Employer/Group Administrator FAQ's


	Home > Help > FAQs > Employer/Group Administrator FAQ's

	Employer/Group Administrator FAQ's Will your plan send out detailed benefits information to employees? When does coverage begin? What type of wellness or health promotion programs do you offer to your members? Does COBRA coverage count as creditable coverage? Who is eligible for HIPAA? How does crediting for pre-existing condition waiting periods work under HIPAA How will the latest HIPAA requirements regarding security, privacy, etc. affect the products your plan offers? What qualifies as creditable coverage? How does an employer-imposed waiting period affect a break in coverage? How does a new employer or insurance carrier know that an employee had prior group coverage? What products and services do you offer? Does a group or a subscriber within a group have to take prescription drug coverage? What documentation is necessary for enrolling a group? Does the renewal paperwork require signatures from the broker and/or the group, if there are no changes other than the renewal rates? What are the enrollment deadlines for a new group? Can a group upgrade medical and/or dental at a time other than renewal if the group has grown? Can a group downgrade to a less expensive product at a time other than its normal renewal date? How do I submit enrollment files to the plan? Can I e-mail enrollment files to the plan? What is the average turnaround time required to determine a group or a subscriber's eligibility or underwriting status? Describe your provider networks (e.g., types of networks for each product). Is payment required at the time of application? How do I obtain a small-group quote? How to I obtain a large-group quote? What percentage of premium does the employer have to contribute? Who must be notified of a change of address or other administrative change? How do I change the waiting /elimination/probationary period on a group's policy? What is the maximum waiting /elimination/probationary period a group can impose? How are claims handled for employees with more than one health insurance plan? When traveling, can my employees receive coverage out of area? Do I have to offer COBRA to terminating employees or their dependents? How will newly hired employees prove that they had prior creditable coverage? I have an employee out on disability. How long am I required to keep him/her on the group health insurance policy? Can a small group get lower rates if they do not use a broker? What should my employee do if a claim is denied? When will my employees need to file a claim? Coverage/Benefits 1. Will your plan send out detailed benefits information to employees? Aetna will provide the following standard communication materials to new members: Member ID cards Claim forms Summary plan descriptions Enrollment forms Member handbooks There may be a charge associated with certain materials. 2. When does coverage begin? New employees are eligible for medical coverage effective on their date of hire and are allowed 31 days to complete their enrollment information. Their coverage becomes effective after complete enrollment data has been received. We must receive the request to enroll newborns or adopted children within 31 days of the date of birth or adoption. On late enrollment requests, if adding the newborn/adopted child would have generated no additional premium at the time of the event, the effective date is the date of birth or adoption. 3. What type of wellness or health promotion programs do you offer to your members? With our innovative Member Health Education programs, we offer special health education, preventive care and wellness programs. The following programs provide our members with materials – in conjunction with care and advice from their physician – that promote a healthy lifestyle and good health. Aetna continually strives to educate members about the importance of preventive care and timely disease screenings. As a result, a host of proactive health education programs is available as part of our HMO-based products. For all other Aetna plans, many of the programs can be added to your specific benefit plan. Detailed information about our wellness or health promotion programs can be found on our website. The address is www.aetna.com. One of the features of this website is Aetna Navigator, a Web-based resource center that assists members in using their health plan and in making informed health choices. Aetna Navigator includes a full description of our Member Health Education programs, a preventive health schedule that can be customized by the member's age and gender, and a link to Aetna InteliHealth¹, our award-winning health content site offered in partnership with Harvard Medical School and the University of Pennsylvania School of Dental Medicine. Aetna InteliHealth provides medical, health, fitness and nutrition information members need to actively participate in their health care management and wellness. It is easy to use, with thousands of articles on health topics that give members the information they need and "cool tools" that make learning about their health both educational and fun. ¹ Aetna InteliHealth Inc. All rights reserved. All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician before starting a new fitness regimen. Use of this online service is subject to the disclaimer and the terms and conditions. External website links provided on this site are meant for convenience and for informational purposes only; they do not constitute an endorsement. These external links open in a different window. Aetna InteliHealth is a founding member of Hi-Ethics. We also subscribe to the HONcode principles of the Health On the Net Foundation. "Aetna InteliHealth" and "The Trusted Source" are trademarks of Aetna InteliHealth Inc. COBRA 4. Does COBRA coverage count as creditable coverage? Yes, as defined in federal HIPAA legislation, COBRA coverage qualifies as creditable coverage. HIPAA 5. Who is eligible for HIPAA? HIPAA is directed at health insurance carriers and plan sponsors. Anyone covered under a full-risk health benefits plan issued by a carrier or covered under a self-insured health benefits plan offered by a plan sponsor, is subject to federal HIPAA. 6. How does crediting for pre-existing condition waiting periods work under HIPAA? In determining prior creditable coverage held by an individual, we will recognize 90 days* as the allowable maximum gap in coverage, from the date prior creditable coverage terminated, to the enrollment date of the individual under the group health plan. In addition, we will apply credit for prior creditable coverage to the pre-existing conditions exclusion under the group health plan as follows: if an individual has any prior creditable coverage within the 90 days* prior to his or her enrollment date, we will waive the pre-existing conditions exclusion period under the plan. if an individual has no prior creditable coverage within the 90 days* prior to his or her enrollment date, we will apply the plan's pre-existing conditions exclusion (to a maximum period of 365 days, or as mandated by state law). * If a state law mandates a gap period greater than 90 days, that longer gap period will be used to determine creditable coverage. 7. How will the latest HIPAA requirements regarding security, privacy, etc. affect the products your plan offers? The HIPAA Administrative Simplification and Privacy (AS&P) Regulations will have a far-reaching impact on the health care industry. We are making changes to our information technology systems, business policies and processes. The Electronic Transactions and Code Sets Regulations require us to convert our systems to conform to the new standards. The Privacy Regulations prescribe how we can use and disclose member health information. However, conforming to specific HIPAA requirements will not impact the products we offer, just how they are administered. 8. What qualifies as creditable coverage? Creditable coverage, as defined under federal HIPAA, is considered as "creditable coverage" by Aetna, including: group health plan coverage (including a governmental or church plan), group or individual health insurance coverage, Medicare, Medicaid, military-sponsored health care (CHAMPUS), a program of the Indian Health Service, a state health benefits risk pool, the FEHBP, a public health plan as defined in the federal HIPAA regulations, and any health benefits plan under section 5(e) of the Peace Corps Act. Not included as creditable coverage is any coverage that is exempt from the law; for example, dental-only coverage, or dental coverage that is provided in a separate policy or even in the same policy as medical, if such coverage is separately elected and results in additional premium. 9. How does an employer-imposed waiting period affect a break in coverage? An employer-imposed waiting period does not count in the consideration of whether or not an individual has a break in coverage. 10. How does a new employer or insurance carrier know that an employee had prior group coverage? The employee must provide proof of prior creditable coverage by presenting a Certification of Prior Group Health Plan Coverage, or other acceptable means of proof. When a potential pre-existing condition claim is received, the claim office will request the Certification of Prior Group Health Plan Coverage to determine if an individual has had prior creditable coverage within the 90 days prior to enrollment. , The member should retain the Certification until the claim office requests that form. Products 11. What products and services do you offer? We offer flexibility in plan design and will work with our customers to design plans that best meet a company's needs. A fast-growing network of providers complements our flexible plan designs. Detailed information regarding our products and services can be found at the following URL: http://www.aetna.com/producer/index.html Additionally, we offer a variety of technological innovations for customers, members and providers. Aetna Navigator is our online tool that provides members with health and benefits information. Once registered, employees can log in to a secure website (www.aetnanavigator.com) to check their claims status, order replacement ID cards and even change their primary care dentist or physician through our online provider directory, DocFind. DocFind will advise members if the provider they are selecting is currently accepting new patients. Also, the member's e-mail address that Aetna has on file will be displayed. Additionally, registered Aetna Navigator users now have the ability to contact member services online in Spanish 24 hours a day, 7 days a week. Aetna InteliHealth¹, our award-winning health content site, is offered in partnership with Harvard Medical School and the University of Pennsylvania School of Dental Medicine. Aetna InteliHealth has been awarded Health website accreditation by the American Accreditation HealthCare Commission (URAC). URAC's Health website Accreditation program is the first of its kind, and promotes quality and accountability in online health information and services. Aetna InteliHealth is among the first to achieve this important distinction. Aetna InteliHealth provides medical, health, fitness and nutrition information members need to actively participate in their health care management and wellness. It is easy to use, with thousands of articles on health topics that give members the information they need and "cool tools" that make learning about their health both educational and fun. ¹ InteliHealth Inc. All rights reserved. All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician before starting a new fitness regimen. Use of this online service is subject to the disclaimer and the terms and conditions. External website links provided on this site are meant for convenience and for informational purposes only; they do not constitute an endorsement. These external links open in a different window. InteliHealth has been awarded Health website accreditation by URAC <http://www.urac.org> and is a founding member of Hi-Ethics. We also subscribe to the HONcode principles of the Health On the Net Foundation. "Aetna InteliHealth" and "The Trusted Source" are trademarks of Aetna InteliHealth Inc. Pharmacy: 12. Does a group or a subscriber within a group have to take prescription drug coverage? We offer multiple plan design options for our customers encompassing a variety of plan provisions. As a result, group contracts vary by customer. However, a plan administrator may opt to offer several different plans to provide choices for their members. If more than one option is available, members can select a benefits plan that includes or excludes prescription coverage. Once a member selects a plan, coverage is provided as a package. Enrollments and Renewals 13. 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 a local Aetna sales office. 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. 14. 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. Premium/Rate and Quotes 15. 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 the local Aetna sales office for your state. 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. 16. 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. 17. 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. 18. 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™ 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™ 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. SecureTransport is a trademark of ValiCert, Inc., used under license. Notification of Changes 19. 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. Eligibility 20. 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 21. 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. Premium/Rate and Quotes 22. 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. 23. How do I obtain a small-group quote? Small group quotes can be obtained through the local Sales and Marketing office. In addition, quoting tools may be available in some locations. Brokers, General Agents, consultants and producers can obtain contact information for our Sales and Marketing offices in the Producer section of our website at www.aetna.com. 24. How to 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. 25. 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 26. 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. 27. 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. 28. 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 29. 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. 30. When traveling, can my employees receive coverage out of area? A member seeking urgent care while out of the service area can visit any facility or provider and be reimbursed all but the appropriate copay for covered services. No prior authorization or referral is needed. For routine treatment, a member is responsible for contacting the PCP for a referral to a physician outside of the home network in order to receive benefits and pay a copay. Members may also visit a provider without a referral and receive a nonreferred benefit level subject to deductible and coinsurance. We cover emergency care at the preferred level. COBRA 31. Do I have to offer COBRA to terminating employees or their dependents? COBRA requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end. The law covers group health plans maintained by employers with 20 or more employees in the prior year. It applies to plans in the private sector and those sponsored by state and local governments. Provisions of COBRA covering state and local government plans are administered by the Department of Health and Human Services. For additional information about COBRA requirements and other Department of Labor (DOL) regulations, refer to www.dol.gov. HIPAA 32. How will newly hired employees prove that they had prior creditable coverage? The employee must provide proof of prior creditable coverage by presenting a Certification of Prior Group Health Plan Coverage, or other acceptable means of proof. Disabled Employees 33. I have an employee out on disability. How long am I required to keep him/her on the group health insurance policy? The length of extension of benefits is determined by the plan selected by the employer. Once the extension of benefits has expired, the member is eligible for COBRA coverage. Premium Rates 34. Can a small group get lower rates if they do not use a broker? Rating considerations for broker commissions vary by product and by site. Claims 35. What should my employee do if a claim is denied? Once a claim is denied, the right to appeal is set forth in the initial denial letter. To start the appeals process, the member or a duly authorized representative acting on behalf of the member submits an oral or written request asking for a change in the initial determination decision regarding claim payment, plan interpretation, benefit determination or eligibility. The member, or provider/representative acting on behalf of the member, has 180 days after receipt of a coverage decision to file an appeal, unless otherwise required by law. Within five business days of receipt of a written appeal, an acknowledgment letter is sent. This letter states that the member, provider and facility will receive a response no later than 30 days from receipt of the appeal. 36. When will my employees need to file a claim? HMO, Aetna Open Access HMO, Elect Choice EPO, Aetna Open Access Elect Choice EPO, Members generally do not need to file claims. We do not require claim forms for in-network services unless members have paid for emergency out-of-area urgent care. Network providers submit claims on behalf of the member. The claim submission process is paperless from the member's point of view when the member uses network providers. QPOS, USAccess, Managed Choice POS, Aetna Open Access Managed Choice POS We do not require claim forms for in-network services. Network providers submit claims on behalf of the member. The claim submission process is paperless from the member's point of view when the member uses network providers. For non-network or out-of-area services, the member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our Explanation of Benefits (EOB.) Traditional Choice Members can access care through any licensed provider; there are no networks in this plan. The member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our EOB.

Aetna Company Names

Program Provisions