MEDICAL UNDERWRITING GUIDELINES LARGE GROUP - … · Rev. Date 5/12/15 Page 1 of 12 MEDICAL...

Rev. Date 5/12/15 of 12

MEDICAL UNDERWRITING GUIDELINES LARGE GROUP

AETNA

PRODUCT OFFERINGS

Rates Composite, 4-tier structure.

Product Combinations May offer up to 2 HMO plans alongside 1 OAMC; must have 5 enrolled in each plan offered. See Multiple HMO Pairing Options in 51–100 Plan Guide to determine which HMO plans may be combined.

Split Carrier Product Combinations

Plan design should not promote adverse selection relative to the other options being offered. Aetna will provide a full replacement quote OR an alongside Kaiser quote, but not both.

Networks HMO PPOHMO Network (Full) Basic HMO Network (Smallest) OAMC Network (Full)Value Network (Narrow) PrimeCare HMO Network (Inland Empire) Open Choice PPO (Full)HMO Deductible Network (Narrow) Vitalidad HMO (SIMNSA only) Savings Plus Network (Narrow)

PrimeCare OAMC Network (Inland Empire)Note: Plans may be offered with multiple network options; not all plans are available with all networks.

HRA & Wrap Groups can not fund in excess of 50% of the deductible annually whether through an HRA, HSA, CDHP or any other arrangement. GAP plans paid for by the employer must also follow the standard funding guidelines. GAP plans that are paid for by the employee can be used alongside any plan; there are no restrictions.

ELIGIBILITY

Group Size 51–100

Contribution Minimum 75% employee or Minimum 50% employee & dependent.If employer contributes 100% toward employee premium, then 100% participation is required.

Participation Minimum 75% participation, excluding spousal waivers. (Must have 50% regardless of spousal waivers)Groups that do not meet participation may have an additional factor applied.

Split Carrier Contribution Minimum 75% employee or Minimum 50% employee & dependent. Employer contribution strategy must not disadvantage Aetna offering. If employer contributes 100% toward employee premium, then 100% participation is required.

Split Carrier Participation Standard is 75%, 50% regardless of spousal waivers. Groups that don’t meet participation may have a factor applied.

Minimum Enrolled N/A. Groups with low enrollment may have a factor applied.

Carve-Outs Standard contribution/participation guidelines apply. Enrolled carve-out population must be no less than 40 EEs. Groups that carve out a specific class of EEs may have additional factor applied even if standard participation requirements are met. No location carve-outs.

Out-of-State Employees No maximum. Group must be quoted by the state in which the majority of employees are located.

COBRA/Cal-COBRA Groups with more than 10% COBRA/Cal-COBRA may have a factor applied.

Employee Only Coverage Not allowed. Employee-only coverage is only permitted for self-funded large groups.

Waiting Period Options 1st of the month following date of hire or first of the month following 30 days from date of hire.

QUOTING CRITERIA

Bundling Discounts None.

Carrier Persistency No more than 2 carriers in the past 5 years.

Census or Online Enrollment Census enrollment available.

Common Ownership One owner must have controlling interest of all business; companies must be eligible to file a combined tax return. Subject to underwriting approval. SICs may vary, however rates will be based on the company with the majority of the employees.

Divisional Billing Available; up to 3 locations can be set up at installation. Billing to each location is not available.

Ineligible Employees 109s, directors, stockholders, partners or other outside consultants who are not active, permanent FT EEsemployees meeting employer contribution requirements.

Ineligible Groups Associations, Taft-Hartley Groups, MEWA’s, PEO’s or multiple employer groups.

Medical Questions Group medical questionnaire must be completed; group may be rated up. Must disclose all claims in excess of $25,000.

Quoted vs. Enrolled If enrollment varies from quoted census by +/- 10% then the group may be re-rated.

Virgin Groups Groups must provide the Virgin Groups Request for Proposal Checklist; will be declined if not provided. Individual Health Statements are required and the group may be rated up.

Notes • Current carrier is small group: must provide official renewal w/rates per EE & RAF. Must show current and renewal rates.• RFPs submitted within 60 days of the requested effective MUST include renewal information from current carrier.• Groups with more than 10% Early/Non-Medicare Retirees may have a factor applied.• Groups leaving Trinet PEO may be quoted even if they are still with the PEO.

This comparison reflects the general guidelines set by a carrier. Guidelines may vary depending on group demographics and carrier approval.

LARGE GROUP MEDICAL UNDERWRITING GUIDELINES

Rev. Date 5/12/15 of 12

ANTHEM BLUE CROSS 51–99 EMPLOYEE ELECT

PRODUCT OFFERINGS

Rates Age banded. Composite rates are NOT available.RAF 0.90: Available to groups with 50% or higher participation, excluding zip codes listed below). Standard RAF may be reduced with the following sold product combinations:

• Medical & Dental or Life: .89 RAF• Medical, Dental & Life: .88 RAF

RAF 1.10: For groups with less than 50% participation or the following SIC codes: 5511-5599, 5812-5813, 7011, 8011-8099, 8111, 8322-8399, 8661RAF may be reduced with the following sold product combinations:

• Medical & Dental or Life: 1.09 RAF• Medical, Dental & Life: 1.08 RAF

Product Combinations All plans may be offered. Traditional network HMO’s may not be written alongside Select network HMO’s. Product may only be combined with Dental and Life offered through EmployeeElect 51–99. May not be sold with other small or large group products such as Dental, Life or Blue View Vision.


All plans may be offered. Traditional network HMO’s may not be written alongside Select network HMO’s. Product may only be combined with Dental and Life offered through EmployeeElect 51–99. May not be sold with other small or large group products such as Dental, Life or Blue View Vision.

Networks HMO PPOTraditional HMO Network (Full) SELECT Plus HMO Network (Narrow) Statewide PPO Network (Full)SELECT HMO Network (Narrow) Priority SELECT HMO Network (Narrow) SELECT PPO Network (Narrow)

Note: Not all plans are available with all networks.

HRA & Wrap Not allowed.

ELIGIBILITY

Group Size 51–99

Contribution Traditional: Minimum 50% employeePercentage & Plan: Minimum 50% employee tied to any single plan offeredFixed Dollar: Minimum $100 per employee or greater (in increments of $5)

Participation RAF issued based on participation level and SIC. (see Rates section above)

Split Carrier Contribution Traditional: Minimum 50% employee

Split Carrier Participation Minimum 50% participation with Anthem. Only available alongside Kaiser.

Minimum Enrolled N/A

Carve-Outs Total eligible group size of carve-out population must be 51–99.

Out-of-State Employees No more than 49% may be out of state.

COBRA/Cal-COBRA No more than 10% may be COBRA/Cal-COBRA.

Employee Only Coverage Not allowed.

Waiting Period Options 1st of the month following: date of hire, one month from date of hire, or two months from date of hire not to exceed 90 days.

QUOTING CRITERIA

Bundling Discounts 2% discount on medical when enrolling in insured dental and $25,000+ life. 10% discount on workers comp through Employers when enrolling in medical.

Carrier Persistency N/A

Census or Online Enrollment Not available for initial enrollment. Online enrollment available for existing groups through EmployerAccess.

Common Ownership One owner must have controlling interest of all business (51%); companies must provide letter once sold (from CEO, CFO or attorney) on company letterhead stating the name of each person with at least 51% ownership & the name of each company.

Divisional Billing Not available.

Ineligible Employees Leased employees, retirees, seasonal and temporary employees, domestic household-staff, and employees residing in HI.

Ineligible Groups Associations, JPA’s, MET’s, MEWA’s, PEO’s, HealthCare Alliances, Student Health plans, Taft-Hartley Groups, Groups with Hour Bank eligibility, Leasing Firms, Public Entities and Schools.

Medical Questions Include details on large claims and disabilities.

Quoted vs. Enrolled N/A

Virgin Groups N/A

Notes 1099’s may be considered eligible if they work full time/year-round for the employer, no more than 50% of the employees are 1099, and the employer extends coverae to all eligible 1099s.


Rev. Date 5/12/15 of 12

ANTHEM BLUE CROSS 51–125

PRODUCT OFFERINGS

Rates Composite.

Product Combinations May offer 1 plan from each family (HMO, PPO, CDHP). Dual HMO selections require a 10% rate load to the high HMO.Groups with no prior coverage may offer HMO only or dual option HMO/PPO. EQ may be quoted in the following instances:

• Groups with EE’s currently offered coverage AND EE’s who are newly eligible and never offered coverage by the company will have current EE’s offered standard plans, while all newly eligible EE’s will be quoted on EQ. The newly eligible population can work any amount of hours as long as it is over 30 hours per week.

• Virgin Groups with all EE’s working 30-39 hours (No 40+ hour EE’s) will be quoted all on EQ.• Virgin Groups with a census that splits 30-39 hour and 40+ hour employees will have 30-39 hour EE’s quoted on EQ

plans, and 40+ hour EE’s quoted on standard plans. • Virgin Groups with no break up of hours worked will be quoted Standard plans only - EQ will not be available


Will quote any combination of products.

Networks HMO PPOTraditional HMO Network (Full) SELECT Plus HMO Network (Narrow) Statewide PPO Network (Full)SELECT HMO Network (Narrow) Priority SELECT HMO Network (Narrow) SELECT PPO Network (Narrow)


HRA & Wrap HRA plans assume the employer will fund 50% of the deductible for both employees and families. The plans can not be modified. Anthem must be the administrator. GAP plans paid for by the employer must follow the funding guideline above. GAP plans that are paid for by the employee can be used alongside any plan; there are no restrictions.

ELIGIBILITY

Group Size 51–125

Contribution Minimum 50% employee. Groups with no prior coverage: Minimum 85% HMO, minimum 50% PPO

Participation 75% excluding spousal waivers. 50% regardless of spousal waivers; 70% regardless of spousal waivers if no prior coverage. Will no longer decline if participation is not met, however rates will receive a load.

Split Carrier Contribution Minimum 50% employee.

Split Carrier Participation 50% participation. If participation is between 40%-50% the employer must offer Anthem HMO similar to Kaiser HMO and the employee cost to enroll must be the same for each. Certification required at renewal to verify Kaiser contribution amount and enrollment. Groups with no prior coverage are not eligible.

Minimum Enrolled Will not decline if participation is not met, however rates will receive a load.

Carve-Outs Total group size may be no more than 250 FT EEs. Standard guidelines apply to the carve-out for participation & contribution.

Out-of-State Employees No more than 90% may be out of state.


Employee Only Coverage Not allowed.

Waiting Period Options 1st of the month following: date of hire or 30 days from date of hire.

QUOTING CRITERIA

Bundling Discounts 4% total discount available on medical premiums when also enrolling in the following ancillary lines: 1% for dental, 1% for $25,000+ life, 1% for vision, 0.5% for STD, 0.5% for LTD.

Carrier Persistency No more than 3 carriers in the past 5 years.

Census or Online Enrollment Not available for initial enrollment. Online enrollment available for existing groups through EmployerAccess.

Common Ownership One owner must have controlling interest of all business (51%); companies must provide letter once sold (from CEO, CFO or attorney) on company letterhead stating the name of each person who has at least 51% ownership & name of each company.

Divisional Billing Available. Billing to each location is not available.

Ineligible Employees Leased employees, retirees, 1099’s, seasonal and part-time employees.

Ineligible Groups PEO’s and leasing firms.

Medical Questions Include details on large claims and disabilities.

Quoted vs. Enrolled If enrollment & subsequent rating varies from quoted by +/- 10% (20% for 51-99) then the group may be re-rated.

Virgin Groups Anthem must be sole carrier. HMO only or HMO/PPO dual option. Minimum 85% contribution for HMO, 50% for PPO. Minimum 75% participation regardless of spousal waivers or 70% of gross eligible if spousal waivers can’t be determined.

Notes • DE-9C is required to quote any group currently enrolled in small group, includes Anthem and/or other SG carrier.• Groups currently with Anthem SG: a release is required to quote large group. Letter must be provided to Anthem with the

group number. Letter can be sent by GA (if BOR), Broker (if BOR, including release to LISI), or Group (if broker is not the BOR, including release to broker and LISI).


Rev. Date 5/12/15 of 12

BLUE SHIELD

PRODUCT OFFERINGS

Rates Composite.

Product Combinations Up to 4 plans may be selected. There is a 2% surcharge (for all plans) if 3+ are offered.


Up to 4 plans may be selected. There is a 2% surcharge (for all plans) if 3+ are offered.

Networks HMO PPOAccess+ HMO (Full) PPO Network (Full)Access+ HMO SaveNet (Limited)Local Access+ HMO (Limited)


HRA & Wrap Non-HSA PPO plans may be paired with an HRA, HIA or FSA. HSA PPO plans may be paired with an HIA, HRA, or HSA.GAP plans paid for by the employer will require approval. GAP plans that are paid for by the employee can be used alongside any plan; they are not tracked by BSC.

ELIGIBILITY

Group Size 51–299

Contribution Minimum 75% employee or Minimum 50% employee & dependent

Participation Minimum 75% participation

Split Carrier Contribution Minimum 75% employee or Minimum 50% employee & dependent

Split Carrier Participation Minimum 75% of eligible employees must enroll in a plan, 50% must be with Blue Shield. If offering SaveNet, must have 100 eligible with a minimum of 50 enrolled.

Minimum Enrolled Minimum 40 enrolled.

Carve-Outs Not available

Out-of-State Employees No maximum


Employee Only Coverage Details pending

Waiting Period Options 1st of the month following: date of hire or 30 days from date of hire.

QUOTING CRITERIA

Bundling Discounts 3% total discount available on medical premiums when also enrolling in the following ancillary lines: 1% for dental, 1% for life, 1% for vision.


Census or Online Enrollment Census and online enrollment (QuickEnroll) options available.

Common Ownership Must provide name and TIN for each company. Companies must be eligible to file a combined tax return.

Divisional Billing Available.

Ineligible Employees Leased employees, retirees, 1099 employees, seasonal employees and temporary employees

Ineligible Groups Associations, Multiple Employer Trusts, PEO’s, Taft Hartley Trusts, Groups with Hour Bank eligibility, Leasing firms, Public Entities and Schools

Medical Questions Must provide details on large claims.

Quoted vs. Enrolled N/A

Virgin Groups Must provide salary information for all employees; allows them to predict who is most likely to enroll.

Notes Groups leaving Trinet PEO will be auto-declined without a termination letter from Trinet.


Rev. Date 5/12/15 of 12

CALCPA

PRODUCT OFFERINGS

Rates Composite.

Product Combinations ProtectPlus PPO: Employer may offer one plan, a combination of plans, or all plans. Must select either full or limited network.One HMO plan may be offered alongside the selected ProtectPlus plan(s). Solo Practitioners are not eligible to enroll in the HMO plans.


May be offered alongside Kaiser; no other group health plan is allowed. ProtectPlus PPO: Employer may offer one plan, a combination of plans, or all plans. Must select either full or limited network. One HMO plan may be offered alongside the selected ProtectPlus plan(s). Solo Practitioners are not eligible to enroll in the HMO plans.

Networks HMO PPOAnthem HMO Network (Full) Anthem PPO Network (Full)

Anthem Select PPO Network (Limited)

HRA & Wrap Allowed; employer must notify the Trust of it’s intent. No restrictions on how much can be funded.

ELIGIBILITY

Group Size 51+. DE-9C required. Must be headquartered in California. Available to accounting firms in public practice or firms offering general financial services (SIC 8721). To be eligible, more than 50% of all of the firm’s owners (principals, proprietors, partners, shareholders, or other owners) must be CPA members of CalCPA, or Associate members of CalCPA. All CPA owners must be members of CalCPA in good standing.

Contribution Minimum 50% of employee rate. If employer contributes 100% toward EE premiums, 100% participation is required.

Participation Minimum 75% of eligible employees

Split Carrier Contribution Minimum 50% of employee rate. If employer contributes 100% toward EE premiums, 100% participation is required.

Split Carrier Participation Minimum 75% of eligible employees with at least 1 enrolled in CalCPA. Kaiser enrollees are considered valid waivers.


Carve-Outs Not allowed.

Out-of-State Employees 49% maximum.

COBRA/Cal-COBRA No maximum.

Employee Only Coverage This is not allowed as part of their contract, however they allow the employer to control dependent eligibility. If a dependent is listed on an EE application they will be enrolled. Dependent waivers will be required.

Waiting Period Options • 1st of the month following date of hire• 1st of the month following 30 days from date of hire

QUOTING CRITERIA


Carrier Persistency No limit on prior carriers.

Census or Online Enrollment Online enrollment available.

Common Ownership All employers deemed to be part of an affiliated group under Internal Revenue Code Sections 414 (b), (c), or (m) are considered to be a single employer.

Divisional Billing Available, can be setup at time of installation. Billing to each location is available.

Ineligible Employees 1099s, seasonal, substitute, temporary and leased employees.

Ineligible Groups See Group Size Above.

Medical Questions Must provide details on: enrollees hospitalized within the last 12 months, major medical conditions, claims in excess of $25,000 in the last 12 months, pregnancies, and disabilities.

Quoted vs. Enrolled Group may be re-rated if enrollment varies.

Virgin Groups N/A

Notes • Submit reason for shopping with quote request. • If currently with Anthem large group, CalCPA rates can’t come in less than 5% from current.


Rev. Date 5/12/15 of 12

CALIFORNIACHOICE®

PRODUCT OFFERINGS

Rates Composite.

Product Combinations All plans available. There are no limitations to product combinations.


Not allowed.

Networks HMO PPOHealth Net HMO (Full) Health Net PPO (Full)Health Net Silver HMO (Narrow)Health Net Salud HMO y Mas (Narrow) IndemnityKaiser Permanente HMO (Full) Health Net Flex NetWestern Health Advantage HMO (Full)

Note: Not all plans are available with all networks. Health Net Full and Silver HMO networks may be not combined.

HRA & Wrap Deductible plans, except designated HRA plans, are sold as stand-alone plans and are not to be used in conjunction with self-funding arrangements, such as wrapping (or self-funding) member expenses either directly or through a third-party administrator (TPA). Groups, may make contributions to health savings accounts (HSAs), but not as a member-expense reimbursement mechanism where the consumer-directed aspect of consumer directed health plans (CDHPs) is lost.

ELIGIBILITY

Group Size 51–199.

Contribution Minimum 50% of the lowest cost plan for each employee. (excludes Salud)

Participation 70% of all eligible employees. Employees waiving due to other group coverage will count against participation if the employer contribution is 100%.

Split Carrier Contribution Not allowed.

Split Carrier Participation Not allowed.


Carve-Outs Not available. For Union/Non-Union, the Union employees are considered ineligible.

Out-of-State Employees No more than 49%.

COBRA/Cal-COBRA Subject to underwriting, no set guideline.

Employee Only Coverage Employers may elect to offer employee-only coverage.

Waiting Period Options • 1st of the month following 30 days from date of hire

QUOTING CRITERIA


Carrier Persistency Carrier requests 5 year history.

Census or Online Enrollment Not available.

Common Ownership Each company must share a minimum of 50% common ownership. All companies must have previously filed a combined tax return. Common ownership statement is required.

Divisional Billing Available. Setup done by group through the CalChoice website.

Ineligible Employees 1099, commissioned, permanent employees who are eligible for medical healthcare coverage offered by or through a labor union, Per Diem, part-time working less than 30 hours, seasonal, temporary and employees on a leave of absence not categorized as FMLA, Workers Compensation or Military.

Ineligible Groups Groups with major medical conditions. Groups currently enrolled in small group who have 51-100 total employees will automatically be declined (due to Kaiser enrollment rule). Groups with less than 2 health plans available to 70% of eligible employees (excluding out of state employees).

Medical Questions Groups with major medical conditions will be declined.

Quoted vs. Enrolled If rates calculated at enrollment exceed quoted rates by 5% or more, your group will be charged the higher rates.

Virgin Groups N/A

Notes -


Rev. Date 5/12/15 of 12

CIGNA

PRODUCT OFFERINGS

Rates Composite.

Product Combinations Up to 3 or 4 plans may be offered if that is what the group currently offers.


Up to 3 or 4 plans may be offered if that is what the group currently offers.

Networks HMO PPOHMO Network (Full) PPO Network (Full)

Open Access Plus Network (Full)

HRA & Wrap Details pending

ELIGIBILITY

Group Size 51–250.

Contribution Minimum 50% employee.

Participation Fully-Insured: 50% of eligible employees for groups under 100. 75% for groups 100+. Valid waivers are not removed from participation calculation.Self-Funded/Level Funded: 75% of all eligible employees

Split Carrier Contribution Minimum 50% employee.

Split Carrier Participation 75% of eligible employees must enroll on a group sponsored plan; 50% of those enrolled must enroll with Cigna. Minimum 25 enrolled with Cigna for Self-funding plans, 50 enrolled for Fully-insured plans. Will only split with Kaiser if Kaiser has been in place for at least 2 years in a split arrangement with another carrier. Cigna will write alongside Kaiser composite or age-banded rates - they don’t put restrictions on this.


Carve-Outs Total eligible group size of carve-out population must be 51–99.

Out-of-State Employees No more than 49%

COBRA/Cal-COBRA No more than 20%

Employee Only Coverage Details pending

Waiting Period Options Details pending

QUOTING CRITERIA

Bundling Discounts Discount available on medical premiums when also enrolling in the following ancillary lines: 1% for dental, 0.5% for STD and LTD, 1.5% for dental, STD and LTD.



Common Ownership Owner must have 80% ownership in each company.

Divisional Billing Available. Billing can be set to each location.

Ineligible Employees Leased employees, retirees, 1099’s, seasonal and temporary employees.

Ineligible Groups Associations, MET’s, PEO’s, Taft-Hartley Groups, Groups with Hour Bank eligibility, Leasing Firms, Public Entities and Schools.

Medical Questions Health questions must be answered by employees.

Quoted vs. Enrolled If enrollment & subsequent rating varies from quoted by +/- 10% then the group may be re-rated.

Virgin Groups Level-funding only. Individual health statements required. Must have 50% participation and 70% contribution.

Notes Some locations no longer quote fully-insured products for groups under 100.


Rev. Date 5/12/15 of 12

HEALTH NET

PRODUCT OFFERINGS

Rates 4-tier composite.

Product Combinations All plans within a package are available. Packages include: Enhanced Choice, ExcelCare Choice, and SmartCare Choice.For non-standard case submissions, employers may offer one of the following plan options: Value HMO 40 Dual Network, Advantage EOA 45, or HRA 5000.


Writing alongside KaiserAll plans within a package are available. Packages include: Enhanced Choice, ExcelCare Choice, and SmartCare Choice.Writing alongside another carrier other than KaiserEmployers may offer one of the following plan options: Value HMO 40 Dual Network, Advantage EOA 45, or HRA 5000.

Networks HMO PPOHMO Network (Full) SmartCare Network (Narrow) PPO Network (Full)ExcelCare Network (Narrow) Salud HMO y Mas Network (Narrow)


HRA & Wrap With the exception of the HRA product, under no circumstances may any plan, including HMO, EOA, POS, PPO, and HSA compatible plans, be combined with any form of partial self-funding or insuring of the deductible, be it in a wraparound, addition, or companion capacity. GAP plans are not allowed regardless of whether they are paid for by the ER or the EE.

ELIGIBILITY

Group Size 51–100. DE-9C required for groups enrolling less than 51 and groups currently on an age-rated product.

Contribution Minimum 50%, or minimum flat amount of $175 per employee.

Participation 75% of all eligible employees.

Split Carrier Contribution Minimum 50%, or minimum flat amount of $175 per employee. If the employer contributions to Kaiser are higher than the Health Net minimum, the employer must match Kaiser’s contribution. Kaiser plans must be composite rated.

Split Carrier Participation 75% of all eligible employees must enroll (Health Net + other carrier enrollment). 38% and a minimum of 19 eligible employees, whichever is greater, must enroll with Health Net.


Carve-Outs Not allowed, including union/non-union.

Out-of-State Employees No more than 49%


Employee Only Coverage This is not allowed as part of their contract, however Health Net allows the employer to control dependent eligibility.

Waiting Period Options 1st of the month following: date of hire, 30 days from date of hire, 60 days from date of hire, or 1 month from date of hire.

QUOTING CRITERIA

Bundling Discounts 2% total discount available on medical premiums when also enrolling in the following ancillary lines: 1% for dental, 0.5% for life, 0.5% for vision.

Carrier Persistency 5 year history required. Must provide current and renewal rates.

Census or Online Enrollment Not available.

Common Ownership Must provide a letter from CPA detailing the company structure and how they are eligible to be considered a single employer.

Divisional Billing Available. Billing can be set to each location (within reason).

Ineligible Employees Leased employees, Board Members, 1099 employees, seasonal employees, retirees, temporary and part time employees (employee eligibility can be defined as 20 or 30 hours per week).

Ineligible Groups All industries are subject to underwriting review.

Medical Questions Must include details on claims in excess of $25,000 including diagnosis. Health Net may request more information to determine appropriate rating level.

Quoted vs. Enrolled If premium varies from quoted census by more than 5% then group may be re-rated.

Virgin Groups N/A

Notes • Non-Standard guidelines apply to the following group types: Those that do not meet minimum participation and/or contribution, groups writing alongside another carrier other than Kaiser, newly established groups (in business less than 12 months), PEO/leased employee arrangements, temporary staffing agencies, groups with more than 49% out of state (eligible or enrolled), Spin-off groups without prior coverage.

• PEO groups: The group must demonstrate it has the right to direct the work of its employees, as well as the right to make personnel decisions, such as hiring and firing. All other standard underwriting guidelines apply.

Groups 100+ Eligible Participation: 33% minimum participation for Virgin or Alongside Kaiser. 55% minimum participation for Total Takeover.Contribution: Minimum 50% towards the lowest cost option.Bundling Discounts: 1% discount for Dental, 1% for Life, 0.5% for Vision


Rev. Date 5/12/15 of 12

KAISER

PRODUCT OFFERINGS

Rates Composite.

Product Combinations High/Low combo available. No minimum enrollment per plan. POS/PPO/Out-of-Area enrollment must be less than 25% of enrolled population.


If offering High/Low combination, the other carrier must also have a high/low option available. All eligible employees must be offered the Kaiser plan. Coverage provided should be uniform across all plans offered to prevent adverse selection. May not be offered alongside an age-banded plan.

Networks HMO PPOKaiser Network (Full) Private Healthcare Systems (PHCS) Network (Full)

HRA & Wrap For employers who choose to fund or directly reimburse employees for deductibles, coinsurance, or copayments (except as noted below for HMO with HRA plans), the broker must inform Kaiser prior to the start of any employer reimbursement. Kaiser will factor the funding arrangement into the group’s new or renewal rate quotation.Employers who choose a deductible HMO plan with HRA must contribute to their employees’ HRAs. GAP plans that are paid for by the employee can be used alongside any plan.

ELIGIBILITY

Group Size 51+

Contribution Minimum 50% employee.

Participation 75% of eligible employees must enroll in an employer-sponsored health plan. (Must have 50% regardless of spousal waivers)

Split Carrier Contribution Minimum 50% employee. Contributions must not favor one carrier.

Split Carrier Participation 75% of eligible employees must enroll in an employer-sponsored health plan. (Must have 50% regardless of spousal waivers)

Minimum Enrolled Minimum 5 enrolled or 10%, whichever is greater. If company is statewide then must have 5 enrolled or 10% in Southern CA and 5 enrolled or 10% in Northern CA.

Carve-Outs Carve-outs allowed.Note: Will not accept management/non-management or any other carve-out request that does not meet non-discrimination requirements.

Out-of-State Employees All employees must reside in a service area.



Waiting Period Options • 1st of the month following: date of hire, or 30 days from date of hire• 60 days following date of hire*• Any day*

* Members enrolling by the 15th of the month will be charged a full months premium. Members enrolling from the 16th on will not be charged until the following month.

QUOTING CRITERIA


Carrier Persistency No more than 3 carriers in the last 5 years if quoting HMO & PPO/POS.

Census or Online Enrollment Online available; Not available to groups moving from CalChoice 51+.

Common Ownership Common Ownership form required, must be signed by accountant, attorney or officer of the company. Groups must qualify as a single employer under section 414 of the internal revenue code.

Divisional Billing Available; up to 2 locations can be set up. Billing can be sent to each location.

Ineligible Employees Leased employees, Contract or 1099’s.

Ineligible Groups Leasing Firms, PEO’s. Kaiser Large Group products may not be offered alongside an age-rated medical plan.Groups currently enrolled in Kaiser small group who have 51-100 total employees will automatically be declined.

Medical Questions Must provide details all medical conditions and claims in excess of $10,000.

Quoted vs. Enrolled Will re-rate if enrollment varies +/- 10% from quoted census.

Virgin Groups POS/PPO/Out-of-Area not available unless 1 year prior coverage.

Notes A group exiting a pool must retain the previous parent group’s rate for at least 6 months but for no more than 18 months before being rated separately.


Rev. Date 5/12/15 of 12

SHARP HEALTH PLAN

PRODUCT OFFERINGS

Rates Composite; rating tiers from 1-6 available.

Product Combinations Plan combinations subject to underwriting approval.


Plan combinations subject to underwriting approval.

Networks HMOChoice Network (Full) Performance Network (Narrow)Value Network (Narrow) Premier Network (Narrow, select zip codes only)

HRA & Wrap No plans are eligible as the standard guideline, however funding arrangements may be submitted to underwriting for case-by-case review.

ELIGIBILITY

Group Size 51+

Contribution Minimum 50% employee. Defined contribution: Minimum $100 per employee.

Participation 70% of eligible employees.

Split Carrier Contribution Minimum 50% employee. Defined contribution: Minimum $100 per employee.

Split Carrier Participation Minimum 50% must enroll with Sharp.

Minimum Enrolled Reviewed on a case by case basis.

Carve-Outs 100% participation must be met by carve-out population. Note: Will not accept management/non-management requests.

Out-of-State Employees None.

COBRA/Cal-COBRA No more than 5%.


Waiting Period Options • 1st of the month following date of hire• 1st of the month following 30 days from date of hire• 30 days following date of hire* • 60 days following date of hire*

* Members enrolling prior to the 15th of the month will be charged a full months premium. Members enrolling from the 15th on will not be charged until the following month.

QUOTING CRITERIA


Carrier Persistency Prefer to have no more than 2 carriers in the past 5 years (not a requirement).

Census or Online Enrollment Not available. Can accept a data feed from vendors for open enrollment.

Common Ownership Must be reviewed by underwriting on a case-by-case basis.

Divisional Billing Available.

Ineligible Employees 1099’s, part-time employees (unless SB1790 eligible), domestic help, leased and seasonal employees.

Ineligible Groups PEO’s.

Medical Questions Details pending

Quoted vs. Enrolled If premium varies from quoted census by +/-10% then group may be re-rated.

Virgin Groups N/A

Notes -


Rev. Date 5/12/15 of 12

UNITEDHEALTHCARE 51-99

PRODUCT OFFERINGS

Rates Composite; 3 or 4 tier composite available.

Product Combinations No restrictions on Select Plus PPO or HSA offerings. Up to 5 HMO plans may be selected with pairing restrictions - always check with UHC to ensure valid products are being combined; may vary by group and locations. In general: Northern CA may pair Signature and Advantage networks together. Alliance may not be paired.Southern CA may pair Signature and Advantage or Signature and Alliance networks together.


May select up to 3 plans; will receive a 1% rate load. Alongside staff model HMO only; Kaiser rates must be composite and have the same tier structure.

Networks HMO PPOSignature (Full) Select Plus (Full)Advantage (Limited)Alliance (Hi-Performance)


HRA & Wrap All HRA plans are eligible. Funding it limited to 50% of the deductible. May not fund the coinsurance or any other portion of the plan. GAP plans that are paid for by the employee can be used alongside any plan.

ELIGIBILITY

Group Size 51–99

Contribution Minimum 50% of the employee rate.

Participation 75% of all eligible employees. (Must have 50% regardless of spousal waivers)

Split Carrier Contribution Minimum 50% of the employee rate.

Split Carrier Participation 75% of all eligible employees must enroll, must have 50% regardless of spousal waivers. 50% of enrolling population must enroll with UnitedHealthcare.


Carve-Outs Allowed with at least 20 enrolling.

Out-of-State Employees Groups will be rated in the state with 51% of the eligible employees. If 51% does not exist, the state that has 50% of the group enrollment. If 50% does not exist in any one state, the state in which the physical home office resides.

COBRA/Cal-COBRA No max, however may be rated if more than 10% COBRA enrollees.

Employee Only Coverage This is not allowed as part of their contract, however UnitedHealthcare allows the employer to control dependent eligibility.

Waiting Period Options • 1st of the month following date of hire• 1st of the month following 30 days from date of hire• 1st of the month following 60 days from date of hire

QUOTING CRITERIA

Bundling Discounts Savings per employee per month when sold alongside medical: $1 life or STD; $2 vision, or life & STD, or life & LTD; $3 dental, or vision & life; $4 dental and life; $5 dental and vision; $6 dental, vision & life; $7 dental, vision, life and STD.

Carrier Persistency Prefers to have no more than 2 carriers in the last 5 years. Groups with more may be rated/declined.


Common Ownership Must have letter from CPA stating they are eligible to file a consolidated tax return. Letter not required if they have the same TIN and file consolidated taxes.

Divisional Billing Not available for groups 51-99. Can be offered to groups with 100+; billing can be sent to each location.

Ineligible Employees Employees who work less than 30 hours per week. Employees not on payroll or where an employer/employee relationship does not exist.

Ineligible Groups Private households, Membership Organizations (including business associations, political organizations, religious organizations, member organizations not elsewhere classified (NEC), professional organizations, and civic organizations). Professional Employer Organizations (must be referred to Small Business).

Medical Questions Must list all large claims (claims exceeding $25,00).

Quoted vs. Enrolled Typically allows up to 10% membership and/or demographic change; always reserves the right to re-rate.

Virgin Groups Rate load will apply.

Notes -


Rev. Date 5/12/15 of 12

All information published herein is gathered from sources which are thought to be reliable, but the reader should not assume that the information is official or final. Reliance on this information received from LISI shall be at your sole risk, and LISI assumes no responsibility for any errors, omissions, or damages arising. Users of this information are encouraged to confirm with other sources, and to seek qualified advice if embarking on any actions that could carry personal or organizational liabilities.

UNITEDHEALTHCARE 51-99 ALL SAVERS

PRODUCT OFFERINGS

Rates 4 tier composite.

Product Combinations Employer selects a plan level and credit option, employees can choose to customize their own benefits within the plan level.

Credit Options (premium will be reduced for any option that requires the member to ‘earn’ credits): • Standard: members automatically receive a $1,000 annual credit for being enrolled.• Motion: members earn motion credits, up to $4/day or $1,000/year, by wearing a step tracker and meeting daily activity

goals. Administered by Hat Trick Motion. Credits paid to members annually by check.• Wellness: members earn a wellness credit, up to $1,000 per year, by meeting at least 3 target goals or participating in

a 12-week wellness program. Monitored by Streamlines Wellness. Credits earned will be applied towards the members deductible.


Not allowed.

Networks All plans use the Choice Plus Network

HRA & Wrap Not allowed.

ELIGIBILITY

Group Size 51–99 eligible.

Contribution Minimum 50% of the employee rate for the lowest cost plan

Participation 75% of all eligible employees.

Split Carrier Contribution Not allowed.

Split Carrier Participation Not allowed.


Carve-Outs Employer may choose to exclude Union, Hourly or Non-management employees.

Out-of-State Employees Groups will be rated in the state with 51% of the eligible employees. If 51% does not exist, the state that has 50% of the group enrollment. If 50% does not exist in any one state, the state in which the physical home office resides.

COBRA/Cal-COBRA No maximum.

Employee Only Coverage This is not allowed as part of their contract, however UnitedHealthcare allows the employer to control dependent eligibility.

Waiting Period Options • Immediate after 30, 60 or 90 days from date of hire• 1st of the month following 30 or 60 days from date of hire

QUOTING CRITERIA

Bundling Discounts Savings per employee per month when sold alongside medical: $1 life or STD; $2 vision, or life & STD, or life & LTD; $3 dental, or vision & life; $4 dental and life; $5 dental and vision; $6 dental, vision & life; $7 dental, vision, life and STD.

Carrier Persistency Unknown

Census or Online Enrollment Census enrollment only available if currently covered by UHC.

Common Ownership Must have letter from CPA stating they are eligible to file a consolidated tax return. Letter not required if they have the same TIN and file consolidated taxes.

Divisional Billing Not available.

Ineligible Employees Retirees, part time employees working less than 30 hours per week.

Ineligible Groups Non-ERISA groups, Municipalities, and Professional employer organizations (employee leasing firms)

Medical Questions Must provide full health history of all enrollees.

Quoted vs. Enrolled Prices may change based on any change in census (change in group size due to additions or termination of employees during the work-up process), change in plan, change in effective date, or new medical information received after initial offer.

Virgin Groups Rate load will apply.

Notes • Brokers are allowed to work with only one GA at a time. This must be setup through UHC. The broker will not appear in the quote system until this process is complete.

• Dependents may only enroll in the plan if the employee is also enrolled.• $25 monthly billing fee applies for direct bill; waived for electronic.• Employers may elect to be part of the Exchange, however this is not a requirement for coverage.

MEDICAL UNDERWRITING GUIDELINES LARGE GROUP - … · Rev. Date 5/12/15 Page 1 of 12 MEDICAL...

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