FIELD UNDERWRITING GUIDE · 2015-06-03 · WPS Underwriting Guide - All Group . All Groups – Eligible Groups . Standard Groups . Sole proprietorships, partnerships, limited liability

January 2015

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UNDERWRITING GUIDE

Please note: The information in this Guide is not all inclusive. WPS Underwriting reserves the right to revise these guidelines at any time without advance notice.

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Table of Contents

All Groups 5 Eligible Groups 5 Standard Groups 5 Labor Unions 6 Classing Out Employees 6 Health and Welfare Trust Funds 7 Eligibility Rules 7 Eligible Person(s) Domestic Partners on all Risk Groups 9 1099 Employee(s) 11 Ineligible Person(s) 13 New Hires 13 PPACA Special Enrollment Reasons 14 Late Enrollees 14 Loss of Eligibility 15 Covered Members Regaining Eligibility 15 Military Leave 15 Employee 15 Dependent Child(ren) discharged 16 Leave of Absence due to Military Leave 16 Group Quotes 16 Census Information 16 Effective Date 16 Group Size 2-50 Total Employees 16 Group Size 51+ Total Employees 17 Guidelines for Quoting Groups With Out-of-State Residents 17 Carve-Out Rates 17 All Groups Reporting 18 Paid Claim Information 18 Prognosis Information 20 Deductible/Out of Pocket Crediting 20

Back Billing and Credit Adjustments 21 Clerical Errors All Groups - Group Changes 21 Benefit Changes 21 Customer Network Changes 21 Group Adding Network 22 Acquisition of a Subsidiary or Buy-out (Common Ownership or Affiliation) 22 All Groups - Group Renewal 23 Renewal Premium Rates 23 Change in Group Status 23 Changes to Group Anniversary Date 23 All Groups - Group Policy 23 Terminations Reason for Termination 23 Reinstatement 24 All Group’s - Group Coverage Discontinuance and Replacement 24 Military Leave Continuation 24 Liability of Prior and Succeeding 25 Carriers in Group Replacement Situations 25 Groups of 2 to 50 25 Group Size Definition 25 Benefits 26 Health 26 Group Rate Quotes – 51+ Total Employees 26 Internet Quoting 26 Information Needed to Request a Quote 26 Quote Guidelines for Groups with 2-50 Total Employees 27 Age Adjustments 27 Effective Date of Quote 27

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New Group Enrollment – 2 to 50 28 Required Group Enrollment Material 28 Groups Subject to ACA 28 Non-ACA Groups 28 Required Tax Documents for New Group Sales 29 Medically Underwritten 30 Transitional Non-ACA Groups Process for Full Underwriting 30 Effective Dates 30 General Underwriting Issues 31 Participation 31 Probationary Period 32 2-50 Insureds 32 51+ Insureds 32 Retiree Coverage 33 Dual Option Underwriting Regulations 33 Group Renewal and Changes 34 Premium Rates & Increase 34 Groups of 51 or More _________34 Group Size Definition 34 Group Rate Quotes 35 Effective Date 35 Information Needed to 35 Request a Quote Groups 51-99 Without Experience 35 Groups 51-99 With Experience 36 Groups 100+ 36 Freedom Essentials 25+ Insureds 37-39 Freedom Flex 51+ Insureds 39-40 Groups of 51 or More Total Employees - New Group Enrollment 41 Group Enrollment Material Groups of 51 or More Total Employees - Medically Underwritten 41 Process for Full Underwriting

Groups of 51 or more Enrolled - General Underwriting Issues 42 Matching/Duplicating Benefits 42 and/or Administration Negotiated Commissions 42 Retiree Segments 43 Multiple Option Underwriting 43 Groups of 51 or more - Medical Open Enrollment 44 Groups of 51 or more - Group Renewal and Changes 44 Changes in Group Census Changes to Group Anniversary Date Dental Group Guidelines 45 Available Plans 45 Small Employer Plans – General Guidelines 45-46 Special Requirements 47 Plans with 2-4 enrolled Plans with 5-49 enrolled Small Employer Plans - New Group Enrollment 48 Small Employer Plans 2-50 51+ group size Dental Individual Guidelines 49 Individual ACA Guidelines 50 Eligibility Rules 50 Eligibility Loss of Eligibility Enrollment 51 Open Enrollment Periods 51

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Individual Applications 51 Effective Date 52 Changes to Policies 53 Submission Requirements for Special Enrollments 53 Submission Requirements for 54 Limited Enrollment Out of Pocket Crediting 55 Tobacco Rates 56 Individual ACP 57 (Alternative Choice Plan) Eligibility Rules 57 Eligibility Waiting Periods for Pre-existing Conditions Enrollment 58 Individual Applications 58 Effective Date 59 Tobacco Rates 59

Medical Records 59 Consumer Reporting Agencies 60 MIB Ingenix - MedPoint Underwriting Decisions 61 Tele-underwriting Services 61 Height and Weight Charts 61 Female Height and Weight Chart 62 Male Height and Weight Chart 63 Declinable Health Conditions 64-67 Forms 68 Appendix A 68 (Controlled Group Questionnaire) Appendix B 69 (Common Ownership Confirmation Form) Declaration of Domestic 70-72 Partnership Form 1099 Form 73

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WPS Underwriting Guide - All Group

All Groups – Eligible Groups Standard Groups Sole proprietorships, partnerships, limited liability companies and corporations are eligible when the group policy is issued to the employer covering his/her employees. There are three distinct categories of employer groups, including large risk groups, small risk groups and administrative services only (ASO) groups. ▪ Large Risk Groups: Employer groups with 51+ total employees (including full-time, part-time,

and seasonal) ▪ Small Risk Groups: Employer groups with 2-50 total employees (including full-time, part-

time, and seasonal) ▪ ASO Groups: Self-insured employer groups To determine whether a group is eligible for large or small group coverage, group size must be determined based on number of total employees (including full-time, part-time and seasonal). Organizations of Employers (Controlled Groups, Associations, etc.) With very limited exception (see below), in order for WPS to issue a single group policy to an organization of multiple distinct employers, the organization of distinct employers must attest that it meets the definition of a controlled group. A controlled group is a combination of two or more corporations that are under common control. The controlled group is considered a single employer even though they have different names and different tax ID numbers. There are two common types of controlled groups. (1) Parent-subsidiary and (2) Brother-sister. A parent-subsidiary controlled group consists of one or more chains of corporations. A brother-sister controlled group consists of two or more corporations with the same five or fewer owners (i.e. individuals, trusts or estates). If an employer has a unique Tax ID, it has the option to purchase coverage as a single employer even if it is part of a controlled group. An employer with a unique Tax ID who is a member of a controlled group can choose to offer employee benefits independently or in combination with the other members of the controlled group. Whichever way the employer chooses to go, it has guarantee issue into the market it is a part of given the basis on which it chooses to provide benefits. A collection of employers that does not meet the definition of a controlled group is not eligible for coverage under a large group policy. This is true regardless of what the collection of employers calls itself. Common names for such collections of employers include, but are not

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limited to: associations, trusts, multiple employer welfare arrangements (MEWAs), purchasing alliances, purchasing cooperatives, coalitions, collaborative. There are two possible exceptions to this:

▪ A collection of employers deemed an “employer” by the US DOL. This is incredibly rare, and unless the collection of employers can produce documentation from the US DOL, verifying its designation as an “employer” a policy cannot be issued under this exception.

▪ A collection of employers organized as a cooperative under ch.185. Wis. Stat.

The collection of employers must, (1) be legally organized and comply with all applicable statutory requirements, and (2) not include any small employer groups. The Wisconsin cooperative statute is pre-empted by Federal law with respect to small employer groups.

See Appendix A for the Controlled Group Questionnaire and Appendix B for the Common Ownership Confirmation Form. Both the Questionnaire and the Form must be completed and submitted to Underwriting with any application for coverage under a single group plan for an organization of multiple distinct employers. Labor Unions A group policy may be issued in the name of a union to cover union members, employees and officers. Coverage will be available to union members and eligible management actively engaged in their occupation or on layoff and self-pay, as defined in the constitution, bylaws, trust agreement and/or labor agreement. A copy of a document that defines eligibility must be submitted to WPS along with the quote request. Classing Out Employees WPS will allow classing out of established classes of employees provided (1) classes are established in a non-discriminatory manner and (2) coverage is uniformly available to all similarly situated individuals. Proof of coverage for waiving classes, may be required. ASO groups are prohibited by federal nondiscrimination laws from establishing classes that favor highly compensated employees. The ACA extends the prohibition to fully-insured groups, pending issuance of clarifying regulations. WPS does not apply a nondiscrimination test to employer groups. It is the responsibility of the employer group to determine whether established classes of employees are compliant with federal nondiscrimination laws.

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Health and Welfare Trust Funds These groups are usually created as a result of collective bargaining agreements. Health and Welfare Funds are eligible groups when a group policy is issued to trustees of a fund established by one or more employers and/or one or more labor unions to cover employees or members of the union. Coverage will only be available to union members actively engaged in their occupation, as defined in the constitution, bylaws, trust agreement and/or labor agreement and eligible management. A copy of the document that defines eligibility and a description of the method to be used to maintain records and remit premium must be submitted to WPS.

All Groups - Eligibility Rules

Eligible Person(s) Eligible Employee An employee who has met the eligibility requirements for insurance set forth in the group policy. Employees must work 30 hours per week and must be actively at work for groups with 2-50 enrolled employees and 80 hours or more per month for groups with 51 or more enrolled employees. (The employee is actively at work on: each day of a paid vacation; or a regularly scheduled non-working day, provided that, in either case, he/she was at work on his/her last regular working day prior to such date), unless otherwise specified by a group contract agreement. Spouse The person to whom the customer is legally married to, including status of legal separation. A legal spouse may be of the same or opposite sex. A customer who is responsible for providing health insurance to a former spouse under a court order cannot include any former spouse on his or her insurance as a dependent because he or she is not a legal spouse. However, coverage may be provided separately to a former spouse under Wisconsin and Federal (COBRA) Continuation provisions, if applicable. Child(ren) Natural Children - The plan will provide coverage for a single covered

employee’s/individual’s newborn natural child from the moment of that child’s birth and for the next 60 days of that child’s life immediately following that child’s date of birth. The covered employee/individual must change from single to family coverage to provide coverage for the newborn beyond the first 60 days. To do this, he/she must apply for coverage using our application form and either: (a) pay the required premium within the first 60 days after the birth of his/her natural child; or (b) pay all required past-due premium within one year after the birth of his/her natural child and in addition pay interest of such

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premium payments at a rate of 5 1/2% per year.

- WPS will provide coverage for a covered employee’s/individual’s child or step-child, who is less than 26 years of age.

- WPS will provide coverage for a covered employee's/individual’s child or step-child who is a full-time student and meets all of the following criteria: 1. The child was called to federal duty in the national guard or in a reserve component

of the U.S. armed forces while the child was attending, on a full-time basis, an institution of higher education; and

2. The child was under the age of 26 when called to federal active duty; and 3. Within 12 months after returning from federal active duty, the child returned to an

institution of higher education on a full-time basis, regardless of age.

Adopted Children - Wisconsin Statutes 609.25 and 632.896 require coverage for adopted children and children placed for adoption with a customer under the same terms and conditions for other dependent children, with these exceptions:

− Coverage for an adopted child begins on the date a court makes a final order granting

adoption, or on the date the child is placed for adoption with the customer, whichever is earlier.

− Coverage for a child placed for adoption is required whether or not a final order granting

adoption occurs. When the child’s adoptive placement with the customer ends, the child’s coverage will be terminated.

− The customer is required to notify WPS that a child has been adopted or placed for

adoption, and the insured (customer) must pay any premium or fees necessary to cover the child (if applicable). Application for coverage of adopted children must be submitted within 60 days of the final court order granting adoption, or placement in the home, whichever is earlier. If the customer fails to notify WPS or make payment within 60 days, WPS will treat the adoptive child as any other dependent who seeks coverage at other than the time when they are first eligible.

− Stepchildren - Eligible if the step-child(ren) resides with the customer or is supported by the

customer and/or is the child of the customer’s legal spouse, subject to all other dependent child eligibility requirements.

Legal Guardianship - Eligible for coverage when legal guardianship of a dependent child is

obtained by the customer (includes customer and spouse). Children who are not the natural children of the customer and for whom the customer is not legally responsible are not eligible dependents. Relatives of the customer are not eligible dependents unless legal guardianship is obtained.

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Foster Children – For small group plans only, foster children are eligible for coverage upon placement in foster care, and for the duration of the placement. For large group plans, foster children are not eligible for dependent coverage.

Grandchildren - A child of a customer’s covered eligible dependent is eligible for coverage

until the covered eligible dependent reaches age 18.

Overage Handicapped Children – eligible if (1) resides with the (insured) customer (2) is solely dependent on/supported by the insured or the insured’s legal spouse and (3) was a covered dependent on the date he/she reached the limiting age for dependent coverage under the policy. Documentation such as Social Security eligibility and recent tax documents showing the handicapped child (ren) are solely dependent on their natural or adopted parent.

Domestic Partners on all Risk Groups Domestic partners are only eligible for coverage if the group chooses to include this type of coverage upon initial enrollment. If not chosen upon initial enrollment, this coverage can be added by submitting an Employer’s Group Application indicating this change along with all applications for those domestic partners who are eligible. This change will become effective first of month following receipt of change application and will be subject to underwriting requirements (please note: this could result in a change in your rates due to the additional risk). The domestic partner must meet the following definition in order to be eligible for coverage: Domestic partners are defined as two individuals: Who are in a committed relationship of mutual support, caring and commitment with the

intention to remain in such a relationship in the immediate future; Who are financially responsible for each other’s well-being and debts to third parties; Who are not married or legally separated in marriage, and who have not been a party to an

action or proceeding for divorce or annulment within six months of registration, or if one has been married, at least six months have elapsed since the date of the judgment terminating the marriage;

Who are not currently registered in another designated partnership, and if one party has been

in such a registered relationship, at least six months have lapsed since the effective date of termination of that registered relationship before the registration of the current domestic partnership;

Who are each 18 years of age or older and competent to contract; Who are not related by blood closer than would bar marriage in the state of their residence;

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Who live together in the same dwelling unit as a single non-profit housekeeping unit and

have a relationship that is of a permanent and domestic character; Whose relationship is not temporary, social, political, commercial, or economic in nature; Whose relationship has existed for at least six months; Who are not registered with any other domestic partnership; Who, for at least the six-month period immediately preceding the date of this Declaration,

have either: - Obtained a domestic partnership certificate from the city, county or state of

residence or from any other city, count or state offering the ability to register a domestic partnership; or

- Any three of the following with respect to the domestic partner:

-- joint lease, mortgage or deed; -- joint ownership of a vehicle -- joint ownership of a checking account or credit account -- designation of the domestic partner as a beneficiary of the covered

employee’s will -- designation of the domestic partner as a beneficiary for the covered

employee’s life insurance or retirement benefits; -- designation of the domestic partner as holding power of attorney for health

care; or -- shared household expenses

If eligible, the domestic partner form (See Forms in Appendix A) must be completed and submitted along with each Employee Application. Same-Sex Marriage – As a result of the U.S. Supreme Court ruling, effective October 6, 2014, each spouse in a same-sex marriage is eligible to enroll the other as a dependent spouse on his/her health insurance plan, subject to the terms of the enrollee’s certificate of coverage. Generally, spouses must apply at initial enrollment or within 31 days following the date of marriage, with coverage effective on the date of marriage. A same-sex spouse is not considered as a domestic partner; rather, he/she is considered a dependent spouse.

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1099 Employees

The following guidelines apply to groups with less than 51 full-time equivalent employees. Groups with more than 50 full-time equivalent employees will determine eligibility of their 1099 employees in accordance with the Affordable Care Act Shared Responsibility requirements. A wage and tax statement must be provided listing the average hours worked for each listed employee. Leased employees and independent contractors are not eligible for coverage unless all of the following criteria are met. 1099 employees must meet the WPS definition of a full-time employee. 1099 employees must work year round and exclusively for the group. If offering to one eligible 1099 employee, the group must offer coverage to all eligible 1099

employees.

Taxed employee for the purpose of this guideline refers to those employees listed on the State Quarterly wage & tax statement. The group must meet all underwriting requirement on their own, before they can add 1099

employees. Participation will then be measured on all eligible taxed employees and eligible 1099

employees. Employer must contribute the same amount of money toward the 1099 employee’s premium

as the taxed employees. Employer must be eligible for coverage prior to adding the 1099 employee(s). There must be

a minimum of two taxed employees at all times. A minimum of 50% of the insured’s must be taxed employees. Employer application must indicate that 1099 employees are eligible for plan at time of

enrollment. 1099 employees must be effective at original enrollment, at open enrollment or special

enrollment or they will be considered late entrants. Employer must provide copies of all 1099 statements including individuals not electing

coverage.

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1099 employees that are eligible and not electing coverage must complete a waiver

application. 1099 employees will not be eligible for ancillary coverage. 1099 Employees are only eligible for coverage if the group chooses to include this type of coverage upon initial enrollment. If not chosen upon initial enrollment, this coverage can be added by submitting an Employer’s Group Application indicating this change along with applications for all 1099 employees who are eligible. This change will become effective first of month following receipt of change application and will be subject to underwriting requirements (please note: this could result in a change in your rates due to the additional risk). If eligible, the 1099 form attached must be completed and submitted along with the enrollment or change application. (See 1099 Form on page 73 )

Groups with more than 50 full-time equivalent employees will determine eligibility of their 1099 employees in accordance with the Affordable Care Act Shared Responsibility requirements.

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Ineligible Person(s) Overage Dependents A dependent child or step-child ceases to be eligible the day immediately following the last day of the calendar month in which the dependent child or step-child reaches age 26.

New Hires New hires and their dependent(s) are guaranteed coverage if an application is submitted in

accordance with the group’s new hire enrollment requirements. The effective date is the date eligible shown in accordance with the group’s waiting period (the waiting period may not exceed 90 days). If application is made after the group’s initial enrollment period as stated above, the new hire/dependent is considered a late enrollee.

Any requests to waive all or part of the probationary period for a new hire who is a key employee must be submitted in writing to WPS Underwriting. A key employee is someone in an occupation critical to the specific type of business the employer is engaged in, generally in a management or highly specialized position. For Large group Risk, the request must include the employee’s title, salary and completed health questionnaire on the application. This request must be made prior to the individual’s requested effective date of coverage. Approval of any requests for such an exception is at the sole discretion of WPS Underwriting. For ASO, nondiscrimination rules prevent acting in favor of highly compensated employees. Therefore, the probationary periods will not be waived. Waivers: When an employee, spouse, or dependent waives the WPS coverage because of other creditable coverage, a waiver must be signed by the eligible employee. This waiver will be secured on behalf of the spouse or dependent that declines coverage under the WPS policy during the initial enrollment period or as a new entrant, or as an underwritten individual. Anyone waiving coverage because of other creditable coverage must complete the applicable section of the Employee Application identifying the type of coverage they currently have. For groups’ of 51 or more enrollees, the group must maintain in its files proof of waiver for each individual choosing to waive coverage and provide WPS a list of employees waiving coverage.

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PPACA Special Enrollment Reasons

▪ If you fail to make a positive election during the open enrollment period you will be

excluded from purchasing coverage until the next open enrollment in the subsequent year. The only exception to these rules occurs if there is a qualifying life event.

▪ Birth – The effective date of coverage will be the date of event. The application must be

submitted within 60 days following the event, unless within 12 months of birth of the child the insured submits all past due premium plus interest at a rate of 5.5% per year). a. No special documentation needed

▪ Adoption – The effective date of coverage will be the date of event. (Submission of the

application must be within 60 days following the event) a. Submit legal documentation of adoption which includes placement, date, child’s

name and adoptive parent’s name ▪ Marriage – First day of the following the month in which the application was received by

WPS (Submission of application must be within 60 days following the event) a. Submit a copy of applicant’s Marriage Certificate

▪ Loss of Coverage – First Day of the following, the month in which the application was received by WPS (Submission of application must be within 60 days of loss of other coverage)

a. Submit Certificate of Creditable Coverage or other proof of involuntary loss of coverage ▪ For all other reasons: Permanent Move, Gain US Citizenship – If applying between the 1st and 15th of the month, the effective date will be the 1st of the following month. If applying between the 16th and end of the month, the effective date will be the 1st of the second following month.

Late Enrollees A late enrollee is an eligible employee or dependent who did not request coverage during a group’s initial enrollment period, did not apply within 30 days of the end of his/her probationary period or does not qualify for the Special Enrollment Reasons listed above.

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All Groups - Loss of Eligibility Coverage for all covered members ends based on language in the policy issued.

All Groups - Regaining Eligibility An employee that loses eligibility for group coverage and later regains eligibility may be re-issued coverage as long as it is reasonable under the circumstances. A group can require the new hire to meet the plan’s eligibility criteria, including a maximum 90-day waiting period. For groups subject to Shared responsibility, if an employee regains eligibility within 26

weeks otherwise 90 days following the end of the month he or she became ineligible, the previously held coverage will be re-issued effective on the first day of the calendar month following the date he or she regains eligible status if application is submitted within 30 days of rehire (unless a particular group has other specific requirements that supersede this). Benefits will not exceed those available if the employee had been continuously insured, except to the extent the employee would, if continuously insured, have been eligible to enroll dependents based on a special enrollment circumstance.

For group’s subject to Shared responsibility, if an employee’s return to eligible status is more than 26 weeks, otherwise 90 days following the date coverage terminates, the employee will be considered a new hire (i.e., he or she will need to meet the probationary period). Benefits will not exceed those available if the employee had been continuously insured (i.e. single coverage at time of ineligibility will be reinstated as single coverage upon return)

Military Leave

The following applies if a reservist is discharged from a branch of the Armed Services. Employee Under the federal Uniformed Services Employment and Re-employment Rights Act

(USERRA), employees and their dependents are entitled to immediate reinstatement of their civilian insurance coverage upon return to employment, as long as the guidelines below are followed

1. For Active Duty of less than 30 days, the employee must return to work on the next

regularly scheduled workday after receiving adequate time for travel and rest. 2. For Active Duty of 30 to 180 days, the employee must return to work within 14 days after

completion of service.

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3. For Active Duty of more than 180 days, the employee must return to work within 90 days after completion of service.

Subject to the above guidelines, group coverage would be reinstated on the date the

employee returns to work. TRICARE coverage eligibility may continue between the date the Service Member is discharged from Active Duty and the date he/she returns to work; a TRICARE Benefits Counselor should be consulted for details if applicable.

Dependent Child(ren) Discharged

When a dependent child is discharged from the service, coverage will be reinstated under the

group plan, provided he/she meets all other eligibility requirements, including limiting age and full-time student status, if applicable.

Leave of Absence due to Military Leave Coverage shall end on the date the covered employee or covered dependent enters into military service, other than for duty of less than 30 days.

All Groups - Group Quotes Census Information To avoid rate adjustments at the time of enrollment on either an age-rated or composite basis, the quote must be premised on an accurate census. Census information should include: Single/family participation (not marital status). Dates of birth or age (as of the requested effective date) and gender for all employees. Effective Date Group Size 2-50 Total Employees WPS will follow the on-Marketplace requirements for enrollments. The cut-off date will be the 15th of each month for an effective date beginning the first of the following month. For enrollments received after the 15th of the month, the effective date will be the first date of the second following month. For example, an enrollment received on January 16 will have an effective date of March 1st.

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Group Size 51+ Total Employees An effective date within a proposal means that, if WPS quotes rates for a group with an October 1st effective date, the proposal becomes invalid after October 1st. Only Underwriting can agree to extend the effective date and/or modify the rates or terms of the contract. Guidelines for Quoting Groups with Out-of-State Residents All groups to be quoted must be based in Wisconsin. Guidelines for groups with 51+ total employees.

- A maximum of 75% of the group can be out-of-state residents. Please contact WPS Underwriting regarding any such groups which do not meet this guideline. Only Underwriting may grant an exception to this guideline.

No more than 25% of the group can be in any one state outside of Wisconsin.

Special rule for Minnesota: For any size group with employees residing in Minnesota, the

group may be quoted if fewer than 25 employees are Minnesota residents and the employees who are Minnesota residents represent less than 25% of all covered employees. Please contact Underwriting regarding any groups that do not meet this guideline.

For any groups not meeting the above guidelines, please contact WPS Underwriting prior to

requesting a quote.

Carve Out Rates ▪ Small Groups on ACA Metal Tier Plans may not receive carve out rates. ▪ Guidelines below apply to Non-ACA Groups Carve Out rates are available to eligible employee(s) and/or the spouse/dependent of an eligible employee who(m) are Medicare eligible for Part A & B and their WPS coverage is secondary to Medicare Part A & B under Medicare rules. The applicant(s) must receive the same benefits as the rest of the group. WPS is secondary to Medicare in the following situations, thus Carve Out rates are available:

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Medicare eligible due to age (65 and over) For groups under 20 employees (an employer that employs fewer than 20 persons, including

part-time employees, for a minimum of 20 weeks during the current or preceding calendar year)

- Active employees.

- Continuation contracts.

For groups with 100+ employees

- Retirees (Classes must be approved by Underwriting).

- Continuation contracts. Association, Trust, Union

- If the group is part of a multi-employer plan that has at least one group with more than 20 employees, such as a union, sponsored trust, Chamber of Commerce sponsored plan or MEWA but the group has less than 20 employees. The Medicare Intermediary must be notified of this situation.

Medicare disabled (under 65) employee(s) and/or dependent(s) Under 100 employees (an employer that has under 100 people actively employed 50 percent

or more of the regular business days in the preceding calendar year) End-Stage Renal Disease (ESRD) All Groups - after the first 30 months of Medicare eligibility.

All Groups Reporting

Paid Claim Information ▪ Groups with 2-50 enrolled employees. No paid claim information is available unless Self-funded. Groups with 51-99 enrolled employees. Aggregate paid claim summary information is

available on an annual basis from WPS with the group’s renewal rates.

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Groups with 100 or more enrolled employees and all Administrative Services Only (ASO)

groups have access to WPS Data Dashboard. Reports available online include:

- Enrollment reports - Financial summary reports - Provider utilization - Health conditions - High cost claims

WPS Data Dashboard provides access to a group’s health care information at any time through our secure Web site. WPS will appropriately charge the group for any additional requests for paid claim information. All WPS Data Dashboard reports provided to fully insured groups include only de-identified data. WPS Data Dashboard Reporting Package

50-99 100+ 25-50 51-99 100+X X X X XX X X X XX X X X XX X X X X

X X X

X X X XX X X XX X X XX X X X

X X X X X

X X X X XX X X

X X X

Report Availability Plan

Enrollment by Health Plan and NetworkEnrollment by Subgroup and Class

Risk ASO

Claims StrataHigh Cost Patients

Report Family

Top Provider

Report Name

High Cost Claims

Provider Utilization

Claims MatrixLoss Ratio

Financial Summary

Paid By Claim TypePaid By Claim Type by Subgroup & Class

Health Conditions Claims by Dignosis and MDC

Enrollment by Age and Employee PlanEnrollmentEnrollment by Age and Member Type

Form 1095 B-C

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Prognosis Information Fully insured policies do not have the right to access diagnosis or prognosis information on

specific individuals. Therefore, WPS will not give claims runs to any employer that indicates the amount and diagnosis or prognosis on the same run.

Deductible/Out of Pocket Crediting ▪ New groups to WPS/Arise – Credit deductible only ▪ Existing groups voluntarily moving to an ACA plan – credit deductible only ▪ Existing groups moved to an ACA plan ○ Calendar year January anniversary groups – no credit Non-January anniversary groups – Credit deductible & Coinsurance ○ Plan year – No credit (if moved on plan year) ▪ Groups switching from WPS to Arise or Arise to WPS – credit deductible only Please submit deductible credit reports from prior carrier to:

WPS Health Insurance Attn: Claims, Deductible Credit Supervisor

PO Box 8190 Madison WI 53708.

This can also be faxed to the attention of Deductible Credit Supervisor at (608) 223-3603. The deductible credit report should also include employee last name, first name and the specific time frame covered in the report. If the group is unable to obtain a deductible credit report from the prior carrier, WPS will accept an Explanation of Benefits (EOB) from the employee. If employees are submitting EOB’s, please make sure they are submitted timely in order to prevent WPS from taking deductibles on their claims. Only deductibles will be credited, WPS does not credit coinsurance. Any exceptions to credit coinsurance would have to be submitted in advance for review and approval by WPS Underwriting Management.

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All Groups – Back Billing & Credit Adjustments Clerical errors Errors by either the group or by WPS will not invalidate coverage otherwise in force nor continue coverage otherwise terminated. Upon discovery of an error, an equitable adjustment will be made in the premium and/or benefit payment.

All Groups - Group Changes Small Transitional groups can make a change on their existing policy or move to an ACA compliant plan upon renewal. ▪ All transitional relief benefit changes on current policy should be submitted to Underwriting ▪ All small group changes to metal tier plans should be submitted to Member Services Benefit Changes Retroactive benefit changes are not permitted. All benefit changes must be submitted to Member Services for approval and rating before the effective date of the change. In unique situations involving union negotiations or other extenuating circumstances, WPS may allow retroactive benefit changes. WPS will, however, charge an appropriate administrative fee to cover the cost of claims processing, re-billing, etc. Customer Network Changes ▪ Employees changing network offered by group. Employees can change to a different

network offered by the group if he or she has a change during open enrollment or due to a special enrollment reason.

− If employee does not meet the requirements to change networks, WPS will notify the

group.

− If employee meets requirements to change networks, but the group doesn’t offer the requested network, the group can opt to add a network (described below).

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− If employee meets requirements to change networks and the group offers the network requested, WPS will change the employee to the new network the first of the month following receipt of the request in the WPS Member Services Department.

Group Adding Network ▪ To add a network, the group leader should submit these forms to WPS Underwriting for Risk

groups only:

− Employer’s Group Application with the appropriate Sections completed. ‒ A rate quote prepared by WPS Sales or Underwriting and signed by the group leader. ‒ A letter on company letterhead indicating which employees should be transferred to the new network . (For both Risk and ASO)

Acquisition of a Subsidiary or Buy-out (Common Ownership or Affiliation) An existing group that acquires new employees because of a subsidiary purchase or buy out may add any eligible employee from the subsidiary or buy out within 31 days of the purchase or buy out. Employee additions due to acquisition or buy-out are subject to the following requirements: A Quote Request Form and an Employer’s Group Application must be submitted to WPS Underwriting for pre-approval, along with a census for the new employees, medical statement, applications or claims experience for new subsidiary/segment of employees WPS will credit any calendar year deductibles from the prior carrier. WPS must receive the proper enrollment forms, with appropriate medical questions completed. ▪ The Prior Carrier’s most recent billing statement If a change in rating size occurs, WPS Underwriting may re-rate the entire group on the effective date for the new segment. This process would not change the group’s anniversary date. Otherwise, changes in rating size will be implemented on the group’s regular anniversary date. If a new business entity is formed as a result of a buy out or merger, employees covered by

WPS under the old entity will not be subject to medical underwriting if applying for eligible WPS group coverage.

If adding a subsidiary (common ownership or affiliation), this subsidiary must meet all of the

eligibility requirements of a new group on their own in order to be eligible to apply with the existing group

January 2015

23

All Groups - Group Renewal Renewal Premium Rates Premium rate guarantees are not allowed on groups with 2 – 50 employees. Premium rate guarantees on groups with 51+ employees must be approved by WPS Senior Management. Change in Group Status WPS will audit groups prior to the anniversary date to determine whether underwriting

standards and participation requirements continue to be met.

‒ Groups that are below minimum participation will be terminated upon required written notice.

‒ Upon request groups that do not meet minimum participation will be given an additional 60 days to meet such requirements. If, after 60 days, the group has not met minimum Participation the group will be terminated.

Changes to Group Anniversary Changes to a group’s anniversary date must be pre-approved by WPS Underwriting. Without

Underwriting’s approval; WPS cannot honor renewal rates for a date other than the group’s anniversary date, as such a change may not allow ample time for preparation of necessary information to generate renewal rates.

All lines of coverage must have a common anniversary date, unless special circumstances

apply.

All Groups - Group Policy Terminations Reason for Termination There are two main rules for group coverage discontinuance because of non-payment of premium. If coverage terminates for non-payment of premium, WPS is liable for all claims incurred

prior to the end of the grace period. Note: The group is responsible for paying the premium

during the grace period. WPS will provide the group with a written notice of discontinuance before terminating

January 2015

24

coverage for non-payment of premium. The premium must be submitted for the last month of coverage, including the grace period.

Reinstatement A group whose coverage terminated due to non-payment of premium may be reinstated back to the termination date at the discretion of WPS. A group reinstatement for non-payment of premium can only occur once and will be on the terms and conditions determined by WPS. All current and past due premiums must be paid in full.

All Groups - Group Coverage Discontinuance and Replacement

Military Leave Continuation

Standard WPS group policies contain exclusions for coverage of health care services for an illness or injury caused by an atomic or thermonuclear explosion or resulting radiation, or any military action, friendly or hostile. In addition, when a covered employee is called to Active Duty for 30 days or more, most of our standard group policies state he/she and his/her dependents can no longer be covered under the group plan as of the first day of Active Duty. Dependents called for Active Duty for 30 or more days are not covered as of the first day of Active Duty; however, the employee and any other dependents may remain on the group plan. In either situation, the Service Member generally has at least one of the following coverage options: COBRA

- If the group is a COBRA-eligible employer, COBRA can be elected. Standard COBRA guidelines apply.

Uniformed Services Employment and Re-employment Act (USERRA) Continuation - For any size group, the Service Member can elect continuation of group coverage under

USERRA for up to 24 months. If this option is chosen, USERRA states that the maximum premium that can be charged is 2% over the regular premium under the plan, to cover administrative costs. For plans that are subject to COBRA, USERRA continuation runs concurrently with COBRA.

TRICARE Coverage - TRICARE is the federal group health program available through the

U.S. Department of Defense, offered to Service Members and their dependents. Members

January 2015

25

entering active military service for more than 30 days are eligible to enroll in TRICARE. Coverage begins for the Service Member and his/her dependents on the first day of Active Duty. If group coverage is continued under USERRA or COBRA, the group coverage is primary and TRICARE is secondary.

Liability of Prior and Succeeding Carriers in Group Replacement Situations

Crediting Deductibles

− The succeeding carrier must give credit for deductibles that were satisfied by the customer while he or she was covered under the prior plan.

COBRA, Wisconsin Continuation, Extension of Benefits

-- In a replacement situation, the succeeding carrier must insure all customers covered under the previous plan, including those covered under COBRA, Wisconsin continuation or an extension of benefits for as long as they are eligible.

WPS Underwriting Guide - Groups of 2 to 50

2 to 50 Groups - Group Size Definition Groups subject to ACA Insured groups with 2-50 total employees, including full-time, part-time and seasonal, for

federal and/or state compliance purposes. Note: (If a husband and wife are the only two eligible employees of a group, and there are no other employees including fulltime and/or part time showing on the wage statement, they cannot apply for two single contracts (or one single and one limited family) for the sole purpose of qualifying as a two-person group.)

If the actual initial enrollment differs from the group size quoted by WPS, the group will be placed in the correct group size with possible rate and benefit changes. This rule also applies at renewal. It will be based on a 12-month enrollment average.

January 2015 26

2 to 50 Groups - Benefits Groups subject to ACA Group Health Available plans, including benefits, cost-sharing, and restrictions, are set on a calendar year basis. Policies are issued for a 12-month plan year. Employer groups may not be renewed or moved to a different available plan before the expiration of their plan year, except at the option of the employer.

Group Rate Quotes

Quote Guidelines for Groups with 51+Total Employees Non-ACA Group Exceptions to the following quoting guidelines will be reviewed by WPS Underwriting Management on a case-by-case basis. Groups must make full and complete applications to the WPS Underwriting Department upon enrollment before final assessment of risk will be determined, resulting in approved rates (see section on New Group Enrollments below).

Internet Quoting Book-rate quoting capability is available on a limited basis in the Agent’s Corner section of our website at www.wpsic.com. Please contact your WPS Agency Manager for further details. If you do not currently have this Internet quoting access, the information indicated below must be submitted to WPS to request a quote.

Information Needed to Request a Quote The following information is required to request a quote. (Final rates will only be determined upon submission of full enrollment materials and after review of all information, including health information.) Name of Group and Agent/Broker (if applicable)

January 2015 27

Address of Group ‒ Indicate which employee works at which location (if applicable) Industry Classification (SIC) of Group

Census information should include:

‒ Election participation i.e. Single/Family (not marital status) ‒ Dates of birth or age and gender for each employee ‒ Zip Code ‒ Benefit selection if multiple plans Benefit Plan(s) and Network(s) requested

Quote Guidelines for Groups with 2-50 Total Employees Groups subject to ACA – all per-member age rated; family coverage rated based on total per-member rates for employee, dependents age 18+, and up to three children age 0-17. Transitional Non-ACA groups (issued prior to 1/1/2014) All groups of 2-25 will be age rated and groups of 26+ will be composite rated.

Age Adjustments ACA & Non-ACA Groups ▪ All age-band adjustments will be adjusted at time of renewal. Effective Date of Quote Subject to ACA For groups with 50 or less total employees, rates will be quoted for effective dates no more than 60 days in advance. Non-ACA Group

January 2015 28

For groups with 50+ enrolled employees, rates will be quoted for effective dates no more than 90 days in advance. Group quoting beyond the 90 days requires Underwriting’s approval.

2 to 50 Employees - New Group Enrollment

Required Group Enrollment Material Groups subject to ACA ▪ WPS Employer Application ▪ WPS Disclosure Notice with 2-50 total employees ▪ Employee Applications (those employees still in their probationary period and employees Who are presently on COBRA/State continuation). ▪ Most recent Quarterly Wage and Tax Statement (Please see the “Required Tax Documents For New Group Sales” section below for further detail.) ▪ Copy of the sold quote ▪ Copy of Sold Quote Age Rate Matrix Grid Initial Monthly Premium Groups that choose the direct billing option should submit their premium with their enrollment. If they choose ACH we will withdraw the first month’s premium from the ACH account. Standard grace period will still apply to the first month’s premium. The policy will be terminated if payment is not made in a timely manner. Non-ACA Groups WPS Employer Application Employee Medically Underwritten Applications - with appropriate Health Questions

completed for each eligible employee and or dependent(s) enrolling for coverage, and also for those employees still in their probationary period and employees who are presently on COBRA/State continuation.

Employee Waiver Applications – with Waiver Section completed for all eligible employees

January 2015 29

waiving coverage with WPS. Copy of COBRA/State Continuation election forms for any terminated employee that has not

elected COBRA/State Continuation, but still appears on the prior carrier billing statement. Most recent billing statement from the group’s current carrier (if applicable). Most recent Quarterly Wage and Tax Statement. (Please see the “Required Tax Documents

for New Group Sales” section below for further detail.) Copy of the sold proposal/quote given to the agent, broker, and/or the policyholder.

Required Tax Documents for New Group All Businesses of two or more eligible employees must supply the following documentation: Most recent Quarterly Contribution/Wage Report, or if not required to file a Quarterly

Contribution/Wage Report, we need all of the items listed under the group’s specific business type (see subheadings below).

“C” Corporations Articles of Incorporation Form 1120 Payroll “S” Corporations Articles of Incorporation Form 1120S Payroll Partnership Partnership Agreement Form 1065 Payroll Sole Proprietorship Business license Form 1040/Schedule C Payroll Church Form 941 Payroll

January 2015 30

Limited Liability Company (LLC) LLC agreement and documentation for either a “C” Corporation or a Partnership (see above), depending on how they file with the state.

If the business has been in existence less than one year and not filed a Quarterly

Contribution/Wage Report, we will accept Corporation or Partnership papers and payroll. Farmers - If not a corporation or partnership, farmers are required to submit Schedule F,

itemization of line 24 and copies of W-2 for all employees.

2 to 50 Groups - Medically Underwritten Transitional Non-ACA Groups (issued prior to 1/1/2014) (2-50 enrolled employees but more than 50 total employees) Applications including the Health Information Questionnaire section are required by WPS for groups between 2-50 enrolled employees electing coverage. WPS will not require that employees and dependent(s) who waive coverage complete the Health Information Questionnaire, unless the employee is listed as covered on the prior carrier’s bill and who is now waiving coverage during the application process for WPS. If the employee can provide a copy of an ID card with proof of other existing qualifying coverage, the health questions will not be required.

Process for Full Underwriting New small employer groups are initially reviewed by WPS Underwriting. WPS Underwriting reviews the information for completeness of forms, eligibility

requirements, and medical history that may impact future claims. WPS Underwriting utilizes industry-wide underwriting manuals and other resources to

determine a group’s risk, including the Attending Physician Statement (APS) which may be requested for specific information.

• Teleunderwriting services may be utilized by WPS when underwriting group policies.

Applicants should be made aware that they may be contacted by telephone if necessary to obtain additional medical information.

Effective Dates 51+ groups Non-ACA Group

January 2015 31

The following describes the method of assigning effective dates to new non-ACA group business. The group enrollment must be submitted to WPS Underwriting on or before the requested

effective date month. All underwriting information (including the signed rates) must be received by the 15th of the requested effective date month or the effective date will be moved ahead.

If the group enrollment is submitted after the 1st of the requested effective date month.

The earliest effective date a group can have, is the first of the following month.

2 to 50 Groups - General Underwriting Issues

Participation Small groups subject to ACA Participation requirements may be applied except for group enrollments received between 11-15 through 12-15 each year during open enrollment, or if new plan offerings are introduced with a 4/1, 7/1, or 10/1 effective date. If participation requirements may be applied, WPS may terminate a policy immediately following the last day of a renewal period if it determines the number of participating employees falls below the minimum participation requirements. The group will be reviewed and audited by WPS annually to ensure it meets applicable minimum participation requirements. Health Coverage When determining participation levels, WPS does not count eligible employees who have

other coverage that is creditable coverage. WPS does not allow dual choice on 2-50 size groups. This means that WPS will not offer

coverage to 2-50 size groups who have employees that are covered under another health benefit plan that is sponsored by the same employer.

The minimum size of any group is 2 enrolled employees regardless of number of eligible

employees who have other creditable coverage. Eligible Employees Minimum Enrollment 2 to 4 2 employees 5 to 6 3 employees 7 4 employees 8 to 9 5 employees 10 6 employees

January 2015 32

Example: 10 eligible employees - 5 eligible employees who have other coverage that is creditable coverage = 5 eligible employees for participation purposes. Minimum enrollment for this example would be 3 employees. Eligible Employees Minimum Enrollment 11 to 50 70% Employee: 50 eligible employees - 25 eligible employees who have other coverage that is creditable coverage = 25 eligible employees for participation purposes. Minimum enrollment for this example would be 17 employees Probationary Period 2-50 Insureds There may only be one probationary period in a group with 2-50 enrolled lives.

Probationary Period options are as follows: 1st day of the calendar month following one month of full-time employment 1st day of the calendar month following two months of full-time employment The day following 90 days of full-time employment ▪ The maximum probationary period may not extend beyond 90 days after an individual has satisfied all other plan eligibility requirements. The probationary period can only be waived for new employees who are key employees on a very limited exception basis, at the sole discretion of WPS Underwriting. Please see “New Hires” in the All Groups section of this Guide. New employees in new groups enrolling with WPS are automatically given coverage as of the group’s effective date with WPS even if they have not completed their probationary period, unless the group wants them to finish the probationary period. 51+ Insureds ▪ Can offer multiple probationary options such as: ▪ Date of hire

January 2015 33

▪ 1st of the month following date of hire The maximum probationary period may not exceed beyond 90 days.

Retiree Coverage No retiree coverage is available for groups under 51 enrolled active employees

Dual Option Underwriting Regulations Groups subject to ACA & Non-ACA Dual Option (Multiple Options offered by one carrier) Available to groups with enrollment of 2 or more contracts. Limit of four benefit plan offerings (within WPS standard product offerings). The four plans

can vary by product, deductible, coinsurance, out-of-pocket limit, drug coverage, and/or office visit co-pays.

Employees with active coverage in the group can change between benefit offered plans

during their open enrollment period once per year or at any qualifying event during the year. Application for the request to transfer to the other benefit plan must be received by WPS Member Services at least 30 days prior to the end of the open enrollment.

Employees not currently covered must enroll during open enrollment. Groups may be able to select among multiple networks, subject to some restrictions on

network offerings due to contractual parameters. Please contact your WPS Sales Representative to determine the networks that can be offered in a dual option situation.

With the exception of the above, all other existing underwriting regulations apply for dual option situations.

January 2015 34

Group Renewal and Changes Groups with 2-50 Total Employees Group renewals will be mailed at least 30 days prior to renewal date

Premium Rates & Increase Guidelines Small group rates are subject to Affordable Care Act and will be determined based on:

‒ Age ‒ Number of dependents ‒ County/area, location of the group ‒ Tobacco Use/Arise only Rates can be changed annually upon renewal with 30 days written notice to the employer; 60 days if the increase is 25% or more.

WPS Underwriting Guide - Groups of 51 or More

Groups of 51 or More - Group Size Definition 51 or more enrolled employees for rating and underwriting guidelines. 51 or more total employees, including full-time, a part-time and seasonal employee, for

federal and/or state compliance purposes. If the actual initial enrollment differs from the group size quoted by WPS, the group will be placed in the correct group rated size with possible rate and benefit changes. This rule also applies at renewal. It will be based on a 12-month enrollment average during the most recent experience period.

January 2015 35

Groups of 51 or More - Group Rate Quotes

Effective Date Rates will be quoted for effective dates of no more than four months into the future for corporate groups and six months into the future for public groups, such as schools and municipalities if claim experience is provided. Groups 51+ with Experience

Rates will be quoted for effective dates no more than six months beyond the most recent date of experience received. Updated loss experience will be required to extend an effective date.

▪ Groups 51+ without Experience Rates will be quoted at book rate, but only for effective dates not more than 90 days In the future An effective date within a proposal means that if WPS quotes a group with a 10/01 effective date, the proposal becomes invalid after 10/01. Additionally, only Underwriting can agree to extend the effective date and/or reduce/increase any quoted rate. Exceptions to these guidelines will be reviewed by WPS Underwriting Management on a case-by-case basis.

Information Needed to Request a Quote

Groups 51-99 Without Experience The following information is required to request a quote. (Final rates will only be determined upon submission of full enrollment materials and after review of all information, including health information.) Name of Group and Agent/Broker (if applicable)

Address of Group ‒ Indicate which employee works at which location (if applicable)

Industry Classification (SIC) of Group Census information should include:

‒ Election participation i.e. Single/Family (not marital status) ‒ Dates of birth or age and gender for each employee

January 2015 36

‒ Zip Code ‒ Benefit selection if multiple plans Benefit Plan(s) and Network(s) requested

‒ Preferred: Benefit Booklet/Certificate ‒ Will Accept: Schedule of Benefits or SBC Desired commission level

Group 51-99 With Experience For all experience-rated quotes, a field-rated, system-generated quote should be run. In addition, the following information is required: Minimum of two years of claims experience; should be on carrier or company letterhead.

It should specify dates, and claims amounts. Experience must be within six months of the effective date

Average or monthly contracts for each experience period, if group has more than one

benefit level, contracts should be segmented accordingly Current benefits, and benefit history if there have been any changes during the experience

period provided Current rates and rate history are required

‒ Premium rates (if fully insured) ‒ COBRA/funding rates (if self-insured) Groups 100+ Two years (20-24 months) loss experience to within six months of the requested effective

date. Exceptions may be considered on a case-by-case basis. Experience information must be on company letterhead, a prior carrier report or formatted agent report.

‒ Preferred: Month-by-month (aggregate report if self-funded) ‒ Will accept: Current year-to-date or prior 12 months Customer counts for the loss experience periods

‒ Preferred: Month-by-month ‒ Will accept: Current year-to-date average count or prior 12-month average Shock loss information

‒ Total amount paid for the corresponding experience paid ‒ Diagnosis (and prognosis if self-funded) ‒ 50% Report (if self-funded)

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‒ Preferred: Prognosis and Current status: Active, Disabled, Wisconsin ‒ Continuation/COBRA (with effective date and end date)

Current benefit plan and any changes made during the loss experience periods

‒ Preferred: Complete booklet ‒ Will accept: Schedule or SBC Current employee contributions for single, limited family (if available), and family

Carrier history

Current rates and rate history

-Premium rates (if fully insured) -Specific rates (if self-funded) -Aggregate factors (if self-funded) -COBRA/funding rates (if self-funded) -Admin Fee (if self-funded) -Base admin -Network fees -UR/LCM fee -Rx fee -Rx rebate % ■ Top Provider Reports ■ Pending claims report (if available Freedom Essentials: New Group Quote Request 25+ Insureds Quoting Groups with Out-of-State Residents A maximum of 75% of the group can be out-of-state residents. Sales sends quote request to WPSASO Mailbox Information Sales needs to send based on the type of quote requested. If Sales does not send in the appropriate information, send an email back to the sales agent requesting the missing information. Inform the sales agent that the group is on hold until all information is received.

1. Book Quote

• Book Quote must have correct effective date, counts, and benefits • Census

i. Single/Family Participation

January 2015 38

ii. DOB or Age iii. Gender iv. Zip Code v. Benefit Selections (if multiple plans)

• ASO Quote request form completely filled out

2. Book Quote with Applications

• Book Quote must have correct effective date, counts, and benefits • Census

i. Single/Family Participation ii. DOB or Age

iii. Gender iv. Zip Code v. Benefit Selections (if multiple plans)

• ASO Quote request form completely filled out • Individual Medical Applications, signed and dated by group members

3. Claims Experience with Book Quote

• Census


iii. Gender iv. Zip Code v. Benefit Selections (if multiple plans)

• Book Quote must have correct effective date, counts, and benefits • ASO Quote request form completely filled out • Claims Experience month by month (Aggregate report if available), 2 to 3 years

of experience within 4 months of requested effective date. • Customer Counts for the loss experience periods month by month, single/family • Shock loss information for each loss experience period

i. Total amount paid for each experience period ii. Diagnosis and prognosis on each individual

iii. Current status of individuals (Active, Disabled, COBRA, and termed with end dates)

• Current benefit plan and any changes made during the loss experience periods • Current rates (and Renewal Rates, if available)

i. Premium rates (if fully insured) ii. Specific rates (if self-funded)

iii. Aggregate factors (if self-funded) iv. Admin Fee (if self-funded)

4. Claims Experience with Applications and Book Quote

January 2015 39

• Census i. Single/Family Participation

ii. DOB or Age iii. Gender iv. Zip Code v. Benefit Selections (if multiple plans)

• Book Quote must have correct effective date, counts, and benefits • ASO Quote request form completely filled out • Claims Experience month by month (Aggregate report if available), 2 to 3 years

of experience within 4 months of requested effective date. • Customer Counts for the loss experience periods month by month, single/family • Shock loss information for each loss experience period






Individual Medical Applications, signed and dated by group member Freedom Flex: New Group Quote Request 51+ Insureds Quoting Groups with Out-of-State Residents A maximum of 75% of the group can be out-of-state residents. Sales sends quote request to WPSASO Mailbox Information Sales needs to send based on the type of quote requested. If Sales does not send in the appropriate information, send an email back to the sales agent requesting the missing information. Inform the sales agent that the group is on hold until all information is received.

1. Claims Experience • Census


iii. Gender iv. Zip Code

• ASO Quote request form completely filled out

January 2015 40

• Claims Experience month by month (Aggregate report if available), 2 to 3 years of experience within 4 months of requested effective date.

• Customer Counts for the loss experience periods month by month, single/family • Shock loss information for each loss experience period






2. Claims Experience with Applications

• Census i. Single/Family Participation

ii. DOB or Age iii. Gender iv. Zip Code

• ASO Quote request form completely filled out • Claims Experience month by month (Aggregate report if available), 2 to 3 years

of experience within 4 months of requested effective date.

• Customer Counts for the loss experience periods month by month, single/family • Shock loss information for each loss experience period



• Current benefit plan and any changes made during the loss experience periods

• Current rates (and Renewal Rates, if available) i. Premium rates (if fully insured)

ii. Specific rates (if self-funded) iii. Aggregate factors (if self-funded) iv. Admin Fee (if self-funded)

• Individual Medical Applications, signed and dated by group members

January 2015 41

Groups of 51 or More Total Employees New Group Enrollment

Group Enrollment Material Group Application

Most recent quarterly wage and tax statement with employee status indicated for all

employees listed as to whom is presently full time, part time, seasonal and or terminated. Most recent prior carrier billing statement (if applicable). Employee’s Medically Underwritten Application for each eligible employee and

dependent(s) enrolling for coverage. Employee’s Waiver Applications for each eligible employee who will be waiving the health

coverage. Copy of the proposal given to the agent, broker, and/or the policyholder.

Groups of 51 or More Total Employees Medically Underwritten

Applications including the Health Information Questionnaires are required by WPS for groups that do not have claims experience. WPS will not require that employees and dependent(s) who waive coverage complete the Health Information Questionnaires. The one exception to this policy is employees or dependent(s) who are listed as covered on the prior carrier bill and who waive coverage during the application process for WPS. However, if the employee can provide a copy of their recent ID card showing that present coverage is enforce, the health information questionnaires will not be required.

Process for Full Underwriting Large employer groups with 51+ total employees are initially reviewed by WPS Health

Underwriting. WPS Health Underwriting reviews the information for completeness of forms, eligibility

requirements, and medical history that may impact future claims.

January 2015 42

WPS Health Underwriting utilizes industry-wide underwriting manuals and other resources to determine a group’s risk, including the Attending Physician Statement (APS) which may be requested for specific information.

Tele-underwriting services may be utilized by WPS when underwriting group policies. Applicants should be made aware that they may be contacted by telephone if necessary to obtain additional medical information.

Groups of 51 or More Enrolled- General Underwriting Issues

Matching/Duplicating Benefits and/or Administration For groups of 100+ enrolling WPS can match a group’s Schedule of Benefits (i.e. deductibles, coinsurance, etc.), if approved by Underwriting and can be administered by Policyholder Services and/or WPS Claims. WPS cannot match contractual wording from any other carrier. Administration of contract benefits will be WPS’ standard administration. Exceptions will be considered only for 100+ groups on a case-by-case basis. WPS Underwriting, Claims and/or Policyholder Services must approve all exceptions and determine if a single-case filing with OCI will be required. WPS may consider matching benefits and other administrative exceptions for 100+ groups on a case-by-case basis but will charge the group an appropriate additional administrative fee.

Negotiated Commissions A preliminary discussion should take place between the WPS Sales Representative and the Regional Vice President to determine the desired agent/broker commission level (if other than standard). The final negotiated commission must be approved by the Regional Vice President prior to completing the Request for Proposal (RFP). A completed Group Commission Amendment form must accompany the enrollment reflecting the final negotiated commission. Quoted rates may be affected.

January 2015 43

Retiree Segments The following underwriting rules apply to groups that offer formal age retirement programs and wish to establish a retiree group. Prior approval from WPS Underwriting is required to establish a retiree group. WPS will consider retiree classes for groups with 51 or greater enrolled active employees on a case-by-case basis. Enrolled retirees cannot exceed 10% of the enrollment. The employer must cooperate fully in the administration of the group, e.g., centralized billing

and payment of premiums. The retiree must transfer into the retiree group directly from the employer sponsored WPS

non-retiree plan. If the retiree subsequently leaves the plan, he/she is no longer eligible. Individual changes in coverage (e.g., marriage) are allowed as described in enrollment

section of the group policy. WPS will establish a separate class. Retirees with individual policies from a prior carrier are not eligible to transfer to the WPS

retiree group.

Multiple Option Underwriting Regulations Multiple Options − Minimum of 10% or 25 contracts (whichever is less) enrollees per plan − Limit of four benefit plan offerings.

− Groups may be able to select among multiple networks, subject to some restrictions on

network offerings due to contractual parameters. Please contact your WPS Sales Representative to determine the networks that can be offered in a dual options situation.

Enrollees covered under any employer sponsored WPS plan are eligible for annual choice

between the plans. Employees not currently covered must enroll based on standard enrollment requirements. Dual Choice between Multiple Carriers Review and approval by WPS Underwriting management required.

January 2015 44

Groups of 51 or More - Medical Open Enrollment Open Enrollment is 30 days prior to renewal unless specified different in Employer Policy. WPS must receive all open-enrollment applications within 30 days prior to the open-

enrollment period.. All applications received during an open enrollment must be for the same effective date.

Groups of 51 or More - Group Renewal and Changes Changes in Group Census ▪ WPS reserves the right to evaluate an entire group upon a change in census of 10% or more and apply a rate change as necessary. Changes to Group Anniversary Date Changes to a group’s anniversary date must be pre-approved by WPS Underwriting.

All lines of coverage must have a common anniversary date, unless special circumstances

apply. Groups with an average of 50 or less enrolled employees during the renewal period will be

Health Underwritten. Groups with an average of 51 or more enrolled employees during the renewal period will be

experience rated. Both Risk and ASO Rates can be changed with 30 days written notice to the employer; 60 days if increase is 25% or more.

January 2015 45

WPS Underwriting Guide - Dental

Dental –Available Plans n The following Small Employer Dental Plans are available for groups with 2–49 enrollees: 2-4 enrollees: 2-4 Premier Plus PPO 2-4 Advantage PPO 5-49 enrollees: Ultra Savings Plan Savings Plan Passive Plan Enhanced Plan Choice Plan

Under each of these Plans, an MAC (Maximum Allowable Charge) plan option is available, but not required.

Groups with 50+ enrollees are experience rated and quote requests are sent to Delta Dental

Plan of Wisconsin

Dental – Small Employer Plans, General Guidelines d

In order to honor the requested effective date of coverage, all materials must be received

by Delta Dental no later than five business days prior to the requested effective date.

The plan must be sponsored by the employer. The employer will collect premiums via payroll deduction.

A clear employer-employee relationship must exist.

Employment must be full-time, year-round and not experience layoffs.

The business has not been cancelled by another dental carrier within the past 36 months.

Participation is based on enrollment of all eligible employees except those who are waiving

due to other coverage.

Only one dental plan can be offered.

January 2015 46

The types of businesses listed below are eligible for a dental plan if they meet all underwriting guidelines. However, these businesses require an 18% adjustment on the standard rates. This list is not all inclusive. If uncertain about the industry type and whether a rate adjustment would apply, contact the Delta Dental Sales Department.

-- Accounting, Auditing & Bookkeeping -- Advertising -- Agricultural Production – Crops -- Agricultural Production – Livestock & Animal Specialties -- Attorneys & Legal Services -- Automotive Dealers, New & Used -- Beauty/Barber Shops -- Boat Dealers -- Bowling Alleys -- Business & Professional Organizations -- Churches -- Dentist Offices -- Eating & Drinking Establishments -- Engineering & Architectural Services -- Gas Stations, Convenience Stores -- Holding & Other Investment Offices -- Home Healthcare -- Hospitals, Medical and Dental Labs -- Hotels, Motels, Campgrounds -- Insurance Agents, Brokers & Service -- Insurance Carriers -- Labor, Political, Civic & Social Organizations -- Local & Suburban Transit & Interurban Hwy. Passenger Trans. -- Management & Public Relations -- Medical Service & Health Insurance -- Mobile Home Dealers -- Motorcycle Dealers -- Movie Theaters -- Personal Services -- Physician, Other Healthcare Offices -- Real Estate Brokers -- Recreation & Utility Trailer Dealers -- Research & Testing Services -- Schools, including Colleges & Universities -- Security & Commodity Brokers , Dealers, Exchanges & Services -- Sub-dividers & Developers -- Transportation Services -- Travel Agents/Tour Operators -- Unclassified Health Services -- Unclassified Membership Organizations -- Unclassified Services

January 2015 47

Dental – Special Requirements for Plans with 2-4 Enrolled The Delta Dental 2–4 Enrolled Plans, are available to groups with 2 – 4 enrolled

employees.

Two-person groups may not consist of enrollees residing at the same address.

The total number of eligible employees and dependents participating must be equal to or greater than the percentage of the employer contribution. Example: With an employer contribution of 75 percent, a minimum of 75 percent of eligible employees must participate.

The most recent company Wage & Tax Statement must accompany the new group

enrollment.

Dental – Special Requirements for UltraSavings, Savings, Passive, Enhanced and Choice Plans

The Delta Dental small-employer dental plans are available to groups with 5 – 49

enrolled employees. Orthodontic coverage is available only to groups of 10 or more enrolled employees.

If orthodontic coverage is purchased, all families must accept the orthodontic benefit

with the same maximum.

January 2015 48

Dental – Small Employer Plans, New Group Enrollment

If the group is applying for a dental plan and applying for WPS health coverage(or currently has WPS health coverage), the following are the dental enrollment requirements:

A Completed Delta Dental Employer Application A check for the first month’s dental premium, payable to WPS The completed ACH form (if ACH is selected) A copy of the sold dental proposal outlining the benefits A copy of the most recent Wage & Tax Statement (applies only to employers with 2-4

enrollees)

Completed enrollment forms for each eligible employee (enrollment forms may not be required if eligibility reporting method is a spreadsheet or electronic). For any eligible employees waiving coverage, include the reason for waiving.

For groups with 2-50 total eligible employees, the dental enrollment should be

forwarded to the WPS Billing & Enrollment Department in Madison WI.

For groups with 51+ total eligible employees, the dental enrollment should be forwarded to the WPS Underwriting Department in Madison WI.

If the group is applying for a dental plan only and has no current WPS health

coverage, the enrollment should be forwarded to Delta Dental for processing. This would be considered a standalone plan.

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Dental - Individual Guidelines

WPS offers dental plan coverage to individuals/families applying for a WPS individual plan. The dental plan coverage is underwritten by Delta Dental of Wisconsin. The dental plan coverage is subject to the following guidelines: WPS offers dental plan coverage to individuals/families applying for a WPS individual plan. The dental plan coverage is underwritten by Delta Dental of Wisconsin. The dental plan coverage is subject to the following guidelines:

The applicant must be approved for the WPS individual medical plan to be eligible for the dental plan coverage.

If the applicant can show at least two years of current continuous coverage with a prior Delta Dental plan, their waiting periods for the dental coverage may be waived at the discretion of Delta Dental.

If any person applying for coverage has other Dental coverage that is not cancelling and will not be replaced NO ONE on the policy can have Dental coverage.

Once approved, a customer may cancel their medical coverage and still keep the dental plan coverage. WPS will continue to do the billing for the dental plan coverage unless otherwise requested by the customer.

If not applied for at the time of enrollment, Dental coverage can only be added at the time of renewal.

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WPS Underwriting Guide – Individual (ACA)

Individual - Eligibility Rules

Eligibility The policyholder must be 18 years of age or older unless applying for an Arise child only

plan. Arise will sell a child-only policy on and off the Marketplace. WPS will not be offering a child-only policy.

Applicant and spouse must be a permanent resident of the State of Wisconsin. Residency

means he or she must live in Wisconsin six or more months out of every calendar year. All applicants must be a citizen of the United States or a resident legal alien. The following are NOT eligible:

o Domestic partners, grandchildren, foster children o Handicapped children, dependent children age 26 or older o Any applicant enrolled in Medicare.

If individual medical coverage is issued to 3 or more employees of the same employer then

Wisconsin considers this as small employer group coverage. Thus, group coverage must be obtained and those employees do not qualify for individual coverage.

Individuals who are eligible for a catastrophic plan must be between the age of 18 and 29 at

time of issue. Individuals who are over the age of 29 may be eligible under a hardship exemption. Individuals who think they may have a hardship exemption must go to the ‘Marketplace’ and obtain a hardship exemption form to submit with the application.

Loss of Eligibility Under WPS individual policies, when a member is called to active military duty for more

than 30 days, they are no longer eligible for coverage starting the first day of their active duty. If coverage is terminated for any member of a WPS individual policy, the member may reapply for another policy at a later date.

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Individual - Enrollment

Open Enrollment Periods 2015 November 15, 2014 – February 15, 2015

Individual Applications To apply for the currently marketed Individual Plan, you must submit the WPS individual application. WPS website for Online Applications - www.wpsic.com WPS Individual enrollments should be sent to Member Services. WPS Health Insurance P.O. Box 8190 Madison, WI 53708 Scan and Email to [email protected] Fax (608) 223-3639 Arise Individual enrollments should be sent to Billing & Enrollment. Arise Health Plan PO Box 11625 Green Bay, WI 54307 Fax (920) 490-6928 An individual could apply for an Arise on-marketplace product using a Health Insurance

Marketplace paper application. This application is sent directly to the Marketplace and not to Arise. The Marketplace will determine eligibility and then contact the individual about choosing a plan and completing enrollment.

Initial premium may be submitted with individual applications. We will not accept

business checks unless the individual is a sole proprietor. The sole proprietor form must be completed and submitted with the application. This rule is due to requirements under state law.

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WPS and Arise Off Exchange - Members who choose the direct billing option should submit their premium with their application. If they choose ACH or credit card, we will withdraw the first month’s premium from the ACH account or credit card. Standard grace period of 10 days applies to the first month premium. The policy will be terminated if payment is not made in a timely manner. Arise On Exchange – the applicant must pay the 1st month’s premium prior to the effective date of coverage, or the coverage is not effectuated. Once the first month’s premium is paid & coverage is in force, then the rules are:

1) If the person is taking the advanced payment of premium tax credits (APTC), then the grace period is 3 months.

2) If the person is not taking the advanced payment of premium tax credits (APTC), then

the grace period is 10 days. New individual policies written on or after January 1, 2014 or existing policies renewed

on an ACA plan will have their rates guaranteed until the following Jan. 1. When an insured has a birthday, the rate change will occur at the renewal of their policy.

It is now allowable to coordinate benefits for insured’s covered under individual policies.

If an individual is age 65 or older, or disabled and has Medicare coverage, they should be

excluded from being eligible to purchase and individual policy. Consistent with the longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare beneficiaries (section 1882(d) of the Social Security Act), it is illegal to knowingly sell or issue a Qualified Health Plan (QHP) to a Medicare beneficiary. This prohibition does not apply in the Small Business Health Options Program (SHOP). The WPS individual policy coordination of benefits provision does not include Medicare. However, there is an exclusion in the policy which indicates coverage is not provided for services covered by Medicare.

Effective Date WPS & Arise will follow the Marketplace requirements for enrollments. The cut-off date

will be the 15th of each month for an effective date beginning the first of the following month. For applications received after the 15th of the month, the effective date will be the first date of the second following month.

For example, an application received on Jan. 16 will have an effective date of March 1.

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Changes to Policies If an individual would like to make a change, they must be received in Member Services

by the last day of the month prior to the effective date. Individuals on the Marketplace (Arise only) can only make benefit changes during an

open enrollment period or if they have a special enrollment reason. Individuals off Marketplace (WPS and Arise) can elect to reduce their benefits on the

first of any month. The application to switch benefits must be received by the last day of the month prior to the requested effective date.

Members with an ACA-compliant plan can only increase benefits during open enrollment

or if they have a special enrollment reason. A current member without an ACA-compliant plan can change their benefits during open

enrollment or with a special enrollment reason, but they must change to an ACA-compliant plan.

Dependents may enroll in an existing non-ACA policy but are subject to medical

underwriting. For on – Marketplace products (Arise only), all plan changes should be processed

through the Healthcare.gov website.

Submission Requirements for Special Enrollment

(1) Birth - The effective date of coverage will be the date of event. (submission of the application must be within 60 days following the event)

a. No special documentation needed. (2) Adoption – The effective date of coverage will be the date of event. (submission of

the application must be within 60 days following the event) a. Submit legal documentation of adoption which includes placement, date,

child’s name and adoptive parent’s name. (3) riage – The effective date of coverage will be the first day of the following month in

which the application was received by WPS (submission of application must within 60 days following the event)

a. Submit a copy of applicants Marriage Certificate.

(4) Involuntary Loss of Coverage other than fraud, intentional misrepresentation of a material fact, or failure to pay premium – The effective date of coverage will be the

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first Day of the following month in which the application was received by WPS. (submission of the application must be within 60 days of loss of other coverage)

a. Submit the applicant’s Certificate of Creditable Coverage. b. Submit a letter, on company letterhead, from the employer/group, indicating

the applicant is losing insurance coverage, the date, and the reason why. This letter can be signed by the owner of the company or a representative of the company.

c. Submit an email indicating loss of coverage, the date, and the reason why, from the owner of the company or a representative of the company.

(5) Loss of Coverage due to renewal increase in premium – The effective date of coverage will be the first Day of the following month in which the application was received by WPS. (submission of the application must be within 60 days of loss of other coverage)

a. Submit a letter from the other carrier indicating renewal and increase in premium is occurring. NOTE: There is no minimum amount of increase - any amount qualifies.

(6) For all other reasons: Permanent Move, Gain US Citizenship - If applying between the 1st and 15th of the month, the effective date will be the 1st of the following month If applying between the 16th and end of the month, the effective date will be the 1st of the second following month

a. Submit all supporting documentation based on your special enrollment reason. A voluntary loss of coverage in the individual market is not a qualifying event.

Submission Requirements for Limited Enrollment ** To be eligible for coverage, all applications for limited enrollment reasons must be received by WPS within 60 days of the event.

(1) Individuals and any dependent losing minimum essential coverage (credible coverage – does not include situations involving failure to pay premiums on a timely basis and/or rescissions). The effective date of coverage will be the first Day of the following month in which the application was received by WPS.

a. No special documentation is needed. (2) An individual gaining or becoming a dependent through marriage, birth, adoption, or

placement for adoption. For marriage the effective date of coverage will be the first Day of the following month in which the application was received by WPS. For a newborn, the effective date of coverage will be the date of birth. For adoption/placement, the effective date of coverage will be the date of adoption/placement.

a. Submit legal documentation of adoption, which includes placement date, child’s name, and adoptive parent’s name.

(3) An individual experiencing an error in enrollment. The effective date of coverage will be the first Day of the following month in which the application was received by WPS.

a. Submit a letter stating what caused the error including a date and signature.

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(4) An individual adequately demonstrating that the plan or issuer substantially violated a material provision of the contract in which he or she is enrolled. The effective date of coverage will be the first Day of the following month in which the application was received by WPS.

a. Submit a letter explaining violation of material provision of the contract including a date and signature. NOTE: If applicant is stating the agent made an error, we need a letter from the agent indicating what took place; also must have a date and signature from the agent.

(5) An individual becoming newly eligible or newly ineligible for advanced payments of the premium tax credit or experiencing a change in eligibility for cost-sharing reductions. The effective date of coverage will be the first Day of the following month in which the application was received by WPS.

a. See a supervisor for assistance. These are reviewed on a case by case situation.

New coverage becoming available to an individual, as a result of a permanent move. NOTE: This applies to an individual coming out of an institution or from incarceration. The effective date of coverage will be the first Day of the following month in which the application was received by WPS.

a. Submit supporting documentation based on your permanent move including documentation from new address and old address.

(6) Loss of coverage due to renewal increase in premium. The effective date of coverage will be the first Day of the following month in which the application was received by WPS.

a. Submit a letter from other carrier indicating renewal and increase in premium is occurring. NOTE: There is no minimum amount of increase – any amount qualifies.

Out of Pocket Crediting Off Exchange

• New individuals to WPS / Arise – No credit • Existing individuals voluntarily moving from a Non-ACA plan to an ACA plan – No

credit • Existing individuals WPS or Arise moved to an ACA plan – Credit deductible and

coinsurance • Individuals switching from WPS to Arise or Arise to WPS – No credit • Individuals with existing WPS / Arise ACA plans changing plan designs to another ACA

plan – No credit for individuals making a change that improves their benefits. Credit deductible for members changing to a lesser benefit level.

On Exchange

• New individuals to Arise – No credit • Individuals with existing WPS / Arise ACA plans changing plan designs to another ACA

plan – No credit for individuals making a change that improves their benefits except as

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provided for QHP changes outlined below. Credit deductible for members changing to a lesser benefit level.

SPECIAL NOTE: Credit will only apply to in network out of pocket. QHP

• Rule requires QHP issuers to credit cost sharing paid by an individual under a previous plan variation (or standard plan without cost sharing reductions) to the new plan variation (or standard plan without cost sharing reductions). The rule requires crediting when there is a change in assignment to a different plan variation (or standard plan without cost sharing reductions) of the “same QHP” in the course of a benefit year. “Same QHP” is defined as identical benefits, premium, cost-sharing structure, provider network and service area. Thus the crediting rule would only apply to changes between Arise plans. The federal cost-sharing crediting rule does not apply to non-QHP plans, such as those offered by WPS. Situations in which Arise should credit cost sharing:

o The person either becomes eligible for or becomes ineligible for cost-sharing reductions, but stays on the same QHP either on or off the Exchange (i.e. the QHP has the same provider network, service area, benefits, overall premium(i.e. rate set by the plan, not what the enrollee is billed) and same cost-sharing structure).

o The person experiences a “qualifying” special enrollment event and as a result of the event, adds or removes family members to the same QHP on or off the exchange (i.e. the QHP has the same provider network, service area, benefits, and is in the same metal tier). The event may be a birth, death, adoption, marriage, divorce or loss of coverage. Only individuals insured on Arise plan prior to the qualifying event and

remaining on the plan would receive an out of pocket credit. o The person re-enrolls into the same QHP they had originally following enrollment

in a different QHP plan or another type of coverage, such as Medicaid. o A Native American enrollee experiences a change in income and moves from a

limited cost sharing plan variation to a zero cost sharing plan variation and then returns to the limited cost sharing plan variation of the same QHP (or vice versa).

Tobacco Rates The tobacco rating applies at a member level. Each member that uses tobacco four or more

times a week will incur an additional tobacco rate on the member level premium, not the entire family premium.

A tobacco user is any individual 18 years or older who uses tobacco four or more times per

week, on average, excluding religious and ceremonial uses. E-cigarettes, nicotine gum, and/or patches are not considered a tobacco product.

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Once you have been tobacco free for a full 6 months, you may send in a written request to Member Services and ask that they change your policy to non-smoker rates.

WPS Underwriting Guide – Individual ACP (Alternative Choice Plan)

Individual - Eligibility Rules

Eligibility The policyholder must be age 18 years of age and under the age of 65. The WPS Individual ACP plan is only offered to individuals not covered by any other

individual or group policy during the same period. Applicants must be a resident of the State of Wisconsin. Residency means he or she must

live in Wisconsin six or more months out of every calendar year. Applicant must be a citizen of the United States or a resident legal alien. The following are NOT eligible:

o Domestic partners, grandchildren, foster children o Handicapped children, dependent children age 26 or older o Any applicant enrolled in Medicare.

If individual medical coverage is issued to 3 or more employees of the same employer then

Wisconsin considers this as small employer group coverage. Thus, group coverage must be obtained and those employees do not qualify for individual coverage.

Waiting Periods for Pre-existing Conditions This ACP policy will only pay benefits for an illness manifesting itself after your effective date of coverage under this policy or for an injury occurring after such effective date unless this policy immediately follows another WPS short term policy, in which case benefits will be payable for any illness or injury that first occurred while the first WPS short term policy is in force, subject to all terms, conditions and provisions of this policy unless WPS accepts the risk of a specific condition(s) at the time of underwriting. Benefits are not payable for expenses

January 2015 58

incurred for health care services for any pre-existing illnesses or injuries or any complications of any such illnesses or injuries.

Individual - Enrollment

Individual Applications To apply for the currently marketed ACP plan, you must submit a completed WPS

Alternative Choice Application for coverage form. This will be subject to our full medical underwriting requirements.

WPS website for Online Applications - www.wpsic.com WPS Alternative Choice Plan enrollments should be sent to Underwriting. WPS Health Insurance Health Underwriting P.O. Box 7898 Madison, WI 53707-7898 Scan and Email to [email protected] Fax (608) 223-3623 Initial premium must be submitted with the Alternative Choice Application form. We will

not accept business checks unless the individual is a sole proprietor. The sole proprietor form must be completed and submitted with the application. This rule is due to requirements under state law.

The choice of payment options for the ACP plan are as follows:

o Prepay the entire coverage period with a personal check.

o Credit/Debit Card - The Credit/Debit Card Payment Authorization Form must be completed.

o ACH – Monthly Bank Draft. The Automatic Withdrawal Payment Authorization

form must be completed. No refunds will be issued for the ACP plan once it is purchased and put into effect. There is not an option for adding family members to an existing ACP plan.

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Effective Date The effective date for an ACP plan will be the later of requested effective date, 7 calendar

days after receipt of the application in underwriting, or upon underwriting approval. The coverage period must be at least 30 days but no more than 364 days. Applicants may choose two consecutive six-month policies. This option is only available for

an initial January 1 effective date. There is no limit to the number of ACP plans an applicant can have in a calendar year.

However, there must be at least a 63 day break in coverage between them. Tobacco Rates The tobacco rating applies at a family level. If one family members uses tobacco, this will

incur an additional tobacco rate on the entire family premium. Once you have been tobacco free for a full 12 months, you may send in a written request to

Member Services and ask that they change your policy to non-smoker rates.

Medical Records Application If WPS Underwriting determines based on information on the application that medical records are needed, WPS will request these medical records from the applicant. WPS will not request nor pay for the records on a short term policy. If the medical records are not received timely, the file will be closed. Decline If an applicant would like to have a recent underwriting decision reviewed, they must submit complete medical records for the time frame indicated in the letter. WPS will not accept a letter from the doctor alone; it must be accompanied by medical records. All other underwriting guidelines will still apply during this process. If information is not received timely, the file will be closed. Medical Records Submission Medical records can be faxed to 608-223-3623 or sent by mail to: WPS HEALTH UNDERWRITING P.O. BOX 7898

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MADISON, WI 53707

Consumer Reporting Agencies Medical Information Bureau (MIB) and Ingenix MedPoint MIB As part of our underwriting process, WPS may make a brief report to the Medical Information Bureau (MIB) on individual applicants. MIB is a non-profit membership organization of insurance companies which operates an information exchange on behalf of its members. The way MIB works, is if you have an applicant that applies to another Bureau member company for life or health insurance, which operates an information exchange on behalf of it’s members and your applicant then applies to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such company with the information in its file. Upon receipt of a request from your applicant, MIB will arrange disclosure of any information it may have in your applicants file. If your applicant questions the accuracy of the information in the Bureau’s file, you may tell them to contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau’s information office is 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734, telephone number is (866) 692-6901 (TTY (866) 346-3642 for hearing impaired). WPS or its reinsurer may also release information in its file to other insurance companies to whom your applicant applies for life or health insurance, or to whom a claim of benefits may be submitted. Ingenix MedPoint WPS also utilizes the consumer reporting agency Ingenix and their online prescription reporting system MedPoint when underwriting individual applications. MedPoint provides information on an applicant’s prescription history, including drugs prescribed, when filled, and the name of the prescribing doctor. MedPoint uses specific information such as name, birth date, social security number, and address to identify an applicant’s prescription history. If an applicant does not feel the information WPS received from MedPoint pertains to them, they can contact MedPoint Compliance at 888-206-0335 or send a letter to MedPoint Compliance, Ingenix, Inc., 2525 Lake Park Blvd., West Valley, UT 84120.

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Underwriting Decisions

All individuals on the ACP application form will be health underwritten. Each person listed on the application is subject to acceptance or denial based on his or her health history.

▪ If a dependent child on the ACP application form has a declinable health condition, the Entire application will be declined.

▪ Letters of coverage denial will be sent by WPS Underwriting to the applicant with a separate Letter to the agent. Tele-underwriting Services Tele-underwriting services may be utilized by WPS when underwriting individual policies. Applicants should be made aware that they may be contacted by telephone if necessary to obtain additional medical information.

Individual – Individual Underwriting Guideline

Height and Weight Charts The following 2 pages contain female and male height and weight charts. These charts provide the height and weight at which the individual will be declined.

August 2012 62

Female Height / Weight

Height Decline

4’8” 189

4’9” 194

4’10” 198

4”11” 203

5’ 209

5’1” 215

5’2” 219

5’3” 226

5’4” 231

5’5” 238

5’6” 244

5’7” 249

5’8” 254

5’9” 262

5’10” 269

5’11” 280

6’ 289

6’1” 300

6’2” 311

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Male Height / Weight

Height Decline

5' 2" 223

5' 3" 228

5' 4" 233

5' 5" 240

5' 6" 248

5' 7" 253

5' 8" 263

5' 9" 266

5' 10" 274

5' 11" 281

6' 290

6' 1" 296

6' 2" 305

6' 3" 312

6' 4" 321

6' 5" 329

6' 6" 339

6' 7" 346

6' 8" 355

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64

Declinable Health Conditions The health conditions listed below are examples of reasons that will cause WPS to automatically decline a person applying for the ACP plan. In the case of a dependent child, these health conditions will result in the entire application being declined. This list is not all-inclusive. Addison’s Disease AIDS Alzheimer’s Disease Alcohol or drug abuse ALS, Lou Gehrig’s Disease Amnesia Aneurysm Aphasia Arthritis in major joints Asperger’s Syndrome Atrial Fibrillation Atrioventricular Block Autism AV Block Barrett’s Esophagus Bechet’s syndrome Bi polar Disorder Bone Marrow Transplant Buerger’s Disease Brain Disorders (Abscess, Chronic brain syndrome, Tumors, Brain Injury) Brittle Bones Bulimia Cardiomegaly Cardiomyopathy Cancer (depending on type) within the last 3-5 years Celiac Sprue Disease Cerebral Palsy Cerebral Vascular Accident (CVA) Charcot-Marie-Tooth Disease Chondrocalcinosis Chronic Hepatitis Chronic Obstructive Pulmonary Disease Chronic Pain Syndrome Cirrhosis of the Liver Congestive Heart Failure Coronary Artery Disease Crohn’s Disease within the last 2 years Cystic Fibrosis Deafness treated with hearing aids Dementia

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Diabetes Dialysis Down’s Syndrome Drug Abuse DWI within the last year Eating disorders Emphysema Enlargement of the heart Epilepsy with a seizure Factor IV Farmer’s Lung Fatty Liver Felty’s Syndrome Fibromyalgia Gilbert’s Syndrome Guillain-Barre Syndrome Heart attack Heart Disorders (Aortic Stenosis, Atrial Fibrillation, bypass surgery, Coronary Artery

Disease, Mitral Insufficiency, Mitral Stenosis, complete Right Bundle Branch Block) Hemochromatosis Hemophilia Hepatitis A within the last 2 years Hepatitis B Hepatitis C High Blood Pressure along with taking two or more medication for it (excluding water

pill) High Blood Pressure and taking the medication Lotrel, Lexxel, or Tarka High cholesterol levels treated with two or more medications HIV Positive Hodgkin’s Disease Huntington’s Chorea Hypogonadism (low testosterone) Hysterectomy within 6 months Idiopathic Thrombocytopenia Ischemic Heart Disease Joint Replacement Kidney Disorders (Dialysis, Nephrectomy within the last 6 months, Nephrosis, Polycystic

Disease, Uremia) Left Bundle Branch Block Legg-Calve-Perthes Disease Leukemia Liver Disease or disorders (Abscess, Cirrhosis, Enlarged, Fatty Liver, elevated liver

enzyme levels) Lou Gehrig’s Disease Lupus Marfan Syndrome

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Marie-Strumpell Disease Mental Retardation Metabolic Syndrome Microtia-Aural Monoclonal Gammopathy Multiple Sclerosis Muscular Dystrophy’s Myasthenia Gravis (MG) Narcolepsy Neurofibromatosis Obsessive-Complusive Disorder Osteoarthropathy, Hypertrophic Osteochondritis Osteoporosis-Osteopenia Osteogenesis Imperfecta Oxygen Use Pacemaker Parkinson’s Panic Disorder Peripheral Vascular Disease Pernicious Anemia Pervasive Developmental Disorders not otherwise specified Pick’s Disease Polycystic Kidney Disease Polycystic Ovarian Syndrome Pregnancy Pseudogout Pulmonary Nodule Psoriatic Arthritis Q Fever Quadriplegia Reiter’s Disease or Syndrome Renal Failure/Renal Insufficiency Restless Leg Syndrome (RLS) Retinitis Pigmentosa Rhabdomyolysis Rheumatoid Arthritis and other Connective Tissue Disorders Right bundle branch block (complete only or associated with other heart disease) Schizophrenia Scleroderma Seizure Senility Sickle Cell Anemia Sinus Bradycardia within the last 2 years Sinus Tachycardia within the last 2 years Sjogren’s Syndrome

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Sleeping Disorders (Sleep Apnea, Narcolepsy) Spina Bifida Spina Bifida Occulta Still’s Disease Stroke Suicide Attempt Tourette’s Syndrome Transient Ischemic Attack (TIA) Transplants Treatment with injections in the past 2 years Turner Syndrome Ulcerative Colitis within the last 2 years Usher Syndrome Ventricular Paroxysmal Tachycardia

Chronic conditions that are treated with a prescription that costs $150 or more a

prescription Any pending or recommended treatments, tests, surgeries or exams, which also includes

refusing any exam or treatment. Any undiagnosed condition

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Forms

Appendix A (Controlled Group Questionnaire)

Common Ownership Controlled Group Questionnaire

Name of Employer Group __________________________________________ Primary Business Location _________________________________________ Federal Tax ID # ____________________________ Background A controlled group is a combination of two or more corporations that are under common control. The controlled group will be considered a single employer even though they have different names and different tax ID numbers. There are two common types of controlled groups that are frequently encountered: (1) Parent-Subsidiary, and (2) Brother-Sister. Parent-Subsidiary The parent-subsidiary group applies to one or more chains of corporations. It does not apply individual owners. Please indicate Yes or No in response to each of the below questions: 1. Is this a group of two or more corporations connected through stock ownership with a common parent

corporation? Yes or No

2. Is 80% of the stock of each corporation (except the common parent) owned by one or more corporations in the group? Yes or No

3. Does the parent corporation own 80% of at least one of the other corporations? Yes or No

If the answer to ALL of the above is Yes, the group would likely meet the controlled group requirements as a parent-subsidiary group. However, the group should consult its tax professional to confirm. Brother-Sister The brother-sister group applies when there are two or more corporations with the same five or fewer owners (i.e., individuals, trusts, or estates). Please indicate Yes or No in response to each of the below questions: 1. Is this a group of two or more corporations with five or fewer common owners? Yes or No

2. Do the common owners own a “controlling interest” of each group (“controlling interest” generally

means 80% or more of the stock of each corporation)? Yes or No

3. Do the common owners have “effective control” (“effective control” generally means they own more than 50% of the stock of each corporation, taking into account the stock ownership of each person only to the extent such stock ownership is identical with respect to each corporation)? Yes or No

If the answer to ALL of the above is Yes, the group would likely meet the controlled group requirements as a brother-sister group. However, the group should consult its tax professional to confirm.

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Appendix B (Common Ownership Confirmation Form) Common Ownership Confirmation Form This form must be completed and signed by the employer’s accountant, attorney or officer of the company. The Health Insurance Portability and Accountability Act of 1996 states that all persons treated as a single employer under subsection (b), (c), (m), or (o) of Section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. Name of Employer Group __________________________________________ Primary Business Location _________________________________________ Federal Tax ID # ____________________________ Please list all companies that would qualify as one employer under the above referenced sections of the Internal Revenue Code. Business Name Fed Tax ID # # of Eligible Employees 1) ___________________________ _____________________ __________________ 2) ___________________________ _____________________ __________________ 3) ___________________________ _____________________ __________________ 4) ___________________________ _____________________ __________________ 5) ___________________________ _____________________ __________________ 6) ___________________________ _____________________ __________________ I certify that the applicant is a single employer under section 414 of the Internal Revenue Code of 1986 (26 U.S.C. Section 414 (b), (c), (m), or (o)) and under any applicable state law. I further certify that there are no other affiliated entities other than the ones listed above who are eligible to file a combined state tax return. I represent that the information I provided is accurate and any misrepresentation or fraudulent statement may result in rescission of the group policy, an increase in premiums retroactive to the policy date, or other consequences permitted by law. Name (please print) & Title: ___________________________________________________ Signature: _____________________________________

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Domestic Partnership

Declaration of Domestic Partnership

Section One

I, _________________________________(name of employee), and

___________________________________(name of domestic partner) attest and certify that we are

each other’s sole domestic partners.

Domestic partners are defined as two individuals: • Who are in a committed relationship of mutual support, caring and commitment with the

intention to remain in such a relationship in the immediate future; • Who are financially responsible for each other’s well-being and debts to third parties; • Who are not married or legally separated in marriage, and who have not been a party to an

action or proceeding for divorce or annulment within six months of registration, or if one has been married, at least six months have elapsed since the date of the judgment terminating the marriage;

• Who are not currently registered in another designated partnership, and if one party has been in

such a registered relationship, at least six months have lapsed since the effective date of termination of that registered relationship before the registration of the current domestic partnership;

• Who are each 18 years of age or older and competent to contract; • Who are not related by blood closer than would bar marriage in the state of their residence; • Who live together in the same dwelling unit as a single non-profit housekeeping unit and have a

relationship that is of a permanent and domestic character; • Whose relationship is not temporary, social, political, commercial, or economic in nature • Whose relationship has existed for at least six months;

Who are not registered with any other domestic partnership:

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• Who, for at least the six-month period immediately preceding the date of this Declaration, have either:

(a) Obtained a domestic partnership certificate from the city, county or state of residence or

from any other city, county or state offering the ability to register a domestic partnership; or

(b) Any three of the following with respect to the domestic partner (check those which

apply): ____ joint lease, mortgage or deed; ____ joint ownership of a vehicle ____ joint ownership of a checking account or credit account ____ designation of the domestic partner as a beneficiary of the covered

employee’s will ____ designation of the domestic partner as a beneficiary for the covered

employee’s life insurance or retirement benefits; ____ designation of the domestic partner as holding power of attorney for

health care; or ____ shared household expenses

Section Two 1. I understand that coverage for my domestic partner and his/her dependents shall terminate upon

the death of my domestic partner or upon a change of circumstances attested to in Section One above.

2. I understand that I am obligated to file a Declaration of Termination of Domestic Partnership with

WPS within 30 days of the death of my domestic partner, or the date on which my domestic partner and I no longer meet the criteria for domestic partners as set forth above, whichever is earlier.

3. I understand that falsely certifying eligibility for domestic partner benefits or failing to inform

WPS if the domestic partnership ceases to meet the eligibility requirements in any respect may lead to disciplinary action, including discharge from employment.

4. I understand that upon submission of this Declaration, I am required to provide evidence of my

domestic partnership as indicated in Section One above. Section Three 1. The covered employee and the domestic partner (hereinafter referred to as “We”) hereby certify

that we are each other’s sole domestic partners as defined above. 2. We have provided the information in this Declaration for use by WPS and its employees for the

sole purpose of determining eligibility of the domestic partner and dependent children of the domestic partner under those policies, guidelines, practices and benefit plans that provide coverage for domestic partners as from time to time established by WPS. We understand that WPS and its employees are permitted to use the information provided on this Declaration to administer the benefits outlined above.

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3. We understand and agree that the employer is not legally required to extend such benefits to

domestic partners and that the employer, in its sole discretion, may change or terminate these benefits, policies, guidelines, and practices at any time without consent of any employee or group of employees.

4. We understand that under federal and state law, benefit coverage of the non-employee domestic

partner and his/her children may result in imputed taxable income to the employee, with possible withholding for payroll taxes (including income and social security taxes).

5. We understand that, in addition to this Declaration, certain benefit plans require the completion

of forms to enroll or dis-enroll a domestic partner and any eligible dependents. 6. We understand that a civil action may be brought against one or both of us for any losses,

including attorney’s fees and court costs, because of any false statement(s) contained in this Declaration or for failure to notify WPS of a change in circumstances required in Section Two. We agree that each of us is and agrees to be jointly and severally liable for such losses.

7. We understand that this Declaration may have legal implication relating, for example, to our

ownership of property or to taxability of benefits provided. We understand that before signing this Declaration we should seek competent legal and tax advice concerning such matters. We acknowledge that the employer or WPS has provided us with no advice in this regard.

8. We understand that failure to provide complete, true, timely and correct information may result

in loss of benefit plan coverage. We have read and understand the terms and conditions contained in the Declaration of Domestic Partnership. We affirm, under penalty of perjury, that the statements in this Declaration are true, complete and correct. ________________________________________ __________________ Employee’s signature Date ________________________________________ __________________ Employee’s printed name ________________________________________ __________________ Domestic Partner’s signature Date ________________________________________ Domestic Partner’s printed name

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(1099 Employees) SECTION 1: Number of FTE employees Indicate the number of fulltime equivalent (FTE) employees employed by the employer (federal FTE counting method, calculator available at: https://www.healthcare.gov/shop-calculators-fte/) Number of FTE employees: ______ If the number of FTE employees is greater than 50, 1099 employees may be added at the discretion of the employer. If the number of FTE employees is 50 or less, proceed to Section 2. SECTION 2: 1099 Guidelines The following criteria must be met in order for WPS to allow 1099 employee’s to be considered an eligible employee for small group insurance.

1. Do your 1099 employees meet the WPS definition of a full-time employee? (one who works 30 hours per week or more)

_____ Yes _____ No

2. Do your 1099 employees work year round and exclusively for your company? (seasonal 1099 employees are not eligible for coverage)

_____ Yes _____ No

3. Will you be offering coverage to all eligible 1099 employees? _____ Yes _____ No

If you answered no to any of the above questions, your 1099 employees are not eligible for coverage with WPS. The following guidelines must also be met in order for your 1099 employees to be eligible for coverage. 1099 Employee Guidelines:

• Participation will be measured on all eligible taxed employees and eligible 1099 employees • Employer must contribute the same amount of money toward the 1099 employee’s premium as the

taxed employees. • Employer must be eligible for coverage prior to adding the 1099 employee(s). There must be a

minimum of two taxed employees at all times. • A minimum of 50% of the insured’s must be taxed employees. • Employer application must indicate that 1099 employees are eligible for plan at time of

enrollment. • Groups that wish to add 1099 employees beyond the original enrollment are subject to medical

underwriting. • Employer must provide copies of all 1099 statements including individuals not electing coverage. • 1099 employees that are eligible and not electing coverage must complete a waiver application. • 1099 employees will not be eligible for ancillary coverage.

For the purposes of this form, taxed employees refer to those employees who appear on your groups

State Quarterly Wage & Tax Statement (UCT-101). Signature of Employer Representative: __________________________________ Date: _____________

https://www.healthcare.gov/shop-calculators-fte/