1-100 Small Group Underwriting Guidelines - Anthem

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1-100 Small GroupUnderwriting guidelinesDesigned for agents and producersEffective January 202045277CABENABC Rev. 12/19

Important contact informationSmall Group Underwriting addressAnthemP.O. Box 9042Oxnard, CA 93031-9042For Agents & Producers section of websiteSmall Group UnderwritingNew business: newsguwca@anthem.comExisting business: sguwca@anthem.comNew business telephone: 1-855-239-9251To order suppliesFax: 1-877-255-4015(fax completed Agent Supply Request form only)My user ID:My password:Online: https://brokerportal.anthem.com/apps/ptb/loginFor overnight delivery onlyAnthemSmall Group Underwriting4553 La Tienda DriveThousand Oaks, CA 91362View these guidelines and other documents onlineGo to https://www.anthem.com/ca/ and selectProducers. Then, log in and select Sales and Training.From there, you can view, download and print formsand documents.Small Group Customer ServiceTelephone: 1-855-854-1429Email: small.group@anthem.comHours: 8 a.m. to 6 p.m. PT (Monday–Friday)Anthem Connect TeamTelephone: 1-877-567-1802Hours: 5 a.m. to 5 p.m. PT (Monday-Thursday)5 a.m to 3 p.m. PT (Friday)Email: connect@anthem.comMail: Anthem Connect730 S. BroadwayGilbert, MN 55741Broker ServicesTelephone: 1-800-678-4466Email: agent.support@anthem.comHours: 8 a.m. to 5 p.m. (Monday–Friday)Summary of Benefits and Coverage (SBC) links} Affordable Care Act-compliant plans:sbc.anthem.comRapid QuoteTelephone: 1-877-275-3700Email: rapidquote@anthem.com}Anthem website: https://www.anthem.com/ca/Making Health Care Reform Work website:makinghealthcarereformwork.comCensus b/loginQuoting nEasy renew:www.anthem.com/easyrenewDental, vision, life and disability quoting}}Producer bkr/stl/product-informationProducer news: news.anthem.com/caAnthem Connect Team (2-25 lives):connect@anthem.comStandard Industry Classification (SIC) codes} listsareus.com/business-sic-codes.htm#codes26-100 ls/imis/sicsearch.html

Table of contentsThank you for choosing Anthem.1Section 3Section 1California underwriting business requirements.15Overview of the underwriting process.2What to submit (employer level).2Employee enrollment.2Sole proprietors. 15Corporations - C Corp, S-Corp. 15Non-Profit Organizations and Corporations. 15Group enrollment solutions.2Partnerships - General and LimitedLiability Partnerships (LLP). 15Completing forms.2Partnership-Limited Partnership (LP’s). 16Submission timeline.3Limited liability companies (LLCs). 16New group submission criteria.3Start-up companies. 16Section 2Professional employer organization (PEO)spin-off groups. 16General underwriting guidelines forSmall Group business.4Union versus nonunion. 16Households. 16Group eligibility requirements.4Employee eligibility requirements.4Section 4Enrolling rehired employees.5General underwriting guidelines for existing business.17Residents of Hawaii.5Open enrollment period.17Contribution.5Benefit modifications.17Medical plan participation.6Benefit modification job aid. 18Medical plan names.6Product types.6Section 5Network options.6Definitions.22Dental coverage.7Vision coverage.7Life coverage.8Disability coverage. 10Premium only plan (POP). 11Takeover provisions. 12Prior deductible credit/annual maximum copay/dentalbenefit waiting period credit. 13Dependent eligibility. 13Federal regulations. 13State regulations.14Notes.23

Thank you for choosing AnthemAt Anthem Blue Cross (Anthem), our goal is to provide you with clear guidance so you can help yourclients choose the best health care options.We want to help you grow your book of business, increase client retention and create aneasy-to-do-business-with environment.Remember, agents are not authorized to bind or guarantee issue coverage. Anthem will make the finaldecision to accept or decline a case. Please advise your prospective clients to maintain their currentcoverage until we notify them in writing that Anthem has approved their coverage.While Anthem is committed to keep all parties informed of any changes to these Small Group Underwritingguidelines in a timely manner, Anthem may change these guidelines at any time without prior notice.The information contained in these guidelines is intended for use by authorized agents only and shouldnot be copied or distributed for any other purpose.1

Overview of the underwriting processGroup enrollment solutionsThe following group-level documentation is requiredwhen submitting new business:Groups enroll in one of our employee enrollmentsolutions tools.}A copy of the agent’s final sold quote— EaseCentral}The most current Employer Enrollment Application/Fillable Application including the COBRA/FMLA/Cal-COBRA questionnaire; the last billing statementlisting COBRA/Cal-COBRA subscribers, if applicable— Salesforce}— Online Census Enrollment toolTo access the Census Enrollment tool, go login.htm.After logging in, select the Sales and Training tab. Fromthere, select the Small Group Business Customer Formstab. Then, select Excel Census Tool.A copy of the company’s most recent Quarterly StateTax Withholding Report with the current employmentstatus of all employees listed* (payroll may be required)— 1st quarter due with state by 4/30Completing forms— 2nd quarter due with state by 7/31— 3rd quarter due with state by 10/31Please ensure all questions are answered and signaturesand dates obtained. Please confirm the followingbefore submitting:— 4th quarter due with state by 1/31}}}If “takeover” coverage, a copy of the prior carrier’slast month’s group billing for all lines of coveragewith status of all listed employees}— Only the employer may fill in, change or modify theEmployer Application.A completed Electronic Debit Payment form for 100%of the first month’s premium made payable to Anthem(If electronic debit is not agreed to, a company checkmay be accepted, subject to additional processing time.)— Only the employee may fill in, change or modify theEmployee Application.}Anthem is required by the Internal Revenue Service andCenters for Medicare & Medicaid (CMS) regulations tocollect Social Security numbersEmployee enrollment}Each eligible employee/owner must complete anapplication or waiver.}Agents must keep a copy of the employeeapplication or waiver.No alterations to preprinted materials will be accepted.Whenever an individual has a language barrier andrequires assistance to properly complete theapplication, the application must be submitted with asigned Anthem Statement of Accountability/TranslatorStatement from the group or the agent.* See section 3,”California underwriting business requirements,” for sole proprietors, partners or corporate officers not appearing on the Quarterly State Tax Withholding Report.2Section 1What to submit (employer level)

Section 1Overview of the underwriting processSubmission timelineFor new group submission, make sure all requiredforms are completed accurately and included withyour submissions.}Anthem will accept new group submissions for thefollowing effective dates:— First of the month — by the 5th working day ofthe month— 15th of the month — by the 12th calendar day ofthe month}If Anthem requests any additional information prior tomaking a new group determination, it should bereceived within 10 days of the original request.}If the information submitted is incomplete andsubsequently not received in a timely manner, thegroup’s application may be withdrawn for themonth requested.}It is the agent’s responsibility to notify theUnderwriting department prior to approval if a changein the requested effective date is to be considered.A request for change will be required in writing fromthe employer.Note: Effective date changes will not beaccepted after approval.New group submission criteriaUnderwriting is based on the following criteria:}Employee and dependent eligibility}Employer contribution}Employee participation}Evidence of insurability will be required for life benefitamounts over guaranteed amount. Evidence ofinsurability is also required for late entrants.}Long–term disability for groups of 2-5 eligibleemployees is medically underwritten. Evidence ofinsurability is required.3

General underwriting guidelines for Small Group businessIneligible for group coverage:Group eligibility requirements— Owner only - owners on their own or with theirspouse/domestic partners, officers or partners.An employer that meets the employer eligibilityrequirements under the ACA and under the California SmallGroup regulations is eligible for guarantee issue andguaranteed renewal under a small group health plan.}— Employer groups with less than 51% of employeesworking in CaliforniaA group must be a person, firm, proprietary or nonprofitcorporation, partnership, public agency or GuaranteedAssociation. The employer must be actively engaged inbusiness or service.}A group must have and maintain business licensureand/or appropriate state filings allowing the companyto conduct business in California.}A group must not have been formed primarily for thepurpose of obtaining health insurance.}A group must involve a bona fide employer-employeerelationship.— Seasonal, temporary, and substitute employees,defined as employees hire with a planned futuretermination date— Contract employees (1099), employees compensatedon a 1099 basis— Sole proprietors, spouses of sole proprietors,partners of a partnership and the spouses ofthose partners— Employees that do not reside within the 48contiguous states, Alaska, Puerto Rico, or UnitedStates Virgin IslandsA group wanting to re-apply for Anthem may be ineligible ifthey have not complied with prior requirements. Categoriesinclude, but are not limited to:}Canceled for non-pay}Termination for recertification non-compliance.To be considered for coverage all prior cases must be ingood standing, all requirements complete.An individual who wholly owns the company on his/her ownor with his/her spouse/domestic partner, the spouses ofsole proprietors, partners of a partnership and their spouses,a 2% S corporation shareholder, a worker described inSection 3508 of Title 26, Internal Revenue Code, or a leasedemployee (as defined in 26 U.S.C. § 414(n)(2)) does not qualifyas an employee for purposes of group eligibility.Employee eligibility requirementsAggregation rules -- All employers treated as a singleemployer under section 414(b), (c), (m) or (o) of theInternal Revenue Service Code are treated as a singleemployer for purposes of determining group size.Therefore, all employees of a controlled group ofentities under section 414(b) or (c), an affiliated servicegroup under section 414(m), or an entity in anarrangement described under section 414(o), are takeninto account in determining whether the members ofthe controlled group or affiliated service group togetherare an applicable large employer.Affiliated companies — Under common control arerequired to enroll separately unless they are eligible tofile a combined tax return for the purposes of statetaxation. In determining group size, affiliated companieseligible to file a combined tax return for purposes ofstate taxation are considered one employer even if theyare not presently filing together.}Permanent employees who are actively engaged ona full-time basis in the conduct of the business of thesmall employer, with a normal work week of anaverage of 30 hours per week over the course of amonth, at the small employer’s regular place ofbusiness, who have met any statutorily authorizedapplicable waiting-period requirements.}Sole proprietors or partners of a partnership, if they areactively engaged on a full-time basis (average of 30 hoursper week over the course of a month) in the employer’ssmall business and included as employees under ahealth care service plan contract of a small employer.}Permanent employees who work at least 20 hours, butnot more than 29 hours, are deemed to be eligibleemployees if all four of the following apply:— The employee otherwise meets the definition ofan eligible employee except for the number ofhours worked.— The employer offers the employees health coverageunder a health benefit plan.4Section 2For plan years beginning on or after January 1, 2016, asmall employer is defined as an employer employing anaverage of at least one, but no more than 100 full-time,including full-time equivalent, employees during thepreceding calendar year and who employs at least oneemployee on the first day of the plan year. For purposesof determining employer eligibility in the smallemployer market, California adopted the federalmethod for counting full-time employees and full-timeequivalent employees (SB 125, 2015).}}— Carve out groups

General underwriting guidelines for Small Group business— All similarly situated individuals are offeredcoverage under the health benefit plan.Section 2— The employee worked at least 20 hours per normalworkweek for at least 50% of the weeks in theprevious calendar quarter. The health care serviceplan may request any necessary information todocument the hours and time period in question,including, but not limited to, payroll records andemployee wage and tax filings.— Please see page 8 for additional life anddisability guidelines.}an employer group, to get group coverage from aHawaii–authorized insurer. This would ensure thatall the state requirements are met.ContributionEmployers may choose their preferred approach forcontributing to employee medical premiums. Payrolldeduction is required, if contributory. Employers havethe following contribution options:MedicalEmployees must reside within the 48 contiguousstates, Alaska, Puerto Rico or United StatesVirgin Islands.Note: Owners may demonstrate that they meetthe eligible employee criteria by providing W-2sor completing an Eligibility Statement.Enrolling rehired employeesIf an enrollee’s employment ends and the employee islater rehired, certain restrictions apply. If the employeeis rehired within 31 days of termination, coverage willresume with no lapse upon our receipt of a writtenrequest from the employer group.If the employee is rehired more than 31 days fromtermination but not more than 91 days, coverage shallrestart effective on the rehire date. The rehiredemployee will not be subject to applicable groupimposed waiting periods and must complete a newEmployee Enrollment Application.If the employee is rehired more than 91 days (13 weeks)after the termination date, the employee is considereda new employee, subject to applicable group-imposedwaiting periods and must complete a new EmployeeEnrollment Application. The group is responsible fornotifying us immediately if an employee is rehired andwill be continuing coverage.Residents of HawaiiHAWAII ALERT — Because Anthem is neither aHawaii–authorized insurer nor a Hawaii HealthCare Contractor, our benefits may not match therequirements of the Prepaid Health Care Act. Werecommend that you get direct quotes for eitheran individual policy for employees who live and workin Hawaii, or if there are several employees within5}Traditional — A minimum contribution of50% of each employee’s monthly health premium}Fixed-dollar — Any fixed-dollar amount 100 orgreater (in 5 increments) for each coveredemployee’s health premium}Percentage and plan — A minimum of 50% toward aspecific plan, chosen by the employerNote: During the annual open enrollment period ofNovember 15 to December 15, contributionrequirements will not be enforced. The effective datewill be January 1 of the following year.Life}Basic life: Minimum employer contribution (notincluding dependent coverage) is 25% forcontributory plans and 100% for noncontributoryplans. Payroll deduction is required, if contributory.}Optional life: 100% employee-paid. Payroll deductionis required.}Voluntary life: 100% employee-paid. Payrolldeduction is required.Disability}Short-term disability: Minimum employercontribution (not including dependent coverage)is 25% for contributory plans and 100% fornoncontributory plans. Payroll deduction isrequired, if contributory.}Voluntary short-term disability: 100%employee-paid. Payroll deduction is required.}Long-term disability: Minimum employercontribution (not including dependent coverage)is 25% for contributory plans and 100% fornoncontributory plans. Payroll deduction isrequired, if contributory.}Voluntary long-term disability: 100% employee-paid.Payroll deduction is required.

The metal structure represents actuarial values (AVs) andcan be used to compare how overall cost sharing differsacross plans. Minimum and maximum AVs for each type ofplan include:Medical plan participationThe group participation requirements are:— 70% — groups with 1-14 eligible employees— 50% — groups with 15 or moreeligible employees— Platinum 88%/92%— Minimum participation is 100%,if noncontributory— Silver 68%/72%— Gold 78%/82%— Bronze 58%/62%Anthem may conduct periodic audits to confirmparticipation levels.Product typesNote: During the annual open enrollment period ofNovember 15 to December 15, participation requirementswill not be enforced. The effecti

1-100 Small Group Underwriting guidelines Designed for agents and producers Effective January 2020. 2 Important contact information Small Group Underwriting address Anthem P.O. Box 9042 Oxnard, CA 93031-9042 Small Group Underwriting New business: newsguwca@anthem.com

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