at * Commission checks are mailed weekly or monthly, as per our agreement. Commission reports will be generated with each commission check. *BCBS Florida: All commissions are paid through the leverage system. All questions should be directed to your assigned area manager or to Marketing Support Department at Declines by Medical Underwriting The Company notifies the Agent of the denial by fax and by mail. Single Applicants, or if Both Spouses are Denied: Refund check of the full amount of Conditional Premium is mailed directly to the applicant(s) with a copy of the denial letter. One Spouse Denied and One Spouse Issued: Refund check of the full amount of Conditional Premium for the denied spouse is mailed to the Agent with the policy for the accepted spouse. 8

12 Administrative Procedures (Cont d.) ALPHABETICALLY ARRANGED Effective Date of the Policy The Conditional Receipt determines the effective date of the policy. There is no interim insurance coverage. Insurability is determined solely by Medical Underwriting. When the applicant is determined to be insurable, Medical Underwriting will assign the Effective Date based on the rules stated on the Conditional Receipt. Note: The Company does final processing on all spouse Applications together. In the event a final decision is made by Medical Underwriting on one spouse before the other spouse is completed, the Effective Dates of the two policies could be different. CAUTION: Spousal Benefit Transfer Rider and Survivorship Rider require that both spouses have the same effective date. It will be the later of the issued policies. Special Effective Date Requests The Effective Date can never be before the Application Signed Date or 60 days greater than the Company-assigned Effective Date. Special effective date requests should be marked on the Application. Final determination is made by the Medical Underwriting Department. Errors When an error is made while completing any required documents, draw a single line through the error and have the APPLICANT INITIAL the error. NEVER USE WHITE-OUT. Issue Age The age of the applicant on the day the Application is Signed will determine the issue age and the associated premium. If the client s birthday is the day the Application is signed, the issue age will be the new age. The Company DOES NOT backdate Applications. Reminder: Our policy requires we receive the Application within 14 days of the Application signed date. Lapse Designee The Agent should request a lapse designee from each applicant. This is the person who will be notified by the Company when the Policyholder s premium is 31 days past due. It should be a person who will take action in assisting the Policyholder to pay the premium. The Company DOES NOT allow the AGENT to be the Lapse Designee unless there is a personal relationship with the client. Payment Mode/Frequency Options available per the Application. Reminder: Monthly is only allowed with credit card or EFT. Policy Delivery Packet All Policies are Mailed to the Agents for Delivery. The policy delivery packet to the Agent will include: The Policy with a Schedule Page. The rate group assigned by Medical Underwriting prints on the Schedule Page of the policy booklet. 9

13 Administrative Procedures (Cont d.) ALPHABETICALLY ARRANGED The Policyholder Acceptance Report for the Agent, detailing the Policyholder s benefit selections and rate group assigned by Medical Underwriting. A Refund check or a Bill IF the rate group assigned by Medical Underwriting is different from the rate the Agent submitted with the Application or the premium collected is not equal to the payment frequency. Policyholder Delivery Receipt Card. REMINDER: You should be sure to closely check the Policyholder Acceptance Report to determine the rate group assigned by Medical Underwriting. If it does not match the rate you submitted with the Application, you have a change to your original sale. Know the details of the policy you are delivering, both premium and benefits, to ensure PLACING the Business. Policy Delivery Receipt Cards The Company requires all policies to be delivered to the Policyholder by the Agent within 7 calendar days of Company delivery to the Agent. The Agent should explain all the provisions and benefits to the Policyholder at delivery. The Agent is required to obtain the Policyholder s signature and record the date of delivery on the Policy Delivery Receipt Card. This receipt must be returned within 7 calendar days to the Company to document the date of delivery and the beginning of the Free-Look Period. Failure to return the Policy Delivery Receipt Cards may cause a DELAY in COMMISSION payment. Policy Changes Policy Changes are defined as changes within the same product. Increases in any of the benefit selections. Requirements: - A new Application - Medical Underwriting The changed policy will be issued at the new age and with a new effective date. Note: A Policy Change Form can be used for benefit increases within the first days of delivery depending on the rules for the product you are selling. These benefit increases will be issued at original issue age and original effective date. Decrease to one or all of the benefit selections. Requirements: - Policy Change Form OR - Policyholder s Written Request. The changed policy is issued at the original issue age and is effective as of the Paid-to-Date of the original policy. 10

14 Administrative Procedures (Cont d.) ALPHABETICALLY ARRANGED Power of Attorney We do NOT accept Applications from Power of Attorney. Any applicant with a Power of Attorney for financial matters or medical matters is NOT ELIGIBLE to apply. Refusals (Not Takes) and Cancellations All refund requests must be in writing and sent to the Company for handling. A verbal request will not be considered. Every request should be dated and signed by the Policyholder. If the Company receives a request to cancel from the Policyholder, the Agent is notified and given 10 days to conserve the business. After the 10 days, the following procedure is used: Within the Free-Look Period A refund check for the full amount of submitted premium is mailed directly to the applicant. A notice of cancellation of the policy is sent to the Policyholder and the Agent. After the Free-Look Period: Depending on state regulations, the refund check will be prorated. If there is no regulation, no refund is made. A notice of cancellation of the policy is sent to the Policyholder and the Agent. Reinstatements Any policy that is beyond the grace period is considered lapsed. In order to put the policy back in force, the Company needs to receive the request in writing from the Policyholder or lapse designee. The Company will review the request, as per Policy language. Replacements Are defined by the Company as substituting a new product for an existing product. There are two types of Replacements. Replacements Always require a Replacement Form. (1) Conversions: Replacement of one of the Company s existing products. Requirements: A new Application Medical Underwriting In the Insurance Information section of the Application: Indicate yes to replacing an existing policy and list the policy currently in force. Replacement Form signed and dated by the applicant The new policy will be issued at the NEW AGE and with a NEW EFFECTIVE DATE. Conversions should be done at Policy Anniversary Only. Split Commissions will be paid meaning Renewal Commission on that portion of premium equal to the premium of the old policy and First Year Commission on the additional premium collected (providing the additional premium is at least a 20% increase in the overall annual premium). 11

15 Administrative Procedures (Cont d.) ALPHABETICALLY ARRANGED Note: If a conversion is requested NOT at Policy Anniversary, Agents will be paid renewal commission only. (2) Replacing Another Company s Policy Requirements: In the Insurance Information section of the Application: Indicate yes to replacing an existing policy and list the policy number and carrier of currently in-force policy. Replacement Form signed and dated by the applicant Depending on the state regulations, the previous carrier is notified at the time of Application submission. Some states also require renewal commission only be paid on the policy. Time Service Standards We recognize that our service to you and your clients will continue to set us apart from the rest. These are our Standards: 95% of all phone interviews are conducted within the first 5 business days we have the Application. 30% of our final underwriting decisions are made after the phone interview. 90% of all policies are delivered within 40 calendar days. Face-to-Face Assessments should be completed within 14 days. Applications aged over 60 days are withdrawn for inability to medically underwrite. This is usually due to a lack of response from the medical record request. (Special requests from the Agent or applicant to extend the time are honored.) Reminder: When the medical record request is 30 days old, we mail the doctor a letter requesting the records to prevent withdrawal of the Application. A copy of this letter goes to the Agent and the applicant. Help at this time from the Agent and applicant often improves our success at obtaining the needed information. 12