Producer’sGuideto ConnectiCar e SOLO · Building Your Business with ConnectiCare® SOLO This guide provides a general overview of our individual product, ConnectiCare …

Producer’s Guide toConnectiCare® SOLO

®

Plan Year 2009

PRODUCER’S GUIDE TO CONNECTICARE® SOLO

Table of ContentsII NN TT RR OO DD UU CC TT II OO NNBuilding Your Business with ConnectiCare® SOLO 2Questions? 2Attractive Commissions! 2Doing Business @ www.connecticare.com 2

NN EE WW BB UU SS II NN EE SS SSEligibility Requirements 3Connecticut Residency 3Online Application 3Steps To Apply – New Business (Paper) 3How Can I Expedite The Application Process? 4EFT Instructions and Guidelines 5Tips for Completing Individual Application/Change Form (Paper) 6Application Checklist 7Health Plans Compatible with HSA 8Important Guidelines for New Business 8Rescissions 9Premium Payments 9Dependents 9

CC HH AA NN GG EE SS

Adding Dependents 10Adding Newborns or Adopted Children 10Renewal Process 10Requesting Off-Cycle Plan Changes 10Termination of Coverage 11

UU NN DD EE RR WW RR II TT II NN GG

Medical Underwriting 11Pre-Screening Guidance 12Condition Waivers 12Future Surgery or Procedures 12Declinable Medications 12Declinable Conditions 13Underwriting Risk Criteria 15Height and Weight Table 16FAQs 16

Building Your Business withConnectiCare® SOLOThis guide provides a general overview of our individual

product, ConnectiCare® SOLO, which offers the same personal

service and choice of providers as our group plans.

You’ll find general information on the application process,

eligibility, general underwriting guidelines and commissions.

This guide is not all-inclusive and is subject to change. Also,

for additional details, please see the ConnectiCare SOLO

Member Guidebook.

ConnectiCare SOLO is designed for:

� Self-employed persons

� Recent college graduates

� Part-time employees

� Early retirees

ConnectiCare SOLO is also a solution for other people who:

� are between jobs

� work for employers that don’t offer health insurance

� are not eligible for group coverage

� are dissatisfied with their present plans

Questions?If you have questions about ConnectiCare SOLO, or would like more information, please contact your ConnectiCare Sales Representative or Account Service Representative, or call 1-800-723-2986.

Attractive Commissions!You can build your business with an attractive schedule of

commissions for ConnectiCare SOLO. For details, please see

our Commission & Incentive brochure.

Doing Business @www.connecticare.comSee the online sales tools for ConnectiCare SOLO on the

Producer section of our Web site at www.connecticare.com.

It’s easier than ever to work with ConnectiCare!

� Apply Online

� Get fast quotes for prospective business

� Send full proposals by e-mail or fax

� View and print rate tables

� Check real-time status of applications and make renewal changes

� Manage your book of business in “My Accounts”

� Manage eligibility

� Change a Primary Care Physician

� View/print billing invoices

� Order ID cards

� Secure messaging service

� Update or change an address

� Download policyholder and member rosters

� Download and send forms

� Order materials and brochures

� And much more!

– 2 –

INDIVIDUAL HEALTH PLANS, THE CONNECTICARE WAY

II NN TT RR OO DD UU CC TT II OO NN �

Eligibility RequirementsIndividuals may apply for ConnectiCare SOLO if they are:

� Legal residents of Connecticut

� Under age 65

� Not enrolled in Medicare

� Single or married; or belong to a civil union/domestic partnership*

Families may apply for coverage for unmarried, dependent

children under age 26.

* Must submit Domestic Partner Verification Form or other satisfactory certification as we determine.

Connecticut ResidencyPlease make sure each family member applying for coverage

meets all of the following eligibility requirements BEFORE

submitting an Individual Application and Individual Health

Statement.

The applicant and dependents must be legal residents of

Connecticut. If residency is questionable, proof of residency

will be required. To demonstrate proof of residency, at least

three of the following items must show the applicant’s name

and current address:

1) Connecticut State Income Tax Return filed within the last 12 months

2) Current Connecticut voter registration card

3) Lease agreement or mortgage document

4) Most recent utility bill

5) Current Connecticut driver’s license

6) Connecticut DMV identification card

7) County or city property tax return filed within the last 12 months.

Online ApplicationNow you are able to offer online application to prospective

ConnectiCare SOLO members, making it even more

convenient to apply for our individual product. We’ve designed

the process to be producer-driven – an individual cannot initiate

online application without being invited to do so by you.

Online application has these advantages:

� It expedites the process because the Individual ApplicationPacket (Parts 1-3) goes directly to our underwriting department.

� It helps to prevent errors on the Individual ApplicationPacket.

� No postage is required.

� It helps us to be more “green” in our business practices. When more people use the Internet, we print fewer formsand conserve paper.

Once you have identified a candidate for online enrollment,

you’ll be able to generate an automatic, pre-formatted e-mail

invitation using a new tool located at “SOLO Quote/Invitation”

on the secure producer section of www.connecticare.com.

Customized with your contact information and whichever plan

option you select, the invitation provides your prospect with

details about the online enrollment process. Plus, you and your

prospect will be able to check online for an updated status of

the application once it’s submitted.

Steps To Apply – New Business(Paper)

APPLICANTS MUST:1) Complete, sign and date the Individual Application/Change Form – PART 1 – no more than 60days prior to the requested effective date. Be sure to:

a. Check the box for the medical plan being selected.

b. Check the boxes for the pharmacy co-pay and pharmacyannual maximum that are being selected (does not apply to HDHP plans).

c. Select a Primary Care Physician (PCP) for each familymember applying for coverage and write the PCP name in the appropriate box. For a complete list of participatingproviders, go to “Find a Doctor” at ww.connecticare.comor see our print directory.

– 3 –


NN EE WW BB UU SS II NN EE SS SS �

2) Accurately and completely answer all questions on the

Individual Health Statement – PART 2 – for each family

member applying for coverage.

If the applicant knowingly provides false informationand/or omits information on the application or healthstatement and such information submitted or omittedmaterially affects the risk assumed by ConnectiCare,ConnectiCare will seek to have the policy rescinded.

3) Complete, sign and date the Underwriting Authorization

Form – PART 3.

4) For applicants under the age of 18, the application must have

a parent/guardian’s signature and date – and the parent/

guardian’s full name must be printed on the application.

5) Applicants do not have to submit their first premium payment

with their application. However, once applicants are approved,

all premiums from the date of approval back to the effective

date are due by the first of the month following the date of their

approval letter. This could mean that applicants could owe us

more than one month of premium and owe the premium

quickly. Also if there is a retro effective date, these members

may get a past due notification. All premiums not received by

the first of the month for the month of coverage are considered

past due. This applies to all premium payment methods –

check, Electric Funds Transfer (EFT) and credit card.

6) If the EFT option is chosen for premium payment, the appli-

cant should complete and sign the Electronic Funds Transfer

Form – FORM 4. Be sure to include a check marked “void.”

Please see the additional information about Electronic Funds

Transfer (EFT) on the next page.

7) If applicable, complete the Domestic Partner Verification

Form or other satisfactory certfication as we determine.

8) OPTIONAL: Broker Authorization Form – must be

completed and received for ConnectiCare to release to the

broker any information that includes the applicant’s personal

health information.

9) All completed forms must be signed, dated and received at

ConnectiCare by the last day of the month for an effective date

on the 1st of the next month. (i.e. A complete application

received by January 31st would be eligible for a February 1st

effective date. A complete application received on February 1st

would be eligible for a March 1st effective date.)

What if the last day of the month falls on a weekendor a holiday?

Online applications – must be submitted to ConnectiCare by

midnight on the last day of the month, regardless of whether it’s

a weekend or a holiday.

Paper applications – must be received at ConnectiCare by the

last business day before the weekend or holiday.

Forms should be mailed to:

ConnectiCareP.O. Box 4058Farmington, CT 06034-4058

Or, forms may be faxed to 860-678-5274.

Approval for an individual health policy is based on the

applicant meeting the eligibility requirements and underwriting

criteria, and on our review of the Individual Health

Statement(s) and any additional medical and/or pharmacy

information that we request and receive.

To obtain copies of the application forms:

� Go to the producer section of www.connecticare.com,where you can download and print them; or

� Contact your ConnectiCare Sales Representative orAccount Service Representative; or

� Call 1-800-723-2986.

10) Incomplete applications may be returned to the producer.

If that happens, the application will need to be resubmitted

to ConnectiCare with all information filled in and all

questions answered. The effective date will be determined

based on the date that this completed application is received.

How Can I Expedite the Application Process?� Submit the Individual Application Packet (Parts 1-3) using

the online application process rather than the mail. Whenyou use the online application process, the forms go directly toour underwriting department.

� Double-check the forms before you submit them toConnectiCare to make sure that every questions is answeredcompletely and accurately, and that all information is filled in.

� Incomplete applications may be returned to you. If this happens, you will have to resubmit the application, and theeffective date will be determined based on the date that thecompleted application is received.

– 4 –


EFT Instructions and GuidelinesWhen it comes to Electronic Funds Transfer (EFT)for premium payments, applicants have two optionsfrom which to choose:

1) They can sign-up for EFT along with their initial application.

All they have to do is complete the EFT form and attach a

voided check or statement savings deposit slip with their

application. Applicants should complete and sign the

Electronic Funds Transfer Form – FORM 4. Applicantsshould be sure to include a check marked “Void”. Once

an applicant is approved as a ConnectiCare SOLO member,

all premiums from the date of approval back to the effective

date are due by the first of the month following the date of

the approval letter. This could mean that the individual may

owe us more than one month of premium.

2) The process for new ConnectiCare SOLO applicants is as

follows:

a. ConnectiCare SOLO application is submitted along with

EFT form and application is approved.

b. Effective date of policy and EFT is established.

c. ConnectiCare sends “Pre-Note” file to the bank to

confirm that the bank routing number and checking

account numbers are correct.

d. Member is mailed letter confirming start date of EFT.

Example: If ConnectiCare were to receive an application and

an EFT form on October 28th, and the policy was approved in

November with an effective date of November 1st. The effective

date of the EFT would be November 1st.

Note: For new ConnectiCare SOLO applications, the EFT process is not started or initiated until the policy has been approved.

3) Applicants can wait to sign up for EFT until they are

accepted by and enrolled in ConnectiCare SOLO. All they

need to do is sign the front of the first invoice voucher and

return it with their premium payment. For future payment

drafts, we will use the checking account number that appears

on the check the applicant submits for the initial premium

payment. This way the applicant does not need to submit

a separate form when enrolling in EFT.

4) The process for current policyholders is as follows:

a. Member signs the front of the invoice stub and mails

invoice stub along with premium payment to

ConnectiCare.

b. ConnectiCare sends “Pre-Note” file to the bank to

confirm that the bank routing number and checking

account numbers are correct.

c. Effective date of EFT is established.

d. Member is mailed letter confirming start date of EFT.

Example: If on October 28th ConnectiCare were to receive the

signed invoice stub authorizing EFT, the November invoice

would still be mailed, and the member would have to pay by

check. The effective date of the EFT would not be earlier than

December 1st.

When determining the effective date of EFT, pleasebe aware that ConnectiCare SOLO members stillmay receive their monthly premium invoice in themail for a short period of time. Members will need to continue to pay by check until EFT goes intoeffect. This is because several steps are involved inimplementing EFT.

– 5 –


Monthly EFT Process:� Transactions take place on the 1st of every month unless the

1st falls on a weekend. In that case the money will be drawnon the first banking day of the month.

� Funds will be reflected in ConnectiCare’s system one day later.

� Funds will be reflected on the producer and member Websites two days after money is withdrawn from the account.

� When there is a failed transaction, the following will occur:

– The money is removed from ConnectiCare’s system.

– A letter is mailed to the account holder explaining the returned EFT transaction.

– A $25 fee will be assessed.

– The EFT transaction will be reattempted on the 15th of the current month.

If the transaction also fails on the 15th, the EFT account will

be automatically terminated. A letter will be sent to the account

holder explaining the reason for EFT termination, and that

future payments will need to be made by check. Outstanding

premiums will need to be paid by check before the 10th of the

next month.

Voluntary Termination of EFT:� A written request from the account holder is necessary

for the termination of an EFT account. The account holdershould include the account number along with his or her name on the written request, and fax it to 860-678-5255, ATTN: Billing Department.

Or, written requests may be mailed to:

ConnectiCare, Inc. & AffiliatesAttn: Billing/EFT175 Scott Swamp RoadFarmington, CT 06034-4050

� The request must be received before the 25th of the current month in order to be removed from the following month’s EFT file.

If you have any questions, you may call ConnectiCare’sBilling Department at 1-800-333-1733, Monday throughFriday, 8:00 a.m. – 5:00 p.m., Eastern Time.

Tips for Completing IndividualApplication/Change Form(Paper)

PLEASE MAKE SURE:1) All forms are completed in ink. Incomplete forms may be returned to the producer.

2) All questions have been answered completely by the

applicant. Producers may not complete questions on behalf

of the applicant.

3) All changes have been initialed and dated by the primary

applicant. Do not use correction fluid. If the applicantadds information that was missing, he/she must re-sign and

re-date the Individual Application/Change Form and the

Individual Health Statement to verify that the added

information is correct.

4) All applicable forms have been signed and dated by all

applicants who are required to do so. Do not date or signfor the applicant.

5) Proof of legal guardianship (an appointment by the Probate

Court) is included, if applicable.

6) If an EFT option is chosen for future payments, make

sure the EFT form is completed and a voided bank check

is included.

7) The medical plan and pharmacy plan have been selected on

the Individual Application/Change Form.

8) Any questions answered “yes” on the Individual Health

Statement must be explained in detail for each familymember noted. The detailed information should beincluded in the spaces provided under the “HealthHistory” section of the Individual Health Statement.The Application and Health Statement may be sent in a

sealed envelope.

– 6 –


9) Any attachments to the Individual Application/Change

Form and Individual Health Statement, including medical

information, are signed and dated by the primary applicant

or parent/legal guardian.

10) Agent and agency name for commission payments are

included.

11) The Producer must be licensed in Connecticut and

appointed by ConnectiCare. If you are licensed but not

appointed, please call our Producer, Sales and Customer

Service Line at 1-800-723-2986.

Application Checklist Required before underwriting:

Signed Application with following completed:

� Application Transaction Request Check Box

� Applicant Name

� Applicant Address

� Selection of Plan Choice and Rx rider

� All Dependents’ Names

� All Dependents’ Add/Delete

� All Dependents’ SSNs

� All Dependents’ Sex

� All Dependents’ DOBs

� PCP – Name/Phone Number

� “Other Insurance Box” checked

� “Other Insurance Box” – if yes, insurance section completed

Signature with date of each:

Applicant/Spouse/Domestic Partner and Dependent 18 or older

� Broker Information

� Broker Authorization Form (not required)

Health Statement:

� All questions (#1 - #30) must be answered.

� Specific explanations for any “Yes” answers in the space provided under “Health History.”

� Supplemental Medical Questionnaires completed as appropriate. These should be submitted with the IndividualApplication/Change Form and Individual Health Statementto expedite application processing. To download and print a Supplemental Medical Questionnaire, go to the secure producer section of www.connecticare.com. Click“SOLO/Individual Plans”, then “Forms/Guides” and“Medical Questionnaires”.

Underwriting Authorization Form:

� Signature w/ date of each Applicant/Spouse/ DomesticPartner and Dependent age 18 or older

� All fields complete

Other required documentation (if applicable):

� Domestic Partner Verification Form or other satisfactory certification as we determine

� Disabled Dependent Form

� Election of Electronic Funds Transfer Form

Examples of Material Pend/Missing Information (which may cause unnecessary delay in application process):

� Any information that is missing from Parts 1, 2 or 3 of theApplication Packet, especially current height and weight onthe Individual Health Statement.

� Signature with date of all applicants age 18 or older

� Multiple applications with one check

� Underwriting authorization missing/not signed/not dated

� Questions on the Individual Health Statement that are leftblank or unexplained.

– 7 –


Health Plans Compatible with HSAConnectiCare SOLO has two plan options that are compatible

with Health Savings Accounts (HSAs): HMO Open Access –

High-Deductible Health Plan and Point-of-Service

Open Access – High Deductible Health Plan.

When combined with a High-Deductible Health Plan

(HDHP), a Health Savings Accounts (HSA) can help to lower

medical plan expenses, preserve quality and empower health

care consumers.

We have selected First HSA as our preferred vendor to manage,

administer and service your clients’ HSA accounts.

First HSA also offers producer compensation for each individual

application. This is a one-time payment when the account is

opened. You must be identified as the agent/agency on the

First HSA application to receive compensation from First HSA.

To start the HSA enrollment process for your client is simple:

1) Submit your client’s application for a ConnectiCare SOLO

High-Deductible Health Plan (HDHP) and wait for approval.

2) Determine your client’s method of making HSA

contributions and First HSA service-fee payment. For

detailed instructions, go to the producer section on

www.connecticare.com (click on “SOLO/Individual”

and see “HSA Administration”). Or contact First HSA at

1-888-769-8696.

3) Upon receipt of your client’s acceptance into a ConnectiCare

SOLO HDHP, submit a First HSA application to First HSA.

Note: Do not set up an account until your client’s enrollmentacceptance is confirmed.

4) First HSA will process the HSA application and mail a

“Welcome Packet” to your client.

Important Guidelines for New Business� Effective dates for coverage are the 1st of the month

following underwriting approval.

� Deadline for complete applications is the last day of themonth prior to effective date of coverage.

� If coverage is denied or terminated by ConnectiCare for non-payment, the individual cannot reapply for coverage for 12 months following the requested effective date of thedenial or 12 months from the date of termination.

� ConnectiCare may accept eligible family members for coverage while denying other family members who do notmeet our eligibility or underwriting requirements. (Alsoknown as a “partial denial.”)

� Applicants will be notified in writing of the underwritingdecision. (Producers will receive a copy of the notification.Note: if the underwriting decision is a denial or partialdenial, the reason will not be included in the producer’s copyto protect the privacy of the applicant’s medical information.)

� The applicant is responsible for providing us with completeand accurate information on all forms, and must notify us immediately of any and all changes in health information, name, address and telephone number, and changes in PCP, while the application is pending.

� Underwriting may request directly from the applicant additional health information, if necessary. A medicalrecords request and/or supplemental medical questionnairewill be mailed or e-mailed to the applicant’s home address/e-mail address, with instructions for completion.

� If ConnectiCare requests a supplemental medical questionnaire and/or medical records, it is the applicant’sresponsibility to request/obtain that medical informationfrom their physician and to pay for any costs the physician’soffice may charge to copy and send us those records.

� If additional information is requested and not received by us within 15 days, we will send a follow-up reminder to theapplicant. If the information is not received within 45 daysof the original request, the application will be consideredincomplete and will be withdrawn.

� The applicant will be required to reapply and complete anew application packet.

– 8 –


RescissionsIn making a determination whether to issue a policy to an

applicant, ConnectiCare will review and rely on the statements

made on the application and health statement. Any material

omission, misrepresentation or misstatements about medical or

pharmacy history, planned treatment or surgeries, weight/height

or other information on the application or health statement

will result in rescission and denial of an otherwise valid claim.

In addition, such omissions, misrepresentations or misstatements

may result in rescission of the policy back to the policy effective

date, and the client would be responsible for reimbursing

ConnectiCare for any paid claims. The premium paid and

collected at the point of rescission would be credited toward the

claims paid by ConnectiCare. This could result in either a refund

owed to the client, or claim payments owed by the client.

Premium PaymentsThe monthly premium payment is due on the 1st of every

month. If premium is not received around the 15th of

the month, a past due notification will be mailed to the

accountholder. Monthly premium payments can be made

by choosing one of the following options:

� Electronic funds transfer (EFT) – members can automatically enroll in EFT with the invoice stub when making a monthly premium payment.

� Online credit card payment.

� Personal check/money order.

In-force premium payments should be mailed to:

ConnectiCare, Inc. & AffiliatesP.O. Box 30726Hartford, CT 06150

For answers to your ConnectiCare SOLO billing questions,

please call 1-800-333-1733.

Note: ConnectiCare SOLO is an individual plan and is notoffered to groups. ConnectiCare SOLO is medically underwrittenand policyholders are required to pay the monthly premiums within the grace period or their policies may be terminated.

DependentsDependents are defined as the spouse/partner and children of

the applicant. Children are defined as a natural child, adopted

child, stepchild, or other child for whom the applicant or

applicant’s spouse has been appointed legal guardian by a

Probate Court. “Child” also includes the insured’s mentally or

physically handicapped, unmarried child – if the disability

began before age 26 and while the child still was eligible for

dependent coverage – and as a result of the disability, the child

is unable to support himself/herself. In the case of a natural

child or stepchild, the child is not required to live with the

applicant. However, in the case of “other child” (i.e., foster

child, grandchild), the child is required to live with the

applicant in a “natural parent/child setting”. Please submit

legal guardianship documentation with the Individual

Application/Change Form anytime the dependent falls into

the “other child” category.

ELIGIBLE CHILDREN MUST ALSO BE:� Unmarried

� Under age 26

� Not able to support himself/herself due to mental or physical handicap that began before age 26 and while thechild was still eligible for dependent converage. Verificationof Dependent Disability Form must be submitted andapproved.

– 9 –


Adding DependentsAn Individual Application/Change Form and Individual

Health Statement must be completed to add dependents to a

ConnectiCare SOLO policy. The application is subject to

medical underwriting, except in the case of newborn or adopted

children if added within the first 31 days of eligibility, or if

there is no change in premium based on the added newborn or

adopted dependent. The effective date for additional dependents

is determined in the same manner as effective dates for

applicants – except for an additional newborn or adopted child.

Adding Newborns or Adopted ChildrenThe insured’s newborn natural child receives coverage for the

first 31 days after birth. The adopted child receives coverage for

the first 31 days from the date of placement with the insured.

Coverage for the newborn or adopted child will end at the

earlier of the termination of the insured’s coverage or the end

of this 31-day period, unless the insured has notified us of the

newborn or adopted child and has paid us any additional

premium, if applicable.

The policyholder must complete an Individual Application and

pay any additional premium within 31 days of birth or legal

placement of the child. Otherwise, the newborn’s or adopted

child’s coverage ends on the 32nd day. If the newborn natural

child or adopted child is not added to the plan within the

31-day period, the dependent will be subject to the complete

medical underwriting process and must meet all enrollment and

underwriting requirements. If approved, coverage will become

effective on the first of the month following approval.

Renewal ProcessAll ConnectiCare SOLO policies renew with a common renewal

date. Written notification is sent directly to the policyholder’s

home address in advance of the renewal date. (Please be sure to

report address changes to us in a timely manner so your clients

will receive this notification.)

You will have online access to your clients’ renewal information.

You’ll also receive a packet in the mail containing a list of all

your clients’ renewal information. Please review your renewals

carefully. If no changes are requested, the policy will

automatically renew.

Note: Additional rate increases may be incurred due to changes in a policyholder’s age-band status.

Requesting Off-Cycle Plan ChangesTo receive prompt, accurate review of your request for an off-

cycle plan change for ConnectiCare SOLO, you should:

� Have your client complete the Individual Application/Change Form (Part 1) and the Underwriting Authorization Form (Part 3);

� Fax both forms to our Intake Department at 860-678-5274.

Our Underwriting Department will review the request and

respond with a decision within two business days. Notification

will be mailed to the policyholder, with a copy mailed to you,

stating that the request has been approved, denied or is pending.

(A request will be “pending” if we have asked the policyholder

for medical records, or if we have sent the policyholder a ques-

tionnaire.) The notification will include a copy of the Individual

Application/Change Form requesting the plan change.

Off-cycle plan change requests that are approved become effec-

tive the first of the month following Underwriting approval.

If the off-cycle plan change request is denied, the notification to

your client will state the reason for denial. In such cases, your

client’s current plan will remain in force.

Important: Retroactive effective dates are not allowed, nor are deductible credits. A new deductible period beginswith the effective date of change. Off-cycle plan changes are limited to one per calendar year.

– 10 –


CC HH AA NN GG EE SS �

Medical UnderwritingOur underwriting department reviews the available medical

history and current health information of applicants and their

dependents to determine underwriting risk in accordance with

ConnectiCare’s guidelines. ConnectiCare will make the final

decision on the acceptance of any insurable risk. All information

discovered during the underwriting process will be used,

including, but not limited to, the health questions on the

Individual Application/Change Form and Individual Health

Statement, claim history, medical and pharmacy records, and

any additional information that may be requested.

1) ConnectiCare reserves the right to accept or deny requested

coverage, based on the information on the Individual Health

Statement provided by the applicant and/or their dependent(s),

and any other information obtained by us or provided to us.

2) An Individual Health Statement must be completed by the

applicant, including all dependents requesting coverage.

3) Underwriting may request additional information related to

specific conditions directly from the applicant and/or any

dependents. A medical records request and/or a supplemental

medical questionnaire will be mailed or e-mailed to the

applicant’s and/or dependent’s home address/e-mail address,

with instructions for completion.

4) In an attempt for underwriting to make a fair and accurate

determination on the current health status of a prospective

member who has not been to a provider for any reason,

including a physical exam, he/she will be required to have

a medical professional complete a series of questions for

underwriting review. These questions include the following:

a. Height/weight in office

b. Blood pressure in office

c. Documentation of any abnormal lab values in the last 5 years

d. A list of any symptoms the member has been experiencing

– 11 –


Termination of CoverageCANCELING DEPENDENTSTo cancel dependent coverage, an Individual Application/

Change Form (or other written request) must be completed.

Non-payment of premium is NOT considered a cancellation request.

If the policyholder wishes to cancel a dependent from the

policy, he or she will need to provide written notification within

30 days of the termination date. If a spouse/partner is to be

removed from a policy due to divorce or legal separation,

legal documentation must be attached to the Individual

Application/Change Form, and the Individual Application/

Change Form must be signed by the policyholder.

ConnectiCare will not process requests to make termination

effective retroactively.

CANCELING A POLICYIf a member wishes to terminate his or her policy, he or she

will need to provide written notification 30 days before the

identified termination date. The member must submit this

signed notification and include the date requested for termina-

tion of the policy.

Non-payment of premium is NOT considered a cancella-tion request. Cancellation requests should be sent to:

Mailing Address: ConnectiCare, Inc. & Affiliates175 Scott Swamp RoadP.O. Box 4058Farmington, CT 06034-4058

E-mail Address: [email protected] Number: 860-678-5255

ConnectiCare will not process requests to make a termination effective retroactively.

5) Dependents requesting coverage after the policyholder’s

effective date of coverage are required to complete an

Individual Application/Change Form, Individual Health

Statement and Underwriting Authorization Form, except

adopted children or newborn children added within 31 days.

6) Anytime we received a request to remove an existing

ConnectiCare SOLO member from his or her current policy

and issue the individual a new ConnectiCare SOLO policy,

medical underwriting will be required. Rationale: Since the

member is applying for coverage under a new policy, the

application is subject to the same underwriting requirements

as any other new application.

In the event of a policyholder’s death or divorce, or if the

policyholder becomes eligible for Medicare, then the

dependent can be moved to policyholder status without

medical underwriting.

Note: An Individual Application/Change Form is required to move the dependent to policyholder status.

7) If additional information is requested and not received by us within 15 days, we will send a follow-up reminder to theapplicant. If the information is not received within 45 days of the original request, the application will be considered incomplete and will be withdrawn. Also, the original effectivedate will become void. The application will need to be resubmitted to ConnectiCare with all information filled in and all questions answered – along with the additional information that was requested previously. A new effective datewill then be determined based on the date that this completedapplication is received.

Pre-Screening GuidanceConnectiCare SOLO’s pre-screening guidance allows producers

to obtain a preliminary response from our underwriting

department to questions regarding medical eligibility for

ConnectiCare SOLO prospects.

Note: Information that ConnectiCare provides during this pre-screening process is not a guarantee of coverage or eligibility,and is not intended to be the source for underwriting decisions.ConnectiCare reserves the right to request additional information or to decline coverage. ConnectiCare’s final decisionwill be based on enrollment requirements, a review of the completed application and medical underwriting.

� All requests for pre-screening guidance must be submittedusing the “Request for Pre-Screening Guidance” form, which may be downloaded from the secure producer site at www.connecticare.com. The form should be sent to theunderwriting department by fax 860-678-5204 or e-mail: [email protected].

� The form will ask for all medical history, including: condition/diagnosis; onset date; details (symptoms, treatment, tests, results); medications (name, dose, frequency); date last treated; and current status.

Underwriting will respond by fax or e-mail within 48 hours of

receiving the request for pre-screening guidance. This response is

not the final decision regarding acceptance for coverage.

A final decision will be based upon a completed application

which includes the health statement and any additional

information provided to underwriting.

Remember: To obtain a final decision on coverage, you must

follow the “Steps To Apply” on page 3.

Condition WaiversCondition waivers are not offered.

Future Surgery or ProceduresApplicants who are advised to have – or have scheduled – future

surgery, tests, or procedures are subject to further review.

Pertinent details should be provided on the Individual Health

Statement.

– 12 –


UU NN DD EE RR WW RR II TT II NN GG �

Declinable MedicationsIf the applicant (or any dependents) is currently using any of the following medications, or has a condition

mentioned on the Declinable Conditions list (next page), the application will be automatically declined:

This list is not all-inclusive and is subject to change.

*Prior use of any of the drugs listed below will be subject to medical underwriting.

– 13 –


ABATACEPT CYCLOSPORINE MEPRON REMICADE

ABILIFY DIPYRIDAMOLE METHADONE REMINYL

ACCUTANE ENBREL METHOTREXATE REMODULIN

AGGRENOX EPOGEN MIRAPEX RENAGEL

AGRYLIN ETHAMBUTOL MYFORTIC REQUIP

ALDURAZYME EXELON NAMENDA RIFAMPIN

AMEVIVE FABRAZYME NEORAL RILUTEK

APOKYN FEMARA NEULASTA RISPERDAL

ARANESP FLOLAN NEUPOGEN SANDOSTATIN

ARAVA FRAGMIN NITROGLYCERIN SELEGILINE HCL

ARICEPT GEODON ORGARAN SENSIPAR

ARIXTRA GLEEVEC OTHOCLONEOKT3 SEROQUEL

AROMASIN GROWTH HORMONE PARLODEL SINEMET CR

AVONEX HEPARIN SODIUM PEGASYS STALEVO

AZATHIOPRINE HUMIRA PEG-INTRON SUBOXONE

BETASERON IMMUNE GLOBULIN (IVIG)

PERGOLIDEMESYLATE

SYNVISC/HYLAN G F20

BROMOCRIPTINEMESYLATE INFERGEN PLAVIX TEMODAR

BUPHENYL INSULIN PLETAL THALOMID

CARBIDOPA/LEVODOPA INTRON A PROCRIT TICLOPIDINE HCL

CASODEX IRESSA PROGRAF TRACLEER

CELLCEPT ISONIAZID PULMOZYME XELODA

CLOZAPINE LEUKINE PURINETHOL XOLAIR

COGNEX LITHIUM RAPAMUNE XYREM

COMTAN LOVENOX RAPTIVA ZYPREXA

COPAXONE LUPRON(MALES ONLY) REBIF

Declinable ConditionsThis list is not all-inclusive and is subject to change.

– 14 –


AIDS/HIV

Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease)

Alzheimer’s Disease

Angina

Angioplasty

Ankylosing Spondylitis

Any Artery or Vein Bypass – including Heart

Bipolar disorder (manic depression)

Cancer (current)

Carcinoid Syndrome

Chronic Lung Disease, including Emphysema, Chronic Bronchitis & COPD

Cirrhosis of the Liver

Congestive Heart Failure

Coronary Heart Disease

Crohn’s Disease

Cystic Fibrosis

Diabetes

Gastric Bypass or any Intestinal Bypass or bariatric (obesity) surgery

Gaucher’s Disease or other lipid storage disease

Heart Attack (see Heart Disease on Underwriting Risk Criteria)

Hemiplegia

Hemophilia

Hepatitis B or C

Interstitial Cystitis

Ischemic Heart Disease

Leukemia

Major Depression

Morbid Obesity – current or present

Multiple Sclerosis

Muscular Dystrophy

Myocardial Infarction (Heart Attack)

Obsessive-Compulsive Disorder (OCD)

Pacemaker/defibrillator

Paraplegia

Parkinson’s Disease

Polycystic Kidneys

Pregnancy/expectant parent

Psychosis

Pulmonary Fibrosis

Pulmonary Hypertension

Pulmonary Stenosis

Quadriplegia

Renal Failure

Rheumatoid Arthritis (Juvenile/Adult)

Sickle Cell Anemia

Sideroblastic Anemia

Sleep Apnea

Spina Bifida

Stroke

Systemic Lupus

Thalassemia Major

Any Transplant except Corneal

(Cardiac) Valve Replacement

– 15 –


CONDITION RISK CRITERIA UNDERWRITING ACTION

Alcohol abuse History of alcohol abuse: no alcohol consumption, counselingor treatment for prior 5 years; normal liver function. Underwriting review

Amyotrophic Lateral Sclerosis(ALS or Lou Gehrig’s Disease) Diagnosed Deny

Anxiety – Includes: panic attacks, PMS, chestpains, abnormal heart beat, migraines

Situational–one medication for anxiety and one medication for sleep, both prescribed by PCP or psychiatrist (M.D.) withonly one visit per quarter for medication management.

Underwriting review

Arrhythmias, Dysrhythmias,Irregulare Heartbeat, Palpitations

Given individual consideration based on type, severity andtreatment Underwriting review

Arthritis – Osteoarthritis: mildNot a candidate for, or history of, reconstructive surgery orjoint replacement. Over-the-counter medications only, nosteroids, no hospitalization for prior 2 years.

Underwriting review

Arthritis – Juvenile/adult rheumatoid arthritis Diagnosed Deny

Asthma Mild – seasonal, 1 medication, no hospitalizations, no steroids,non-smoker and BMI under 26. Underwriting review

Basal cell carcinoma – face

Removed within 12 months.

12 or more months from treatment, all borders clear, no reconstructive surgery required, recent exam shows no recurrence and no other lesions of any kind.

Deny

Underwriting review

Basal cell carcinoma – all other locations on the body

Within last 6 months

6 or more months from treatment, all borders clear, no reconstructive surgery required, recent exam shows norecurrence and no other lesions of any kind.

Deny

Underwriting review

Bipolar; manic depression; OCD Diagnosed Deny

Breast cancer Prior 5 years cancer-free. Current exam shows no recurrence,no other malignancy. Underwriting review

Breast implants (saline, soya, etc., and no associated complications) Underwriting review

Breast implants (silicone) 5 years with no complications Underwriting review

Colitis, including Diverticulosis, UlcerativeColitis and Ulcerative Proctitis

Intermittent constipation and diarrhea. No medication taken,no bleeding, no hospitalization. Underwriting review

DepressionSituational–one medication for depression and one medicationfor sleep, both prescribed by PCP or psychiatrist (M.D.) withonly one visit per quarter for medication management only.

Underwriting review

Diabetes – All Types Diagnosed Deny

Drug abuse – illegal drugsNo illegal drug use for 10 years; no ongoing therapy, medications or hospital confinements for 10 years,except for Narcotics Anonymous or Alcoholics Anonymous

Underwriting review

Drug abuse – marijuana use only

No marijuana use for 1 or more years; no chronic respiratoryconditions, no ongoing medical therapy, medications or hospital confinements for 2 years, except for NarcoticsAnonymous or Alcoholics Anonymous

Underwriting review

Drug abuse – prescription drugsNo illegal drug use for 5 years; no ongoing therapy, medications or hospital confinements for 5 years, except forNarcotics Anonymous or Alcoholics Anonymous.

Underwriting review

Underwriting Risk CriteriaThe following table lists: � different medical conditions or combinations thereof;

� the risk criteria associated with each condition; and

� the corresponding underwriting action based on severity and risk potential.

Note: The following risk criteria guidelines are specific only to that condition. Any other conditions discovered through the underwriting process are subject to their own specific underwriting guidelines and will be reviewed accordingly.

Height and Weight TableAGE 14 AND OLDERThe Height and Weight Table at right shows the maximum

allowable weights for males and females age 14 and over.

Applicants who do not fall within the guidelines may be declined.

Accurate height and weight is required for all applicants

on the application.

FAQs for Individual ProductIf you have questions about ConnectiCare SOLO,

or would like more information, please contact your

ConnectiCare Sales Representative or Account Service

Representative, or call 1-800-723-2986. You may also refer

to “Frequently Asked Questions” on the secure producer site

at www.connecticare.com. Choose “SOLO/Individual”

from the left navigation bar, go to “Decision Tools/Resources”

and click on the link for “Frequently Asked Questions.”

– 16 –


CONDITION RISK CRITERIA UNDERWRITING ACTION

Eating disorders including Anorexia andBulemia

No hospital admissions for 5 years; no treatment, therapy ormedication for the last 12 months. BMI must be within normalrange – 18.5 to 25 – for 12 months or more.

Approve

Emphysema Diagnosed Deny

Heart Disease, including Angina, IschemicHeart Disease, Coronary Artery Disease,Myocardial Infarction – Heart Attack

Diagnosed Deny

Hyperactivity; ADD, ADHD No other diagnosed mental health condition Underwriting review

Leukemia – last treatment more than 10 years ago Underwriting review

Leukemia – treatment within 10 years Deny

Lupus Diagnosed Deny

Melanoma 10 years since date of last treatment, including medication;current exam shows no recurrence; no other malignancy. Approve

Migraine headaches – includes vascular, ocular and cluster Underwriting review

Mitral Valve Prolapse, MurmursBenign murmur only: no medications required except precautionary antibiotics, and no other heart/circulato-ry conditions

Approve

OsteoporosisFracture within last 12 monthsNo fracture within last 12 months

DeclineUnderwriting review

Pancreatitis Single episode; full recovery, no treatment or medications for 1 year. Underwriting review

Prostate Cancer10 years since date of last treatment, including medication;current exam shows no recurrence; no other malignancy andcurrent PSA is under 3.

Approve

Psoriasis Diagnosed moderate or severe Deny

Sleep Disorder Underwriting review

HEIGHT WEIGHT4’8” 154

4’9” 159

4’10” 165

4’11” 171

5’0” 176

5’1” 182

5’2” 189

5’3” 195

5’4” 201

5’5” 208

5’6” 214

5’7” 220

5’8” 227

5’9” 234

HEIGHT WEIGHT5’10” 240

5’11” 248

6’0” 255

6’1” 261

6’2” 268

6’3” 277

6’4” 284

6’5” 291

6’6” 299

6’7” 306

6’8” 314

6’9” 322

6’10” 330

6’11” 340

ConnectiCare, Inc. & Affiliates175 Scott Swamp RoadFarmington, CT 06034

HMO coverage is underwritten by ConnectiCare, Inc.; POS coverage is underwritten by ConnectiCare Insurance Company, Inc. This plan is issued on an individual basis and is regulated as an individual health insurance plan. This plan is not available to employer groups. SOLO PG 0409

www.connecticare.com/solo

Questions?If you have questions about ConnectiCare SOLO, or would like moreinformation, please contact your ConnectiCare Sales Representative orAccount Service Representative, or call 1-800-723-2986.

Documents

Producer’sGuideto ConnectiCar e SOLO · Building Your Business with ConnectiCare® SOLO This guide provides a general overview of our individual product, ConnectiCare …