Medical Underwriting Guidelines

Medical Underwriting Guidelines
Small Group
Provider Directory
Aetna
Anthem Blue Cross
Blue Shield
DocFind
Find a Doctor
Find a Provider
Group Size
 1-100 FTEs
 1-100 FTEs
 1-100 FTEs
DE-9C
 1-5 Enrolled: Required
 Required
 1-9 Enrolled: Required
 6-100 Enrolled: Not required
 6-100 Enrolled: May submit carrier bill in lieu of
DE-9C
 10-100 Enrolled: Not required
Rate Guarantee
 12 months
 12 months
 12 months
Rate Adjustments
 January, April, July, October
 January, April, July, October
 January, April, July, October
Rates
 Employee & Dep: Employer zip code
 Employee & Dep: Employer zip code
 Employee & Dep: Employer zip code
 OOS Employee: Employer zip code
 OOS Employee: Employer zip code
 OOS Employee: Employer zip code
 New Hire: Based on age at time of enrollment
 New Hire: Based on age at time of enrollment
 New Hire: Based on age at time of enrollment
 64+: One rate for everyone
 64+: One rate for everyone
 1st of month
 1st of month
 1st of month
 15 of month (only if no prior coverage or prior
carrier termination coincides)
 15 of month
 15th of month allowed (PPO only; only when
group loses Medical coverage mid-month)
 1st of month after date of hire
 1st of month after date of hire
 1st of month after date of hire
 1 of month after 30 days
 1 of month after 1 month
 1st of month after 30 days
 1 of month after 60 days
 1 of month after 2 months
 1st of month after 60 days
 If 1 of month DOH, effective date IS NOT same
day
 If 1 of month DOH, effective date IS NOT same
day
 If 1st of month DOH, effective date IS NOT same
day
 Orientation Period: Excluded
 Orientation Period: Excluded
 Orientation Period: Excluded
 Dual waiting periods are not allowed
 Dual waiting periods are not allowed
 Dual Waiting periods are not allowed
Qualifying Event Window
 60 days
 60 days
 60 days
Open Enrollment
 Yes: Medical
 Yes: All products
 Yes: All products
 Full-Time: Yes
 Full-Time: Yes
 Full-Time: Avg 30+ hrs/week over 1 month
 Part-Time: 20+ hrs/week for at least 50% of the
previous calendar quarter
 Part-Time: 20+ hrs/week for at least 50% of the
weeks in the previous calendar quarter
 Part-Time: 20+ hrs/week for 50% of the previous
calendar quarter
 1099 Employees: Not eligible
 1099 Employees: Not eligible
 1099 Employees: Not eligible
COBRA / Cal-COBRA
 No max
 No max
 No Max
Out-of-Area / State
 Max 49% of eligibles out-of-state
 Max 49% of eligibles out-of-state
 Max 49% of eligibles and enrolled out-of-state
 Employees and dependents in Hawaii and
Vermont are not eligible
 Employees and dependents in Hawaii are not
eligible
 Employees and dependents in Hawaii are not
eligible
 Valid:
 Valid:
Effective Date
th
Waiting Period
st
st
st
th
st
st
st
 No: Dental
Eligibility
 MC & PPO plans not available in HI, LA, ND, and
VT
 Valid:
Waivers
Group spousal coverage
Group spousal coverage
Group spousal coverage
Group coverage with another ER
Group coverage with another ER
Group coverage with another ER
COBRA coverage with another ER
COBRA coverage with another ER
COBRA coverage with another ER
Medicare / Medi-Cal
Medicare / Medi-Cal
Medicare / Medi-Cal
Military
Military
Individual & Individual Exchange
Hawaii state plan
 Non-Valid:
Group coverage through another HMO
Individual & Individual Exchange
 Non-Valid:
Military
 Non-Valid:
Group coverage through another HMO
Individual & Individual Exchange
Group coverage through another HMO
Owner Only Groups
(All Business Structures)
 Only allowed if at least 1 NON-SPOUSE / NONOWNER W2 employee enrolls in Medical
 Only allowed if group has at least 1 NONSPOUSE / NON-OWNER W2 eligible employee
(or an owner qualifying as a common law
employee) except S-Corps or Partnerships
 Only allowed if group has at least 1 NONSPOUSE / NON-OWNER W2 eligible employee
beere&purves │ beerepurves.com │ 1350 treat blvd. suite 470 │ walnut creek ca 94597 │ 888.722.3373 │ lic #0005851 │ pg 1 │110116
Medical Underwriting Guidelines
Small Group
Carve-Outs
Aetna
Anthem Blue Cross
Blue Shield
 Non-Union carve-outs allowed
 Non-Union carve-outs allowed
 Non-Union carve-outs allowed
 Min 5 CA enrollees
 Total group size (union and non-union) must be
100 or fewer FTEs
 Total group size (union and non-union) must be
100 or fewer FTEs
 Total group size (union and non-union) must be
100 or fewer FTEs
Participation
 1-3 Enrolled: 100%
 1-4 Enrolled: 70%
 1-4 Enrolled: 65%
(sole carrier)
 4-100 Enrolled: 60% (rounded down)
 5-100 Enrolled: 30%
 5-100 Enrolled: 25%
 Vitalidad Mexico con Aetna: 65% min 1 enrolled
in Vitalidad network area
 100% contribution requires 100% participation
100% contribution requires 100% participation
 100% contribution requires 100% participation
Participation
 40% min and 5 enrolled
 1-4 Enrolled: 70%
 25% or min 5 enrolled, whichever is greater
(alongside another HMO
carrier)
 Waivers required
 5-100 Enrolled: 30%
 Waivers not required
 Other carrier bill not required
 Waivers required
 Other carrier bill is required
 Other carrier bill not required
Calculating Participation
Alongside Another HMO
Carrier
Start with total eligibles then:
Start with total eligibles then:
Start with total eligibles then:
 Subtract COBRA enrollees
 Subtract COBRA enrollees
 Subtract COBRA enrollees
 Multiply remaining eligibles by 40%
 Subtract valid waivers
 Subtract valid waivers
Eligible for Aetna Pick 5 if:
 1-4 Enrolled: Multiply remaining eligibles by 50%
 Multiply remaining eligibles by 25%
 Aetna enrollees + valid waivers = 40% and
 6-100 Enrolled: Multiply remaining eligibles by
30%
Eligible for Blue Shield if:
 Min 5 Aetna enrollees
 Blue Shield enrollees = 25% and
 Min 5 Blue Shield enrollees in CA
Employer Contribution
 Traditional: Min 50% of employee premium
 Traditional: Min 50% of employee premium
 Traditional: Min 50% of employee premium
 Defined: Min $80 per employee
 Defined: Min $100 per employee
 Defined: Min $100 per employee
 HSA Plans: Min employer contribution required.
See summary
 HRA Plans: Required employer contribution
varies by plan (see summary); must use Anthem
HRA as TPA
Wrapping Position
 Statement of Understanding not required
 Statement of Understanding required; language
included in Employer Application
 Statement of Understanding not required
OON Reimbursement
 100% of Medicare
 Fee Schedule
 Fee Schedule
Network Options
 HMO Networks: Full HMO, Value HMO, HMO
Deductible, Vitalidad HMO, Basic HMO,
PrimeCare
 HMO Networks: CaliforniaCare HMO (Full),
Select HMO, Priority Select HMO
 HMO Networks: Full, Exclusive
 PPO Networks: Full PPO, MC, Savings Plus MC
 PPO Networks: Prudent Buyer PPO (Full), Select
PPO
 Network Pairing: All networks may be mixed-&matched, up to 5 plans
 Network Pairing: HMO Dual Network options
allowed; only 1 PPO network may be offered
 Network Pairing: Full and Narrow networks may
not be offered alongside one another
Product Options
 1-100: Metallic tiers may be mixed-&-matched
 1-100: Metallic tiers may be mixed-&-matched
 1-100: Metallic tiers may be mixed-&-matched
(medical)
 Plan Options: PPO, HSA, HMO
 Plan Options: PPO, HSA, HRA, HMO
 Plan Options: PPO, HMO, HSA
Product Options
 Dental NonVol (2+ eligibles; with Medical)
 Dental NonVol (2+ enrolled; standalone)
 Dental NonVol and Vol (1+ eligibles; standalone)
(other)
 Dental NonVol and Vol (3+ eligibles; standalone)
 Dental Vol (5+ enrolled; standalone)
 Life (2+ eligibles; standalone)
 Life (26+ eligibles; standalone)
 Disability (10+ enrolled; standalone)
 Vision (1+ eligibles; standalone)
 Vision (2+ enrolled; standalone)
 Life (2+ enrolled; standalone)
 PPO Networks: Full, Exclusive
 Vision NonVol (2+ enrolled; standalone)
 Vision Vol (5+ enrolled; standalone)
Life Offerings
 2-9 Eligibles: $20,000
 2-9 Enrolled: $25,000, $30,000, or $50,000
 2-9 Eligibles: $30,000
 10-25 Eligibles: $75,000
 10-100 Enrolled: $25,000 to $350,000
 10-24 Eligibles: $100,000
 26-50 Eligibles: $100,000
 25-100 Eligibles: $150,000
Special Open Window
 Group Size: Small group definition
 Group Size: Small group definition
 Group Size: Small group definition
(11/15-12/15 for 1/1 effective
date)
 Paperwork: Standard requirements including
DE-9C, waivers and Attestation Form
 Paperwork: Standard requirements including
DE-9C and waivers
 Paperwork: Standard requirements including
DE-9C and waivers
 No min participation or contribution
 No min participation or contribution
 No min participation or contribution
 Alongside Kaiser: Not allowed
 Alongside Kaiser: Not allowed
 Alongside Kaiser: Allowed
beere&purves │ beerepurves.com │ 1350 treat blvd. suite 470 │ walnut creek ca 94597 │ 888.722.3373 │ lic #0005851 │ pg 2 │110116
Medical Underwriting Guidelines
Small Group
Provider Directory
CaliforniaChoice
Health Net
UnitedHealthcare
Provider Search
ProviderSearch
Find a Physician
Group Size
 1-100 FTEs
 1-100 FTEs
 1-100 FTEs
DE-9C
 Required
 Required
 1-9 Eligible: Required
 10-100 Eligible: Participation Certification Form
Rate Guarantee
 12 months
 12 months
 12 months
Rate Adjustments
 January, April, July, October
 January, April, July, October
 January, April, July, October
Rates
 Employee & Dep: Employer zip code
 Employee & Dep: Employer zip code
 Employee & Dep: Employer zip code
 OOS Employee: Employer zip code
 OOS Employee: Employer zip code
 OOS Employee: Employer zip code
 New Hire: Based on age at time of enrollment
 New Hire: Age at group’s last anniversary
 New Hire: Based on age at time of enrollment
 64+: One rate for everyone
 64+: One rate for everyone
 64+: One rate for everyone
 1st of month
 1st of month
 1st of month (HMO and PPO)
 15 of month allowed (only when group loses
Medical coverage mid-month)
 15th of month (PPO)
 1st of month after date of hire
 1st of month after date of hire
 1st of month after date of hire
 1 of month after 30 days
 1 of month after 30 days
 1st of month after 30 days
 1 of month after 60 days
 1 of month after 1 month
 1st of month after 60 days
 If 1 of month DOH, effective date IS NOT same
day
 1 of month after 60 days
 If 1st of month DOH, effective date IS NOT same
day
Effective Date
th
Waiting Period
st
st
st
st
st
st
 Orientation Period: Excluded
 If 1 of month DOH, effective date IS NOT same
day
 Dual waiting periods are not allowed
 Orientation Period: Excluded
st
 Orientation Period: Excluded
 Dual waiting periods allowed
 Dual waiting periods are not allowed
Qualifying Event Window
 60 days
 60 days
 60 days
Open Enrollment
 Yes: Medical; other products with Medical
 Yes: All products
 Yes: All products
Eligibility
 Full-Time: Avg 30+ hrs/week over 1 month
 Full-Time: Avg 30+ hrs/week over one month
 Full-Time: Avg 30+ hrs/week over 1 month
 Part-Time: 20+ hrs/week for at least 50% of the
previous calendar quarter
 Part-Time: 20+ hrs/week for 50% of the previous
calendar quarter
 Part-Time: 20-29 hrs/week
 1099 Employees: Not eligible
 1099 Employees: Not eligible
COBRA / Cal-COBRA
 No max
 No Max
 No Max
Out-of-Area / State
 Max 49% of eligibles out-of-state
 Max 49% of eligibles and enrolled out-of-state
 Max 49% of eligibles out-of-state for CA rates
 Principal executive office must be in CA
 Employees and dependents in Hawaii are not
eligible
 If no majority state, rating occurs in state with
largest enrollee population
 Employees and dependents in Hawaii are not
eligible
 1099 Employees: Eligible
 If multiple states possess same number of
enrollees, rating occurs in headquarter state
 Max 25% may be located in VT or MN
 Valid:
Waivers
 Valid:
 Valid:
Group spousal coverage
Group spousal coverage
Group spousal coverage
Group coverage with another ER
Group coverage with another ER
Group coverage with another ER
COBRA coverage with another ER
COBRA coverage with another ER
COBRA coverage with another ER
Medicare / Medi-Cal
Medicare / Medi-Cal
Medicare / Medi-Cal
Military
Military
Military
Hawaii state plan (Anthem only)
 Non-Valid:
Group coverage through another HMO
 Non-Valid:
Individual & Individual Exchange
Group coverage through another HMO
Individual & Individual Exchange
Individual & Individual Exchange
Owner Only Groups
(All Business Structures)
 Only allowed if at least 1 NON-SPOUSE / NONOWNER W2 employee enrolls in Medical
 Only allowed if group has at least 1 NONSPOUSE / NON-OWNER W2 eligible employee
OR if group is Corp with non-shareholding
officer
 Only allowed if group has at least 1 NONSPOUSE / NON-OWNER W2 eligible employee
OR if group is a C- or S-Corp or LLC
beere&purves │ beerepurves.com │ 1350 treat blvd. suite 470 │ walnut creek ca 94597 │ 888.722.3373 │ lic #0005851 │ pg 3 │110116
Medical Underwriting Guidelines
Small Group
Carve-Outs
Participation
(sole carrier)
CaliforniaChoice
Health Net
UnitedHealthcare
 Non-union carve-outs allowed
 Non-Union carve-outs allowed
 Non-Union carve-outs allowed
 Total group size (union and non-union) must be
100 or fewer FTEs
 Total group size (union and non-union) must be
100 or fewer FTEs
 Total group size (union and non-union) must be
100 or fewer FTEs
 1-2 Enrolled: 100%; must include 1 Medically
enrolled employee who is not an owner or
spouse of an owner
 1-5 Eligibles: 66%
 1-100 Enrolled: 60%
 6-100 Eligibles: 50%
 100% contribution requires 100% participation
 Carriers within the portfolio do not require their
own min participation
 1-5 Eligibles: 66%
 ChoiceSimplified: 60% combined and min 5
enrolled with UHC in CA
 Enrollment alongside another carrier is not
allowed
 Waivers required
 3-100 Enrolled: 70%
 100% contribution requires 100% participation;
min 2 enrolled
Participation
(alongside another HMO
carrier)
 6-100 Eligibles: 50%
 Other carrier bill not required
 Multi-Choice State Plans: 75% with UHC
 Alongside only permitted with Kaiser
 Waivers required if not on Kaiser bill
 Kaiser bill is required
Calculating Participation
Alongside Another HMO
Carrier
 Not applicable
Start with total eligibles then:
Choice Simplified:
 Subtract COBRA enrollees
Start with total eligibles then:
 Subtract valid waivers
 Subtract COBRA enrollees
 1-5: Multiply remaining eligibles by 66%
 Subtract valid waivers
 6-100: Multiply remaining eligibles by 50%
 Multiply remaining eligibles by 60%
Eligible for UHC if:
 UHC and Kaiser enrollees = 60% and
 Min 5 UHC enrollees in CA
Employer Contribution
 Traditional: Min 50% of employee premium of
lowest cost plan
 Defined: Min 50% of employee premium of
lowest cost plan
Wrapping Position
OON Reimbursement
 Traditional: Min 50% of the lowest cost plan
 Traditional: Min 50% of employee premium
 Defined: Min $100 per employee
 Defined: Min $100 of employee premium
 HSA Plans: Employer contributions may impact
the plans actuarial value; contact b&p for details
 Statement of Understanding required when 50%
or more enroll in a PPO plan
 Statement of Understanding not required
 Fee Schedule
 Physician Reimbursement: RBRVS
 Statement of Understanding not required
 Wrapping not permitted
 110% of Medicare
 Hospital Reimbursement: Medicare
Networks Options
 HMO Networks: Aetna, Anthem, Health Net,
Kaiser, Sharp, Sutter Health Plus, UHC, Western
Health Advantage
 HMO Networks: Full HMO, WholeCare HMO,
SmartCare HMO, Salud HMO, CommunityCare
 HMO Networks: Signature HMO (Full),
Advantage HMO, Alliance HMO, Focus HMO
 PPO Networks: Anthem (Tiered PPO and Select
PPO plans do not include Sutter), Health Net
 PPO Networks: Full PPO, PureCare EPO/HSP
 Network Pairing: Full and Narrow networks may
not be offered alongside one another
 PPO Networks: Select Plus PPO, Select EPO,
Core PPO
 Network availability will be determined based
on selected metallic level
Product Options
 1-100: 2 adjacent metallic tiers may be offered
(medical)
 Plan Options: PPO, EPO, HMO, HMO HSA
Product Options
(other)
 1-100: Metallic tiers may be mixed-&-matched;
portfolios may not be mixed
 1-100: Metallic tiers may be mixed-&-matched;
portfolios may not be mixed
 Plan Options: PPO, HMO, EPO, HSP
 Plan Options: PPO, EPO, HSA, HMO (HMO HSA
in SoCA only)
 Dental NonVol and Vol (with Medical;
enrollment varies by carrier)
 Dental NonVol and Vol (2+eligibles; standalone)
 Dental NonVol and Vol (2+ enrolled; standalone)
 Life (1+ enrolled; with Medical)
 Life (10+ eligibles; standalone)
 Vision NonVol and Vol (2+ enrolled; standalone)
 Vision NonVol and Vol (2+ eligibles; standalone)
 Life (2-5 enrolled; with Medical / 6+ enrolled;
standalone)
 1-10 Enrolled: $25,000
 2-14 Eligibles: $15,000
 2-5 Eligibles: $25,000
 11-25 Enrolled: $50,000
 15-24 Eligibles: $25,000
 6-19 Eligibles: $50,000
 26-100 Enrolled: $75,000
 25-100 Eligibles: $50,000
 20-50 Eligibles: $100,000
 VisionVol (1+ enrolled; with Medical)
Life Offerings
 Network Pairing: Full and Narrow HMO
networks may be offered alongside one another
 2-99 Eligibles: $15,000 (SBS package)
Special Open Window
 Group Size: Small group definition
 Group Size: Small group definition
 Group Size: Small group definition
(11/15-12/15 for 1/1 effective
date)
 Paperwork: Standard requirements including
DE-9C and waivers
 Paperwork: Standard requirements including
DE-9C and waivers
 Paperwork: Standard requirements including
DE-9C and waivers
 No min participation or contribution
 No min participation or contribution
 No min participation or contribution
 Alongside Kaiser: N/A
 Alongside Kaiser: Allowed
 Alongside Kaiser: Allowed
beere&purves │ beerepurves.com │ 1350 treat blvd. suite 470 │ walnut creek ca 94597 │ 888.722.3373 │ lic #0005851 │ pg 4 │110116