Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Ohio underwriting brochure Plans effective January 1, 2015 For businesses with 1 100 eligible employees www.aetna.com XX.XX.XXX.X 14.02.054.1-OH (X/14) A (11/14)
Underwriting guidelines This material is for informational purposes only and is not intended to be all inclusive. Other policies and guidelines may apply. Note: State and federal legislation/regulations, including Small Group Reform, HIPAA, and ACA take precedence over any and all underwriting rules. Exceptions to underwriting rules require approval of the director of underwriting, except where executive director of underwriting approval is indicated. This information is the property of Aetna and its affiliates ( Aetna ), and may only be used or transmitted with respect to Aetna products and procedures, as specifically authorized by Aetna, in writing. All underwriting guidelines are subject to change without notice. Product Availability Medical Coverage may be written standalone or with ancillary benefits. Only non-occupational injuries and disease will be covered. Dental 1 life Not available. 2 eligible employees Standard dental available with medical. Voluntary dental not available. 3 to 100 eligible employees Standard and voluntary dental plans are available with or without medical. Standalone available. Standalone dental has ineligible Industries. Retirees 50 to 100 eligible employees Standard plans can comprise no more than 10 percent of the group. Voluntary plans not eligible. Orthodontic coverage Available with 10 or more eligible employees with a minimum of five enrolled employees for dependent children only for both standard and voluntary plans. Vision Available to groups with two or more eligible employees. Single option only (dual option, triple option not available). Vision only is allowed; or can be sold with medical and ancillary products. Life and/or disability 1 life not available. 2 to 9 eligible employees if sold with medical. 10 to 50 eligible employees if sold with medical or dental. 26 to 50 eligible employees on a standalone basis. 51 to 100 eligible employees contact your Aetna sales executive. Health/dental benefits plans, health/dental insurance plans, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Health Inc., Aetna Dental Inc. Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.
Product Availability (continued) Packaged life and disability 2 to 50 eligible employees if packaged with medical. 10 to 50 eligible employees on a standalone basis. 51 to 100 eligible employees not available. A plan sponsor cannot purchase both life and packaged life and disability plans. Product packaging rule is a group level requirement. Employees will be able to individually elect life, disability or packaged life and disability insurance even if they do not elect medical coverage. Disability 1 life Not available. 2 to 50 eligible employees Groups are ineligible for coverage if 60 percent or more of eligible employees or 60 percent or more of eligible payroll are for employees over 50 years old. Conversion options are not available. Available to employees only; dependents are not eligible. Employees may elect disability coverage even if they do not elect medical coverage. 51 to 100 eligible employees Contact your Aetna sales executive. Retirees, COBRA and state continuation enrollees Not eligible for life or disability. Case Submission Dates Census Data Groups of 1 to 50 eligible employees must be received by Aetna Underwriting by the requested effective date. Groups of 51 to 100 eligible employees must be received by Aetna Underwriting no later than two business days after the requested effective date. Any case received after the cutoff date will be considered on an exception basis only, as approved by the Underwriting Unit manager. If not approved, the effective date will be moved to the next available effective date, with potential rate impact. Census data must be provided on all eligibles, including enrolled, waivers, COBRA/state continuation eligible employees. 1 to 50 eligible employees include the name, date of birth, gender and tobacco status for each employee, spouse and child; date of hire; dependent status; and residence and work location ZIP codes. 51 to 100 eligible employees the following is needed in Excel format: Member-level census is required for medical and must include first name, last name, date of birth, gender, and residence ZIP codes for all employees and dependents, including the physical work ZIP codes for all employees. The census must also include all waivers and COBRA eligible. EList may be submitted for sold groups. COBRA/State continuation enrollees should be included on the census and noted as COBRA/state continuation enrollees. If both employee and spouse work for the same company they may enroll together or separately. Rates are based on final enrollment. 3
Census Data (continued) COBRA/State Continuation Retirees 1 to 50 eligible employees not eligible. 51 to 100 eligible employees Medical retirees are eligible. A high percent of retirees may result in an additional rate up. Dental retirees cannot comprise more than 10 percent of the group. Census should be split for over and under age 65. Retirees are not eligible for life, disability or voluntary dental. Retirees are not included in the count to determine the group size. COBRA coverage will be extended in accordance with federal legislation/regulations. Employers with 20 or more employees, both full and part time, are required to offer COBRA coverage. Employers with less than 20 full-time and part-time employees are required to offer state continuation. COBRA applies to employers with 20 or more employees on more than 50 percent of its typical business days in the previous calendar year. Include: full time, part time, seasonal, temporary, union, owners, partners, officers. Exclude: self-employed persons, independent contractors (1099), directors. Each part-time employee counts as a fraction of an employee, with the fraction equal to the number of hours a part-time employee worked divided by the hours an employee must work to be considered full time. Because COBRA is directed at employers, the decision to comply with COBRA should be made by the employer. In situations where it may appear the employer is not subject to COBRA, for example a three-life group requesting COBRA, we will ask the employer to validate the number of employees in the prior calendar year in order to determine the number of employees for COBRA purposes. Companies under common ownership are included in the count. COBRA enrollees are not billed separately and are included with the group bill. State continuation is billed separately, directly to the individual. If the COBRA enrollee does not reside in a service area they are only eligible for out-of-network benefits or urgent/emergency care. Life, disability and/or voluntary dental COBRA/state continuation enrollees are not eligible. Eligible enrollees are required to be included on the census. Provide the qualifying event, length, start date and end date. 51 to 100 eligible employees COBRA/state continuation enrollees are included in the medical underwriting of the group. Note: COBRA/State continuation enrollees are not to be included for the purpose of counting employees to determine the size of the group. Once the size of the group has been determined according to the law applicable to the group, COBRA/state continuation enrollees can be included for coverage subject to normal underwriting guidelines. 4
Deductible Credit Dependent Eligibility Deductible credit applies to calendar-year plans on group-to-group takeover for individuals on the prior group plan. Members who are eligible and want to receive credit for deductible paid to prior carrier should submit a copy of the Explanation of Benefits (EOBs). The member s Social Security number (SSN) should be included on the EOB; and/or handwrite the SSN on the form to avoid delay. EOBs may be submitted with the initial new business case submission or with the member s first claim, or can be faxed to claims at 1-866-474-4040 no later than 90 days after the effective date. For faxes, please include ECHS Category: SFRE in the subject line with the group/control number in order to direct the information to the correct area for processing. Deductible credit reports may be submitted and should include the member s Social Security number. Deductible carryover not allowed. Spouse if both employee and spouse work for the same company, they may enroll together or separately. Domestic partners can be considered eligible dependents; however, the employer must choose to cover domestic partners at initial underwriting of the group. If not done at time of enrollment, approval of future request to add coverage for domestic partners will be postponed until the group s next anniversary date. If the plan sponsor elects to cover domestic partners, the plan sponsor is responsible for determining whether the domestic partner is eligible. Dependent children: Medical and dental: Children are eligible as defined in plan documents in accordance with applicable state and federal law, for medical coverage up to age 28 and dental coverage to age 26, regardless of financial dependency, employment, eligibility of other coverage, student status, marital status, tax dependency or residency. This requirement applies to natural and adopted children, stepchildren, and children subject to legal guardianship. Children can only be covered under one parent s plan when both parents work for the same company. Grandchildren are eligible if court ordered. A copy of the court order must be submitted. Incapacitated child: Attainment of limiting age will not terminate the coverage of the child while the child is and continues to be both incapable of self-sustaining employment by reason of mental retardation or physical handicap and chiefly dependent on the employee or member for support and maintenance. The employee or member must provide proof of incapacity and dependency within 31 days of the child s attainment of the limiting age and subsequently as we ask. We will not ask for this proof more often than annually after the two-year period after the child reaches the limiting age. Dependent life: Dependent children are eligible from birth up to their 26th birthday. 2 to 9 eligible employees dependents are not eligible for life and disability. Medical and dental dependents must enroll in the same benefits as the employee (participation not required). Employees may select coverage for eligible dependents under the dental plan even if they selected single coverage under the medical plan. Employees must elect supplemental life to purchase dependent life. Individuals cannot be covered as an employee and dependent under the same plan, nor may children be eligible for coverage through both parents and be covered by both under the same plan. 5
Effective Date Electronic Funds Transfer (EFT) Employee Eligibility The effective date must be the 1 st or the 15 th of the month. The effective date requested by the employer may be up to 60 days in advance. Payment for the first month s premium at new business can be processed by an electronic funds transfer/ach. Once the group is issued, customers can pay their monthly premiums online or by calling an automated phone number, 1-866-350-7644, using their checking account and routing number. There is no extra charge for this service. Eligible employees are those who work for an employer on a full-time basis, with a normal work week of 25 or more hours, and who have met any authorized waiting period requirements. 2 to 50 eligible employees an employer may not set eligibility rules that would require an employee to work more than 25 hours a week to obtain coverage. As long as the employee meets the 25 hour per week standard he or she is considered full-time for purposes of coverage. 51 to 100 employees if the normal work week is more than 25 hours per week, this should be indicated on the employer application at the time of new business submission. Note: the normal work week cannot be less than 25 hours. Eligible employees include union employees, even if currently covered under the union plan. While they must be included in the count in determining whether or not the group meets the definition of a small employer and is subject to SGR rules, the employer may carve out union employees as an excluded class. Ineligible employees include leased, part time, temporary, seasonal or substitute employees, 1099 contractors, uncompensated employees, employees making less than equivalent minimum wage, volunteers, inactive owners, directors, shareholders, officers, outside consultants, managing members who are not active, investors or silent partners. Employees are eligible to enroll in the dental plan even if they do not select medical coverage and vice versa. Retirees 1 to 50 eligible employees Retirees are not eligible to enroll. 51 to 100 eligible employees Medical retirees are eligible. Groups with more than five percent early/non-medicare retirees will have an additional factor applied. Dental retirees cannot comprise more than 10 percent of the group. Life, disability and voluntary dental retirees are not eligible. The retiree must be currently covered with present carrier (must be shown on the bill roster or provide a copy of the ID card). If there were no retirees covered by the prior carrier, the employee must be covered as an employee on the bill roster and on the quarterly wage and tax statement. Retirees are not included in the total count to determine the case size. Employer Contribution Medical 1 to 50 eligible employees 50 percent of employee-only premium or a minimum defined contribution of $120 per employee. Groups that do not meet contribution are eligible to enroll during open enrollment, November 15 through December 15, for a January 1 effective date. 51 to 100 eligible employees 75 percent of the employee-only cost or 50 percent of the total cost of the plan. - - The employer cannot fund the deductible in excess of 50 percent annually whether through a HRA, HSA or any other arrangement or will be subject to a rating adjustment. 6
Employer Contribution (continued) Dental 2 to 50 eligible employees 25 percent of the total cost or 50 percent of the cost of employee-only coverage for dental plans. If the employer contributes less than the above guideline, or if the coverage is 100 percent paid by the employee coverage is deemed voluntary. 51 to 100 eligible employees Standard plans employer must contribute. Excludes employee pay all plans. Voluntary plans 100 percent employee paid. If the employer pays 100 percent the group is not eligible for a voluntary plan and would get a standard plan. Life and disability 2 to 9 eligible employees 100 percent of the total cost of the life and/or disability coverage. 10 to 100 eligible employees 50 to 100 percent. Coverage can be denied based on inadequate contributions. Employer Definition (1 to 50 eligible employees) Employer Eligibility Small employer means, in connection with a group health benefit plan and with respect to a calendar year and a plan year, an employer who employed an average of at least one but no more than fifty eligible employees on business days during the preceding calendar year and who employs at least one employee on the first day of the plan year. Groups that do not meet the definition of a small employer are not eligible. 1 to 50 eligible employees One employee does not include sole proprietors. There must be at least one eligible W-2 employee who is not an owner and not an owner s spouse. A husband and wife with no other employees are considered co-sole proprietors and are not considered a group. They are owners and not employees. It doesn t matter whether they take a draw at the end of the year or receive W-2s. Example Floral shop may have 1 full-time manager with part-time help The owners aren t involved in the day to day business The full-time manager is eligible Medical plans can be offered to sole proprietorships, partnerships or corporations. Organizations must not be formed solely for the purpose of obtaining health coverage. Associations, Taft Hartley groups, professional employers organizations (PEO)/employee leasing firms and closed groups (groups that restrict eligibility through criteria other than employment) and groups where no employer/employee relationship exists are not eligible. Dental and disability have ineligible industries that are listed separately. The dental list does not apply when dental is sold in combination with medical. 7
Excluded Class/ Carve Outs Medical Union employees are the only class of employees that may be excluded. However, union employees are included in the total count of eligible employees in determining the case size. Management carve-outs. 1 to 50 eligible employees not permitted 51 to 100 eligible employees permitted with underwriting management approval. Groups that carve out a specific class of employees for coverage may have an additional factor applied even if standard participation requirements are met. Dental Union employees if packaged with medical. Life and disability Union employees if packaged with medical. Initial Premium Late Applicants The initial premium payment should be the total of the first month s premium for all products (medical, life, disability, dental, vision); and may be in the form of a check or electronic funds transfer (EFT). Submit a copy of the initial premium check payable to Aetna or complete the ACH/EFT form and include with the new business group enrollment applications. Once coverage is approved, we will advise you where to mail the initial premium check. If the check is not submitted, coverage will terminate retroactive to the case effective date. If the EFT method is selected, the initial premium will be withdrawn from the checking account when the group is approved. This is a one-time authorization for the first month s premium only. The initial premium payment is not a binder check and does not bind Aetna to provide coverage. If the initial premium payment is returned by the bank for nonsufficient funds, we will follow the standard termination process. If the request for coverage is withdrawn or denied due to business ineligibility, we will return the premium to the employer. If the group is currently with Aetna and adding another product (medical, dental, life, disability, vision), no premium payment is required at the time of enrollment. An employee or dependent enrolling for coverage more than 31 days from the date first eligible or 31 days of the qualifying event is considered a late enrollee. Applicants without a qualifying life event (that is, marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are subject to the late entrant guidelines as noted below. Voluntary cancellation of coverage is NOT a qualifying event unless it is done at open enrollment. For example, if a spouse is covered through his/her employer and voluntarily cancels the coverage, it is not a qualifying event to be added to the other spouse s plan. The spouse who cancelled the coverage must wait until the next open enrollment to be eligible to enroll. However, if each spouse has different open enrollment dates and drops coverage during their annual open enrollment period, the spouse is eligible to enroll. Medical We will defer late applicants to the next plan anniversary date of the group and may reapply for coverage 30 days before the anniversary date. 8
Late Applicants (continued) Dental An employee or dependent may enroll at any time; however, coverage is limited to preventive and diagnostic services for the first 12 months. No coverage for most basic and major services for first 12 months (24 months for orthodontics). Late entrant provision does not apply to enrollees less than age five. Life and disability Late applicants are deferred to the next plan anniversary date of the group and may reapply for coverage 30 days before the anniversary date. The applicant will be required to complete an individual health statement/questionnaire and provide EOI. Example Group has $50,000 life with $20,000 guarantee issue limit Late enrollee enrolling for $50,000 would not automatically get the $20,000 Since the applicant is late he or she must medically qualify for the entire $50,000 Licensed, Appointed Producers Live/Work (medical) Medical Underwriting (51 to 100 eligible employees) Medicare (MSP) for CMS Reporting Only appropriately licensed agents/producers appointed by Aetna may market, present, sell and receive commission on the sale of Aetna products. License and appointment requirements vary by state and are based on the contract state of the employer group being submitted. To become appointed with Aetna go to www.aetna.com/insurance-producer/index.html and click Start working with Aetna. Health Network Option (HNOption) employees who live or work within 100 miles of the primary business location are eligible for the same plan(s) as the group. PPO, traditional employees who live or work within 60 miles of the primary business location are eligible for the same plan(s) as the group. For employees who reside outside the 60/100 miles, see the out-of-state guidelines in the product specification section. Employees must complete an Aetna individual health questionnaire. These cases may be rated up. Groups seeking coverage for the first time may be required to provide an Aetna individual health questionnaire. These cases may be rated up. Medical conditions of COBRA and/or state continuation enrollees are included in this rating calculation. Medical claims may be reviewed for any individuals who had prior Aetna coverage and used along with the health information included on the employee application(s), and included in the overall medical assessment of the group. Each year, all carriers must report to CMS (Centers for Medicare & Medicaid Services) the number of Medicare secondary payer (MSP) groups and the number of employees, based on the number of employees provided by the employer. MSP is the term used by Medicare when Medicare is not responsible for paying first. This is generally when the Aetna plan would pay primary to Medicare for active employees and would pay first when there are 20 or more total employees (full and part time) for 20 or more weeks during this calendar year or prior calendar year. Include: full time, part time, seasonal, temporary, union, owners, partners, officers Exclude: self-employed persons, independent contractors (1099), directors, leased employees 9
Multi-Option Offerings (medical only) Municipalities and Townships Newly Formed Business (in operation less than 3 months) Allows employers to offer up to three Aetna medical plans to the employees. The group must have five or more enrolled employees. All employees will be rated for each plan. Zero member enrollment is allowed. Savings Plus plans cannot be coupled with their counterpart, non-savings Plus plans in any dual or triple option offering. Only one HSA plan can be offered. Groups may offer an additional PPO/indemnity plan for out-of-state subscribers. These plans will not count toward the maximum noted above. A township is generally a small unit that has the status and powers of local government. A municipality is an administrative entity composed of a clearly defined territory and its population, and commonly denotes a city, town, or village. A municipality is typically governed by a mayor and city council, or municipal council. In most countries a municipality is the smallest administrative subdivision to have its own democratically elected officials. Underwriting requirements for groups with 1 to 50 eligible employees Provide quarterly wage and tax statement (QWTS). W-2 Elected or appointed officials and trustees may be eligible for group coverage based on the charter or legislation. If so, they may not be on the QWTS; rather they may be paid via W-2 and must provide a copy of their W-2. If elected officials are to be covered, provide a copy of the charter or contract indicating which classes or employees are to be covered, the minimum hours required to work per week to be eligible for coverage, and confirmation that coverage will be offered to all employees meeting the minimum number and participation will be maintained. 1 to 50 eligible employees provide the following documentation: Sole proprietor A copy of the business license (not a professional license). Partnership or limited liability partnership Limited liability company Corporation A copy of the partnership agreement. A copy of the articles of organization and the operating agreement to include the signature page(s) of all officers. A copy of the articles of incorporation that includes the signature page(s) of all officers (must be followed up with a copy of the statement of information within 30 days of filing with the state). Each newly formed business must also provide: Proof of employer identification number/federal tax ID number; and Quarterly wage and tax statement. If not available, provide the date when will one be filed; and The two most recent payroll records that include hours worked, taxes withheld, check number and wages earned; or A letter from a CPA with the following information: 1. A list of all employees, to include owners, partners, officers (full time and part time) 2. Number of hours worked by each employee 3. Weekly salary for each employee 4. Date of hire for each employee 5. Whether payroll records have been established 6. When a QWTS will be filed 51 to 100 eligible employees subject to medical underwriting. 10
Option Sales Alongside Other Carriers Medical Medical coverage must be sold on a full-replacement basis in order to meet and maintain participation. Employees covered by the same employer on another group policy are not considered a valid waiver. 1 to 50 eligible employees groups that do not meet participation are eligible to enroll during open enrollment, November 15 through December 15, for a January 1 effective date. 51 to 100 eligible employees groups that do not meet participation may have an additional factor applied. Dental Not allowed. Must be sold on a full-replacement basis. Life and disability Not allowed. Must be sold on a full-replacement basis. Out-of-State (OOS) Employees (residing outside of Ohio) Medical Any active employee who lives in a state other than where the company is domiciled is considered an out-of-state employee. Out-of-state employees must be enrolled in a PPO plan if available, otherwise an indemnity plan. PPO is not available in North Dakota. Indemnity is not available in Hawaii and Vermont. Louisiana residents employees residing in Louisiana are required to have a separate plan quoted and sold based on Louisiana rates and benefits. These employees are still underwritten as part of the group; however, the plans and rates for the Louisiana members will not be based on where the employer is located. This will require Louisiana employer and employee applications to be completed. Dental Members who reside out of state (OOS) will receive the same plan as in-state members (based on state rules and network availability). This applies to DMO, PPO and FOC dental plans. If an OOS member resides in a state that does not allow the in-state plan those members will be placed into an available PPO or indemnity plan. Life and disability Employees are eligible for the same plan selected by the employer. Participation Medical Noncontributory plans (employer pay all) 100 percent participation is required, excluding valid waivers. Contributory plans 75 percent excluding valid waivers, rounding down. Example 12 minus 3 valid waivers = 9 9 x 75 percent = 6.75 = 6 must enroll 1 to 100 eligible employees Dependent participation is not required. All employees waiving coverage must complete the waiver section of the employee application. 11
Participation Medical (continued) 1 to 50 eligible employees Groups that do not meet participation are eligible to enroll during open enrollment, November 15 through December 15, for a January 1 effective date. 51 to 100 eligible employees Groups that do not meet participation may have an additional factor applied. Valid waivers Spousal/parental group coverage Medicare/Medicaid ChampUS/ChampVA Military coverage Individual coverage (on and off exchange) Association coverage (for doctors/lawyers covered under an association who want to cover their employees) Participation Dental 1 life Group dental plans are not available. Noncontributory plans (employer pay all) 100 percent, excluding valid waivers. Contributory plans with medical or standalone (round to the nearest whole number) Standard 2 to 3 eligible employees 100 percent, excluding valid waivers, and a minimum of two enrolled. 4 to 50 eligible employees 75 percent, excluding valid waivers. A minimum of two and 50 percent of total eligible employees must enroll in the dental plan. 51 to 100 eligible employees 30 percent, excluding valid waivers. Voluntary dental 3 to 100 eligible employees 30 percent, excluding valid waivers. Minimum of three must enroll. If a group does not qualify for a standard plan and has 30 percent or more participation then group qualifies for voluntary. Valid waivers Spousal/parental group coverage ChampUS/ChampVA - military coverage Association coverage (for doctors/lawyers covered under an association who want to cover their employees) Voluntary and standalone Employees may select coverage for eligible dependents under the dental plan even if they elected single coverage on the medical plan or vice versa. Coverage can be denied based on inadequate participation. 12
Participation Life and Disability 1 life Group life insurance is not available. 2 to 9 eligible employees 100 percent participation is required. 10 to 50 eligible employees Noncontributory (employer pay all) 100 percent participation is required. Contributory 75 percent participation is required. 51 to 100 eligible employees 50 to 100 percent Standalone life/disability/packaged life & disability 26 to 50 eligible employees 75 percent participation is required. All groups COBRA and state continuation are not eligible. Retirees are not eligible. Employees may elect life insurance even if they do not elect medical coverage and the group must meet the required participation percentage. If not, then life will be declined for the group. Example 9 employees 3 waiving medical 9 must enroll for life Coverage can be denied based on inadequate participation PEO (Professional Employer Organization) groups covered under a PEO Plan Change Ancillary Additions Plan Change Employee Level Groups currently with a PEO may be eligible as long as the PEO provides payroll specific for the enrolling group and we can determine the size and eligibility of the group, even though the group may be reported under the PEO tax ID, the group may be considered subject to underwriting approval. A letter of intent is not needed. 51 to 100 employees groups currently with an Aetna PEO should provide members Social Security numbers with the quote request so claims can be reviewed. The future renewal date of the ancillary products will be the same as the Medical plan renewal date. Package life/disability must be requested 30 days before the desired effective date. Dental plans must be requested 30 days before the desired effective date. Nonpackaged plan changes are available upon renewal. Medical Employees are not eligible to change plans until the group s open enrollment period, which is upon their annual renewal (except for qualified special enrollment events). Dental Freedom-of-Choice may change from DMO to PPO and vice versa at any time but must be received in Aetna underwriting by the 15 th to be effective the next month. Life and disability Employees are not eligible to change plans until the group s open enrollment period, which is upon their annual renewal (except for qualified special enrollment events). 13
Plan Change Group Level Medical Plan anniversary date only. Dental Dental plans must be requested 30 days before the desired effective date. The future renewal date of the change will be the same as the medical plan anniversary date. Life and disability Packaged life/disability must be requested 30 days before the desired effective date. Non-packaged plans are only available on the plan anniversary date. The future renewal date of the change will be the same as the medical plan anniversary date. Prior Aetna Coverage Rates Groups that we have terminated for nonpayment must pay all premiums still owed on the prior Aetna plan before we will issue the new plan. 51 to 100 eligible employees we may review medical claims for any individual who had prior Aetna coverage. We may use that information, along with the health information provided about the employee, and included in the overall medical assessment of the group. 1 to 50 eligible employees Rates are member rated based on each member s date of birth and tobacco status. 51 to 100 eligible employees Current rates are required at initial time of proposal. Composite rates four-tier structure: single, couple, employee plus child(ren), family. New business rating may be rerated if enrollment changes by more than +/- 10% from the initial quote enrollment projection. 1 to 100 eligible employees Rates are based on final enrollment. All quotes are subject to change based on additional information that becomes available in the quoting process and during the case submission/installation, including but not limited to any change in census. If we determine that any of the information we receive is incomplete or incorrect, we reserve the right to adjust rates. Replacing Other Group Coverage Savings Plus Plans Do not cancel any existing medical coverage until the employer has been notified of approval from the Aetna Underwriting unit. 51 to 100 eligible employees claims experience is required unless the prior carrier is known not to release claims experience. Medical underwriting is required; known high-cost or emergent conditions must be provided. Current rates are required from the current carrier and renewal rates should also be provided. The employer must have a history of staying with their carrier for several years. Dental - provide a copy of the benefit summary to verify: Major and orthodontic coverage for standard 2 to 9 and voluntary 3 to 100 eligible employees; and Preventive and basic coverage for voluntary plans. Underwriting guidelines for the Savings Plus plans follow the same guidelines as the small group standard portfolio. Plans can be offered as a triple option (up to three plans with five enrolled) next to a standard plan in the portfolio. Savings Plus plan cannot be offered to a like broad network non-savings Plus plan. Plans cannot be offered to employees out of state (OOS) or outside one of the specified counties/zip codes. Eligible employees must reside or work in the Savings Plus area. 14
Signature Dates Spin-Off Groups (current Aetna customers leaving an Aetna group only) Standard Industrial Classification (SIC) Codes Tax Documents 1 to 9 ENROLLED Employees AND 10 to 50 ENROLLED Employees with NO Prior Coverage The Aetna employer application and all employee applications must be signed and dated before and within 90 days of the requested effective date. The employee himself/herself must complete the employee application. We will consider the group with the following documentation: A letter from the group or broker indicating the group is enrolling as a spin-off. Letter needs to include the name of the group they are spinning off from. Ownership documents showing that the spin-off company is a newly formed separate entity. A minimum of two weeks payroll. If the group that is spinning off has been in business longer than two weeks, payroll will be required for the amount of time in business up to a maximum of six consecutive weeks. 51 to 100 eligible employees current Aetna customers leaving an Aetna group may have medical claims reviewed along with the health information provided on the employee application and included in the overall medical assessment of the group. Underwriting will use a variety of tools, including Dun & Bradstreet, to verify a group s industry code and classify the business correctly. All industries are eligible for medical. 51 to 100 eligible employees the employer should provide the SIC code and/or nature of business. Dental, life and disability have ineligible industries. See dental and life sections. Groups must provide a copy of the most recent quarterly wage and tax statement (QWTS) containing the names, salaries, etc., of all employees of the employer group Newly hired employees, terminated and part-time employees should be noted accordingly on the QWTS The reconciled QWTS should be signed and dated by the employer If a QWTS is not available, explain why and provide a copy of payroll records Churches must provide Form 941, including a copy of the payroll records with employee names, wages and hours matching the totals on Form 941. Proprietors, partners or officers of the business who do not appear on the QWTS must submit one of the following identified documents. This list is not all inclusive. The employer may also provide any additional documentation to establish eligibility. Sole proprietor Franchise Limited liability company (LLC) (operating as a sole proprietor) Partner Partnership Limited liability partnership IRS Form 1040 along with Schedule C (Form 1040) IRS Form 1040 along with Schedule SE (Form 1040) IRS Form 1040 along with Schedule F (Form 1040) IRS Form 1040 along with Schedule K-1 (Form 1065) Any other documentation the owner would like to provide to help determine eligibility IRS Form 1065 (Schedule K-1) IRS Form 1120 S (Schedule K-1) along with Schedule E (Form 1040) Partnership agreement if established within two years listing eligible partners Any other documentation the owner would like to provide to help determine eligibility 15
Tax Documents 1 to 9 ENROLLED Employees AND 10 to 50 ENROLLED Employees with NO Prior Coverage (continued) Corporate officer S-corporation Personal service corporation Corporate officer C-corporation Limited liability company (LLC) operating as C-corp IRS Form 1120 S (Schedule K-1) along with Schedule E (Form 1040) IRS Form 1120 W (Personal Service Corp) IRS Form 1040 ES (Estimated Tax) (S-corp) IRS Form 8832 (Entity classification as a corporation) W-2 Form Articles of Incorporation if established within two years listing corporate officers Any other documentation the owner would like to provide to help determine eligibility If the officers/owners are on the quarterly wage and tax statement, no additional documents are needed 1120 (Corporation income tax return) 1120A (Corporation short-form income tax return) Articles of Incorporation if established within two years - corporate officers must be listed Any other documentation the owners would like to provide to help determine eligibility Tax Documents 10 to 50 ENROLLED Employees with Prior Coverage Tax Documents 51 to 100 Eligible Employees Tobacco Rates (1 to 50 eligible employees) Total Average Employees No documentation is required QWTS or prior carrier bill is not needed. Upon request, the underwriter will contact the broker if a QWTS is necessary. Tax records are not needed. Tobacco rates for medical plans apply to any person age 18 or older (as of the effective date) who has used tobacco products (cigarettes, pipe, cigars, snuff, or chewing tobacco) an average of four or more times per week within the past six months. This only applies to enrolling person(s) that meets or exceeds the state-defined legal tobacco age. Tobacco rates do not apply to: Individuals who are participating in a cessation program; Religious or ceremonial uses of tobacco (for example, by American Indians and Alaska Natives). For new business sold cases, be sure and answer the question on the Aetna employer application. If you have questions, please refer to the Addendum to New Business Input Document (total average employee form) available on Producer World : www.aetna.com/employer-plans/ small-business/index-smallgroup.html. 16
Two or More Companies Affiliated, Associated or Multiple Companies, Common Ownership (1 to 50 eligible employees) Employers who have more than one business with different tax identification numbers (TINs) may be eligible to enroll as one group if the following are met: One owner has controlling interest of all businesses to be included; or The owner files (or is eligible to file) an Affiliations Schedule, IRS Form 851, a combined tax return for all companies to be included. If they are eligible but choose not to file Form 851, please indicate as such and provide a copy of the latest tax return. All businesses filed under one combined tax return will be considered a single group. For example, if the employer has three businesses and files all three under one combined tax return, then all three businesses must be enrolled for coverage. If the request is for only two of the three businesses to be enrolled, the group will be considered a carve-out. Businesses with equal controlling interest may be considered, if the owners of the company designate an individual to act on behalf of all the groups. There are 50 or fewer eligible employees in the combined employer groups. Underwriting reserves the right to final underwriting review, and may consider common ownership on a case-by-case basis. Example One owner has controlling interest of all companies to be included: Company 1 Jim owns 75 percent and Jack owns 25 percent Company 2 Jim owns 55 percent and Jack owns 45 percent Both companies can be written as one group since Jim has controlling interest in both Two or More Companies Affiliated, Associated or Multiple Companies, Common Ownership (51 to 100 eligible employees) Vision If the companies file taxes together, provide a copy of the 851 tax form. If the companies do not file taxes together, provide a letter on company letterhead listing each company and percent of ownership for each individual. One owner must have at least 51 percent ownership in each company. Complete the Single Employer Plans Form. An officer of the company must sign the letter. The two or more groups may have different Standard Industrial Classification (SIC) codes, however, we will base rates on the SIC code for the group with the majority of employees. Available to groups with two or more eligible employees. The employer may only offer one vision plan to all employees. To enroll, submit a list of employees and dependents with vision plan indicated. The list can be sent via e-mail, Word doc, Excel, or, EList. You can also mark vision on the Employee Application. The initial premium can be included with payment for medical, dental or life, or can be separate. No minimum participation or contribution requirements. Waivers are not needed as participation is not required. 17
Waiting Period At initial submission of the group, we will waive the benefits waiting period (BWP) at the employer s request. Please indicate this on the Aetna employer application. An employer may define one or two BWPs and must consistently apply them within the employee classifications. The BWP for future employees may be the 1 st or 15 th of the month following 0 days, 30 days, 60 days or exactly 90 days after the employee s date of hire. Date of hire BWP is not available. You can only change the BWP on the anniversary date. You cannot change a BWP retroactively. You must consistently apply BWPs to all employees, including newly hired key employees. For new hires, the eligibility date will be the first day of the policy month after the waiting period, not to exceed 90 calendar days. Policy month refers to the contract effective date of the 1 st or 15 th. If 0 days is selected and the employee is hired on the first of the month, the effective date will be the date of hire. If Exactly 90 Days is selected the enrollment eligibility date will begin 90 calendar days from the date of hire. If the group has a 15 th of the month bill cycle the new hire will be effective on the 15 th of the month following date of hire. Examples 1 st of the month following the BWP 15 th of the month following the BWP 0 days Date of hire: 4/1 Effective date: 4/1 0 days Date of hire: 4/18 Effective date: 5/1 30 days Date of hire: 4/18 Effective date: 6/1 60 days Date of hire: 4/18 Effective date: 7/1 Date of hire: 4/1 Effective date: 4/15 Date of hire: 4/18 Effective date: 5/15 Date of hire: 4/18 Effective date: 6/15 Date of hire: 4/18 Effective date: 7/15 90 days exact Date of hire: 4/18 Effective date: 7/16 not 8/1 exactly 90 days from the date of hire Date of hire: 4/18 Effective date: 7/16 not 8/15 exactly 90 days from the date of hire 18
Dental Coverage Waiting Period Standard 2 to 9 eligible employees and voluntary 3 to 100 eligible employees PPO and indemnity plans for major and orthodontic services employees, must be an enrolled member of the employer s plan for one year before becoming eligible. Ortho is only available to groups with 10 or more employees. DMO there is no waiting period. Discount plans do not qualify as previous coverage. Future hires waiting period applies regardless if takeover. Virgin group (no prior coverage) the waiting periods apply to employees at case inception as well as any future hires. Takeover/replacement cases (prior coverage) you must provide a copy of the last billing statement and schedule of benefits in order to provide credit. If a group s prior coverage did not lapse more than 90 days prior, the waiting periods are waived. In order for the waiting period to be waived, the group must have had a dental plan in place that covered major (and orthodontic, if applicable) immediately before our takeover of the business. Example Prior major coverage but no orthodontic coverage Aetna plan has coverage for both major and orthodontic The waiting period is waived for major services but not for orthodontic services Standard 10 to 100 eligible employees No waiting period. Creditable Prior Coverage Voluntary plans Plans that cover preventive and basic services will satisfy our requirements for having prior creditable coverage as long as the member was covered for 12 months under a dental plan within the last 90 days that included both preventive and basic coverage. You must provide a copy of the schedule of benefits to receive credit. Preventive only or discount plans do not meet the requirements for having prior creditable coverage. These groups will continue to be written has having no prior coverage. 19
Dental Ineligible Industries All industries are eligible if sold with medical. The following industries are not eligible when dental is sold standalone or packaged only with life. Bowling Centers 7933 7933 Physical Fitness Facilities 7991 7991 Business Associations 8611 8611 Private Households 8811 8811 Dance Studios, Schools 7911 7911 Professional Membership Organizations, Labor Unions, Civic Social and Fraternal Orgs, Political Orgs Employment Agencies 7361 7363 Professional Sports Clubs & Producers, Race Tracks 8621 8651 7941 7948 Miscellaneous Amusement/ Recreation 7999 7999 Public Golf Courses, Amusements, Membership Sports & Recreation Clubs 7992 7997 Miscellaneous Membership Org 8699 8699 Religious Organizations 8661 8661 Miscellaneous Services 8999 8999 Theatrical Producers, Bands, Orchestras, Actors 7922 7929 Open Enrollment Standard An open enrollment is a period when any employee can elect to join the dental plan without penalty, regardless if they previously declined coverage during the first 31 days of initial eligibility. Standard plans with medical or standalone 2 to 9 eligible employees no open enrollment. 10 to 50 eligible employees employees/dependents who do not enroll when initially eligible are now eligible to enroll during a subsequent open enrollment period without being subject to the late entrant provision. Voluntary plans with medical or standalone 2 to 100 eligible employees no open enrollment. Option Sales Product Packaging Reinstatement (applies to voluntary plans only) Option sales alongside another dental carrier are not allowed. All dental plans must be sold on a full-replacement basis. Refer to the Plan Guide dental footnotes page for plan availability. DMO cannot be sold as standalone and must be packaged with any PPO option as dual option. Members once enrolled who have previously terminated their coverage by discontinuing their contributions may not re-enroll for a period of 24 months. All coverage rules will apply from the new effective date including, but not limited to, the coverage waiting period. 20
Life and disability Actively-at-Work Continuity of Coverage (no loss/no gain) Evidence of Insurability (EOI) Employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full-time work one full day. The employee will not lose coverage due to a change in carriers. This protects employees who are not actively at work during a change in insurance carriers. If an employee is not actively at work, we will waive the actively-at-work requirement and provide coverage for a maximum of 12 months from the policy effective date, except no benefits are payable if the prior plan is liable. If the employee has not returned to active work before the end of the 12-month period, you must offer the conversion. Evidence of insurability (EOI) means the person must complete an individual health statement and may have to submit medical records at their expense. EOI is required when one or more of the following conditions exist: Life insurance coverage amounts requested are above the guaranteed standard issue limit. Late enrollee coverage is not requested within 31 days of eligibility for contributory coverage. New coverage is requested during the anniversary period. Coverage is requested outside of the employer s anniversary period due to qualifying life event (that is, marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) Reinstatement or restoration of coverage is requested. Dependent coverage option was initially refused by employee but requested later. The dependent would be considered a late entrant and subject to EOI, and may be declined for medical reasons. Requesting life or disability at the individual level and they are a late enrollee even if enrolling on the case anniversary date. Late enrollees are not eligible for the guarantee issue limit. Example Group has $50,000 life with $20,000 guarantee issue limit Late enrollee enrolling for $50,000 would not automatically get the $20,000 Since the applicant is late, they must medically qualify for the entire $50,000 Guaranteed Issue Coverage Aetna provides certain amounts of life insurance to all timely entrants without requiring an employee to answer any medical questions. These insurance amounts are called guaranteed issue. Employees wishing to obtain increased insurance amounts will be required to submit evidence of insurability, which means they must complete a medical questionnaire and may be required to provide medical records. On-time enrollees who do not meet the requirements of evidence of insurability will receive the guaranteed issue life amount. Late enrollees must qualify for the entire amount and are not guaranteed any coverage. 21