Producer FAQs

General

What documentation is necessary for enrolling a group? 
Documentation requirements for enrolling groups of 2-50 lives (1 life, where required by state law) are regulated by state specific Small Group Reform regulations. Information regarding enrollment activities can be obtained by contacting your regional Broker Liaison/Sales Support team.

To enable a smooth transition into our Middle Market and National Account plans, the following implementation activities are recommended: 

• Both parties have a mutual understanding of the plan design and effective date requested. 
• Both parties meet to agree upon implementation responsibilities and schedules.
• Develop contact list for both parties. 
• Discuss services in progress and the transition of claim history, if applicable. 
• Determine dates, times and locations of any employee enrollment meetings. 
• Copies of current plan booklet certificates provided to us. 
• Determine how eligibility will be provided. If provided electronically, meet to establish layout of tape and possible programming issues. 
• Determine appropriate enrollment materials to be provided to the employees. Develop special employee letters as needed. 
• Test eligibility tape submitted by client if applicable.
• Client schedules enrollment meetings and communicates the transition to all personnel. 
• Enrollment materials delivered to all client locations. Enrollment meetings are conducted by our enrollment team.
• Eligibility is provided to us at least two to three weeks before the effective date.
• Eligibility is fed into eligibility system and member ID cards are produced. ID cards are mailed to the plan members' homes within 10 to 12 business days. 
• Client contracts and employee booklet-certificates of coverage are mailed to the client for distribution to employees. 
• Our customer service personnel meet with client to discuss billing and ongoing maintenance of the dental plan.

The process described above should take place at least two months prior to the effective date. If the client provides eligibility information electronically, three months' advance preparation is preferable.

Does the renewal paperwork require signatures from the broker and/or the group, if there are no changes other than the renewal rates?
A signature may be required upon renewal even if there are no changes other than the renewal rates. This provides confirmation from the employer that they are in agreement with the plan designs and corresponding rates, which become effective on their plan anniversary.

What are the enrollment deadlines for a new group? 
The enrollment deadline for a new small group (2-50 lives (1 life, where required by state law)) varies by state. Deadlines for your state can be obtained by contacting your regional Broker Liaison/Sales Support team.

The time it takes to install a plan varies depending on the number of employees, plan design, customer's system capabilities, and development. Because each customer has individual needs, we are unable to exactly estimate the amount of full-time equivalent hours and lead time for the tasks.

Ideally, we need 60 to 90 days to complete installation. This gives us time to process enrollment, generate and mail ID cards, set up plans in our systems, test systems, etc.

Can a group upgrade medical and/or dental at a time other than renewal if the group has grown? 
The standard time for plan revisions is the renewal date or within 31 days after the renewal date. Midyear plan revisions may be considered, but require Financial Underwriting approval for the exception.

Small Group Note - "Any upgrades to medical and/or dental plans requires approval from the local Aetna Underwriting team."

Can a group downgrade to a less expensive product at a time other than its normal renewal date? 
The standard time for plan revisions is the renewal date or within 31 days after the renewal date. Midyear plan revisions may be considered, but require Financial Underwriting approval for the exception.

How do I submit enrollment files to the plan? 
Enrollment applications are utilized in the Small Group Segment (2-50 lives (1 life, where required by state law)) They can be submitted via paper or fax to the appropriate Plan Sponsor Services unit responsible for underwriting. A hard copy of the enrollment material must follow any faxed documents.

Enrollment files for plans over 50 lives can be submitted via paper, tape or electronic media using one of our secure electronic file transfer processes. Submission of eligibility information by more than one location or via multiple methods will result in additional charges. Costs associated with any custom programming necessary to accept eligibility information are excluded from the initial rates and are billed separately.

The customer's file must be IBM compatible and must contain certain data in a specified format, including employee name, date of birth, Social Security number and covered dependent information.
 
We offer the following online eligibility and enrollment options to Middle Market and National Account customers: 

• EZLink^TM -- EZLink is our Internet-based benefits and human resources (HR) administration solution. Customers can perform online eligibility, enrollment and account maintenance, as well as online billing and electronic funds transfer (EFT) for payment. EZLink also provides standard HR reports and other HR administration capabilities.
  EZLink Key Features: 
  • Online eligibility, enrollment and account maintenance 
  • Consolidated electronic billing and payment 
  • Data export 
  • HR administration and capabilities 
  • Standard benefits and HR reports 
  • The EZLink Alerts messaging system and custom information links 
  • Web-based system - no significant investments in software or hardware; no installation or maintenance issues 
  • Toll-free customer service for implementation, support and billing
  • Security features - Digital certificates and SSL 128-bit encryption technology, and unique IDs and passwords for user verification and system access.
• SecureTransport®* and Aetna EZConnect^TM-- Internet-based solutions for fast and reliable transmission of enrollment and eligibility information from our customers' systems to our systems. These solutions can save valuable time and money by eliminating the need for submitting paper or sending cumbersome tapes, cartridges and diskettes, which can get lost or damaged.
  • SecureTransport is high-performance FTP/HTTPS software that allows the customer to automatically upload eligibility data directly from a PC or UNIX environment through the Internet. This product allows unattended inbound transfer of eligibility data to our systems.
  • Aetna EZConnect is a browser-based HTTPS Internet upload utility that allows customers to upload data, while attended, from their PC into Aetna's mainframes for eligibility, Flexible Spending Account, Life Claim System, Group Universal Life and Long Term Care.

Can I e-mail enrollment files to the plan? 
To protect members' privacy, enrollment files may be submitted via enrollment form or fax. E-mail enrollment data will only be accepted if the files are encrypted prior to transmission. Enrollment files for Small Group business must be submitted via paper or fax to the appropriate Plan Sponsor Services Unit responsible for underwriting. A hard copy of the enrollment material must follow any faxed documents.

What is the average turnaround time required to determine a group or a subscriber's eligibility or underwriting status? 
The average turnaround time for a small group (2-50 lives, (1 life, where required by state law)) is determined by the local Aetna underwriting team. State and federal regulations determine how underwriting is applied to the group or the individual.

For our Middle Market and National Account customers, underwriting would be applicable on a group basis. We work with each of our customers or their consultant to determine when they need renewal pricing completed. Depending on the complexity of the request, a renewal generally takes between one and three weeks to complete.

Provider Network

Describe your provider networks (e.g., types of networks for each product). 
Our accessibility standards utilize GeoAccess indicators for urban, suburban and rural zip codes. Where gaps are identified, we will work with the customer to formulate a potential solution for member coverage. DocFind, our Internet provider directory provides a comprehensive listing of the providers in our networks.

We add physicians to our networks upon request as long as they meet our participation criteria. However, when we review our networks for purposes of adequacy, we follow a distinctive set of guidelines to determine the configuration of each network. Based on population size, we focus on the service area and types of services of each target hospital and its affiliated physicians to see that acceptable levels of care are readily available for members of the managed care program.

We have developed these guidelines so our networks give members reasonable access essential and important medical services.

Each of our networks is developed on a local basis, because each area is unique. Access to network providers (i.e., travel distance and time) must be reasonable for members based on local conditions. Geographic factors that may have an impact on accessibility include: 

• Natural geographic boundaries such as rivers and mountains 
• Man-made boundaries such as bridges and railway tracks 
• Road types ranging from interstate highways to rural roads 
• Local travel conditions (other factors such as periodic traffic congestion)

Our local network representatives are responsible for reviewing on a zip code by zip code basis the appropriateness of the service area. They consider the actual geographic distribution of each broad category of services (i.e., primary care, pediatrics, ob/gyn, specialist and facility) when establishing the zip code service area.

HIPAA

How does HIPAA legislation affect individual coverage? 
If an individual meets the definition of a HIPAA-eligible individual (as defined in HIPAA legislation), then that individual is guaranteed availability of individual coverage from a carrier OR state POOL plan (depending on state requirements) that offers such coverage, and a pre-existing condition exclusion cannot be applied to that individual guaranteed coverage.

Please refer to the HIPAA section of the Centers for Medicare and Medicaid website at http://www.cms.hhs.gov/HIPAAGenInfo/01_Overview.asp for additional information.

Enrollments and Renewals 

When can I get the renewal for a company enrolled with your plan? 
We normally provide the annual renewal 30 days before the end of the policy anniversary date. If the customer requests additional notice for their renewal, we will attempt to meet that request.

For small group, renewal processes vary by region. Contact your regional Broker Liaison/Sales Support team.

Premium/Rate and Quotes

Is payment required at the time of application?
Binder checks are requested at our discretion as a condition of sale for specific groups with more than 50 eligible employees. Groups with 50 employees, or less, require a binder check.

How do I obtain a small-group quote?
Online quoting tools are available in some states to appointed producers who are registered on Producer World®, our secure producer web site on www.aetna.com. For all other states, Small Group quotes can be obtained through your regional Broker Liaison/Sales Support team.

How do I obtain an individual quote?
Online quoting tools are available in some states to appointed producers who are registered on Producer World®, our secure producer web site on www.aetna.com.

How do I obtain a large-group quote? 
Our website address is www.aetna.com. Brokers, consultants and producers can obtain contact information for our Sales and Marketing offices in the Producer section of the website.

What percentage of premium does the employer have to contribute? 
We require the employer to contribute at least 50 percent of the total cost of the plan, or 75 percent of the cost of employee-only coverage. State and federal legislation/regulations, including Small Group Reform and HIPAA, take precedence over any and all underwriting rules. These guidelines may vary by state and group size.

Notification of Changes

Who must be notified of a change of address or other administrative change? 
The plan administrator or producer of record can notify the Plan Sponsor Services for a change of address; however, the account manager can be notified also.

How do I change the waiting /elimination/probationary period on a group's policy?
Our local sales offices provide contact lists for administrative procedures. A request for a revision to the policy must be submitted through the assigned account manager.

What is the maximum waiting /elimination/probationary period a group can impose?
We require that a probationary period be consistently applied within a class of employees. We may match the current carrier's probationary period; however, our standard maximum is six months.

Claims

How are claims handled for employees with more than one health insurance plan? 

Our COB approach is "pursue, then pay." We investigate the availability of other primary benefits before issuing benefits.

When other coverage information is obtained, we flag the online family eligibility record. The claim system will then automatically present a COB flag during claim processing. The notice includes details about the other coverage, which family members the other plan covers, the carrier, type of coverage (e.g., medical only, medical-dental, etc.) and date of the last update.

When a claim is submitted, if we are secondary and the primary carrier's Explanation of Benefits (EOB) is not attached to the claim, the claim is pended for receipt of the primary carrier's EOB.
Upon receipt of the primary carrier's EOB, claims are processed as follows: 

• For maintenance of benefits (MOB) or non-duplication plans, the COB allowable expense is our normal benefit (i.e., our negotiated rate reduced by copays, coinsurance, or other applicable plan provisions). 
• For standard plans, the COB allowable expense is the lesser of the primary plan's negotiated fee (if the primary plan is also a network plan) or the amount submitted to the primary carrier, subject to R&C limitations.

Once we determine the allowable expense, we subtract the primary carrier's payment from it and pay the balance, if any, as long as the balance does not exceed our normal benefit.

Broker Eligibility/Commissions 

How do I become a broker for your company?
Brokers can obtain license and appointment information and download the Producer Agreement (11 pages) from the Producer section on www.aetna.com.

How and when will I receive commission payments?
The compensations forms, for brokers associated with our Small Group business, are filled out internally. An agent or broker just needs to submit fully completed applications to their assigned sales representative. Otherwise the process is as follows:

New Business for a New Broker
If this is a first submission requiring agent/agency appointment, the following must accompany the compensation information: 

• Two Original Brokerage Agreements 
• W9 - Request for Taxpayer Identification Number 
• Copy of Agent/Agency License 
• Appointment Form (if applicable)
• Employer Application (which designates agent of record; otherwise a customer letter that designates agent of record) 
• Confidential Data Sheet (which can be obtained from the Producers Section of www.aetna.com.) 
• Commission payments are generally mailed by the 10th business day of each month and are based on the receipt and application of the customer's premium payment in the accounts receivable system in the previous month.

Agents/Brokers must satisfy company and state licensing & appointment requirements in order to receive commission payments. Commissions are distributed via U.S. postal mail on a monthly basis. Commission is calculated on paid premium received by Aetna. Commission checks usually arrive in agency offices on or around the 23rd of each month for prior months' premium receipts.

New Business for an Existing Broker
If this is new business for an existing broker, the following should be submitted:

• Compensation Form 
• Employer Application which designates agent/broker of record; otherwise a customer letter that designates agent of record.

In each instance, a commission specialist reviews completed paperwork. Once it is determined paperwork is complete, the commission specialist enters information into our systems. Payment is mailed within 10 days provided the customer's premium payment has been received and applied to the appropriate AR system.

Can I have my commission deposited directly to my bank account? 
EFT is available by registering for Producer World and by clicking on the EFT register now button within compensation services.  

*SecureTransport is a trademark of ValiCert, Inc., used under license.