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Common Qualifying Events*
Aetna Individual Policies- 2014
Qualifying Event
Definition
Loss of employer
coverage
Loss of employer coverage due
to termination of employment,
reduction in hours or coverage
no longer offered to
individual's employment class
Supporting
Documentation
Application
Submission:
Effective Date**
-Termination letter from
employer if you have been
terminated, or
Within 60 days
of coverage loss
1st day of mo. following
app receipt
Within 60 days
of loss of
dependent
eligibility event
1st day of mo. following
app receipt
- Pay stubs both current &
previous hours if hours have
been reduced, or
- Letter from employer stating
no longer paying for insurance.
No longer a
dependent
Loss of employer or individual
coverage because no longer
eligible as a dependent
Carrier letter documenting loss
of coverage due to loss of
dependent status, for example:
-dependent age maximum
reached,
-death of policy holder, etc.
Divorce from
policyholder
Loss of coverage due to a
Divorce
Copy of the divorce decree or
custody agreement
Within 60 days
of divorce
1st day of mo. following
app receipt
Loss of Medicaid
or CHIP
Loss of Medicaid or CHIP
coverage
Termination letter of loss of
Medicaid or CHIP coverage
from the Insurance carrier
including the date of the loss
of coverage.
Within 60 days
of loss of
Medicaid or CHIP
coverage.
1st-15th of mo:
1st day of mo. following
app receipt.
16th-last date: First day
of 2nd following mo.
Birth or adoption
Addition of new dependent as
a result of birth, adoption or
placement for adoption
-Birth certificate, or
-Adoption papers
Within 60 days
of event
Date of birth, adoption
or placement for
adoption
Marriage
Addition of new dependent as
a result of marriage
Marriage license or domestic
partner certificate
Within 60 days
of event
1st day of mo. following
app receipt
*T
he above list is not intended to be comprehensive of all qualifying events. Nevada allows a customer without a qualifying event to be enrolled for coverage,
subject to a 90 day waiting period between date of application and effective date.
** Will not occur before the Qualifying Event.
Common Qualifying Events* continued
Aetna Individual Policies- 2014
Qualifying Event
Definition
Loss of eligibility
for health
insurance exchange
subsidies
Loss of eligibility for health
insurance exchange subsidies
Renewal of a
pre-ACA plan
during 2014
The pre-ACA plan renewal or
cancellation occurs in 2014
Supporting
Documentation
Application
Submission:
Documentation showing that
you are no longer eligible for a
health insurance exchange
subsidy.
Within 60 days
of event
Carrier letter communicating
that current pre-ACA coverage
will end on a certain date.
Within 30 days
of loss of
coverage.
Effective Date**
1st-15th of mo: 1st day
of mo. following app
receipt.
16th-last date: First day
of 2nd following mo.
1st-15th of mo:
1st day of mo. following
app receipt.
16th-last date: First
day of 2nd following
mo.
Minimum Essential
Coverage
Existing policy no longer
provides Essential Minimum
Coverage
Letter documenting Loss of
Minimum Essential Coverage
Within 60 days
of event
1st day of mo. following
app receipt
Move
Permanent move to a new area
that offers different plan
options
Proof of move such as utility bill
or rental/lease agreement.
Within 60 days
of event
1st day of mo. following
app receipt
COBRA Expiration
COBRA coverage ends
Documentation showing the
date that COBRA coverage ends
and the people covered by the
COBRA coverage.
Within 60 days
of event
1st day of mo. following
app receipt
Return from active
military service
Newly eligible due to return
from active military service
Supporting paperwork
confirming departure date from
active military service
Within 60 days
of event
1st day of mo. following
app receipt
Release from
Incarceration
Newly eligible due to release
from incarceration
Copy of certified letter
documenting release date from
incarceration
Within 60 days
of event
1st day of mo. following
app receipt
Court Order or
Chapter 11
Coverage directed by Court
Order or resulting from
Chapter 11 filing
Copy of legal supporting
documentation requiring health
coverage
Within 60 days
of event
1st day of mo. following
app receipt
*T
he above list is not intended to be comprehensive of all qualifying events. Nevada allows a customer without a qualifying event to be enrolled for coverage,
subject to a 90 day waiting period between date of application and effective date.
** Will not occur before the Qualifying Event.
THIS INFORMATION IS INTENDED FOR BROKERS ONLY. Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna
Life Insurance Company. Aetna Health Plans (HMO/HNO) are underwritten by Aetna Health Inc. (“Aetna” refers to Aetna Life and/or Aetna Health Inc.).
In some states, individuals may qualify as a business group of one and may be eligible for guaranteed issue, small group health plans.
www.aetna.com
©2014 Aetna Inc.
73.03.022.1 (3/14)
Frequently Asked Questions For 2014 Plans
Q: What is different in 2014?
A: W ith the introduction of the Affordable Care act effective
January 1st 2014, individuals and families can shop and apply
on or off-exchange for coverage. Coverage is mandated for
most individuals.
Q: What is an exchange?
A: P ublic exchanges are online market places where individuals
and small group employers can shop for health insurance. It
can be operated by the state or federal government.
Consumers will be able to compare health plans from
multiple carriers and purchase plans online.
Q: D
oes everyone have to apply for coverage
on-exchange?
A: N o, applicants can apply on or off exchange. In order to
qualify for subsidies or tax credits you have to apply
on-exchange.
Q: What are the types of plan offerings?
A: P lans are divided into metallic levels and must offer essential
health benefits:
• Bronze (60% coverage)
• Silver (70% coverage)
• Gold (80% coverage)
• Platinum (90% coverage)
• Catastrophic Plan
Not all metallic levels are offered in each state.
Q: What are “essential health benefits”?
A: P lans must offer a standard package of coverage known
as “essential health benefits.” They are to include at least
the following: ambulatory patient services; emergency
services; hospitalization; maternity and newborn care;
mental health and substance abuse services; prescription
drugs; rehabilitative and habilitative services and devices;
laboratory services; preventive and wellness services and
chronic disease management; and pediatric services
(including oral and vision care).
Q: What are Catastrophic Plans?
A: Applicants are eligible to select a catastrophic plan if:
• Applicant is under age 30
OR
• A pplicant is age 30 or over and their pre-ACA plan
was cancelled
OR
• A pplicant is age 30 and over and has a certificate of
exemption from the Secretary of Health and Human Services
to confirm applicant is eligible for a Catastrophic Plan due to
hardship or lack of affordable coverage. A “certification” is
awarded making them eligible for this plan. If multiple
individuals are on the application, all individuals must meet
the eligibility criteria for the catastrophic plan.
Q: W
hat extra documentation is required
for a Catastrophic Plan
A:
• Applicant under age 30 submits a 2014 application
• Applicant whose pre-ACA plan was cancelled:
- 2014 application
- Copy of the Carrier’s Cancellation Letter
- A pplication for Exemption from Shared Responsibility
Payment for Individual who Experience Hardship
• A pplicant is age 30 and over and has hardship or lack of
affordable coverage:
- 2014 application
- Certificate of Exemption from HHS.
Applications should be submitted using standard processes.
Documents confirming the Qualifying Event can be sent to
[email protected]
Q: Are there Lifetime Limits on these plans?
A: No; there is no lifetime limit on any of the ACA plans.
Q: Are there pre-existing condition restrictions
or rating increases on these plans?
A: For plan years beginning in 2014, Aetna can’t decline or
charge additional premium because of health conditions.
Same rates for women and men. The only exceptions are:
grandfathered individual health insurance plans and
tobacco use in the past six months.
Q: What’s the definition of tobacco use?
A: Regularly used tobacco products (cigarettes, pipe, cigars,
snuff, or chewing tobacco) within the last 6 months. Regular
use means an average of four or more times per week.
Q: Who is eligible for coverage?
A: U.S. citizens or nationals, legal residents, resident of the
state and zip code where Aetna offers products.
Q: Who is not eligible for coverage?
A:
• Undocumented residents
Q: Who can be on a family plan?
A: A pplicant, spouse or domestic partner, children, legal
guardianship or ward. Children can be added or kept on the
health insurance policy until they turn 26* years old. Children
can join or remain on a plan even if they are:
• Married
• Not living with their parents
• Attending School
• Not financially dependent on their parents
• Eligible to enroll in their employer’s plan
*28 in OH, 30 in FL and in NY parents may purchase additional
coverage to age 30.
• Applicants who do not live in the U.S.
• People who are incarcerated
• A pplicants who live in a state or zip code Aetna does
not offer coverage
• Applicants that are enrolled in or have Medicare benefits.
Q: W
hat proof is required for non-citizens to
provide for eligibility?
A: P rovide proof of U.S. residency can be faxed to (866)
223-2041 or emailed to: [email protected]:
• A lien Registration Receipt Card with photograph (INS Form
1-151 or 1-551)
• US passport (updated or expired)
• Certificate of US Citizenship (INS Form N-560 or N-561)
• Certificate of Naturalization (INS Form N-550 or N-570)
• U pdated foreign passport with I-551 stamp or INS Form I-94
indicating unexpired employment authorization
Q: When is open enrollment?
A: T he open enrollment period is October 1, 2013 to March 31,
2104 for the first year. The next open enrollment period will
be November 15, 2014 – January 15, 2015
Q: What is the first available effective date?
A: J anuary 1st 2014. (Applications with signature date of
December 23rd or earlier) January 1, 2015 for the next open
enrollment period.
Q: What is the effective date off-exchange?
A: 1st of the month.
Q: W
hat is the first available effective date
if I apply Jan 1st off-exchange?
A: February 1st (you will be assigned the first of the
following month).
• Updated Temporary Resident Card (INS Form I-688)
• U pdated Employment Authorization Card (INS Form I-766 or
I-688B)
• Updated Reentry Permit (INS Form 1-327)
• Updated Refugee Travel Documents (INS Form I-571)
• U pdated Employment Authorization Document issued by the
INS containing a photograph (INS Form I-688B)
- L-1 Visa
- L-2 Visa
- H1B Visa (H4 visa for their spouse and children is
acceptable for the same expiration date as the H1B
visa. Both are required as proof of eligibility)
Q: W
hat is the first available effective date
if I apply Jan 16th off-exchange?
A: M arch 1st. (if you apply between the 16 and the end of
the month you will be assigned the first of the second
following month.)
Q: If I apply:
1/16 - 1/31; I get a 3/1 effective date
2/16 - 2/28; I get a 4/1 effective date
3/15 - 3/31; I get a 5/1 effective date
Q: W
hat if there is information missing from the
application?
A: Aetna will notify the applicant of the required information.
Q: W
hat if the information is received months
after my requested date?
A: Aetna will honor the requested effective date as long as the
missing information is received prior to April 10th.
Example: An applicant applies on December 15th requesting a
January 1st effective date. The applicant is notified of missing
eligibility requirements and returns that information to Aetna
on March 1st. Aetna will assign the original effective date of
January 1st. as requested.
Q: W
hat happens if information is missing from a
family application?
A: T here is no SOE (Statement of enrollment) on the new
application. We will notify the primary applicant of the
missing information. At the end of 10 business days we will
enroll the applicants with complete information and close
the applicant(s) with missing information.
Q: W
hat if I don’t apply for coverage during open
enrollment?
A: You are not eligible for coverage until January 2015 unless
you have a qualifying event.
Q: What is a qualifying event?
A:
• Loss of employer coverage due to termination, reduction in
hours or coverage no longer offered by employer
• Loss of employer or individual coverage because no longer
eligible as a dependent
• Marriage
• Birth
• Adoption
• Divorce
• Loss of Medicaid or CHIP coverage
Q: Can the premium rate be appealed?
A: I f a higher premium is given due to tobacco usage, there is no
appeal and the tobacco use rate will apply for the full year.
Q: W
hat happens if the SOA (statement
of accountability) is not completed?
A: Aetna requires the person translating to complete the SOA in
full. The same applies if someone is filling out the application
for someone who is incapacitated.
Q: Who must sign the application?
A: P rimary applicant, spouse/domestic partner and any
dependents age 18 and older. Each of these applicants must
attest they have read the application and the information is
true and complete.
Q: W
ill Aetna accept a paper check or
money order for the initial payment?
A: Yes, we will accept either with the paper application.
Q: D
oes the PHI section of the application need
to be completed?
A: P rimary applicant, spouse/domestic partner and any
dependents age 18 and older. Each of these applicants must
give permission for personal health information to be used.
Q: Can the application be declined?
A: N o. If Aetna cannot confirm the applicant’s eligibility (such as
age or dependent status) the application will be closed.
Q: W
ill Aetna accept a paper application after
March 31st for open enrolment?
A: T he application must be received by April 15th
(allowing 10 business days for delivery.)
Applications received after April 15th will be closed
as ineligible.
• Loss of eligibility for health insurance exchange subsidies
• Loss of coverage due to a permanent move
• US residency
• Death of insured
• Loss of coverage due to unintentional enrollment error or
decertification of existing health plan
• Return from active military duty
• Release from incarceration
• Court order or chapter 11 filing
• Your current plan renews in 2014 (must apply 30 days
prior to plan renewing).
Q: H
ow long do I have to apply for a
qualifying event?
A: A pplicant must apply within 60 days of the qualifying
event to be eligible and proof of the qualifying event will
be required.
Q: W
hat documentation is required as proof
of a qualifying event?
A: Applicant must provide:
• Loss of employer coverage. (Through termination of
employment, reduction in hours, or benefits no longer
offered by an employer).
•T
ermination
- Request from the applicant a termination letter
from their employer.
•R
eduction in Hours
- Request from the applicant a current and prior paystub
showing reduction in hours.
•B
enefits no longer being offered by an employer
-Request from the applicant a letter from their employer
stating they are no longer paying for insurance.
• No longer eligible as a dependent.
-Request from the applicant a copy of the termination letter
from the insurance carrier stating loss of benefits due to age.
• Marriage
-Request a copy of the marriage license or domestic
partner certificate.
• Birth
• Adoption
-Request a copy of the adoption paperwork.
• Divorce
-Request a copy of the divorce decree.
• Loss of Medicaid or CHIP coverage.
- Request from the applicant a copy of the termination
letter from the insurance carrier with the date of the loss
of coverage.
• L oss of eligibility for health insurance
exchange subsidies.
- Request from the applicant a copy of the termination letter
from the insurance carrier.
• Loss of coverage due to a permanent move.
- Request a copy of a utility bill or a rental/lease agreement.
• US residency
- Request a copy of a visa or other documentation. Please
note the US residency requirements have not changed. An
applicant must be a US resident for 6 months and submit a
copy of an accepted Visa (L1, L2 or H1B).
• L oss of coverage due to unintentional enrollment error
or decertification of existing health plan
- Request a copy of a letter from the insurance carrier from
the applicant.
• Return from active military duty.
- Request a certified letter documenting discharge
from service.
• Release from incarceration.
- Request a certified letter documenting release
from custody.
• Court order or chapter 11 filing.
- Request legal documentation.
Q: W
hat effective date is given for a
qualifying event?
A: M ost applicants will receive the first of the following month.
The exceptions are:
• Newborn (covered from DOB)
• Adoptee (covered from date of placement)
• Loss of Medicaid/CHIP or subsidies (follow the open
enrollment rules)
• New US resident or citizen (follow the open enrollment rules)
Q: W
hat about applications submitted on exchange
through healthcare.gov or state exchanges?
A: T he exchange will validate the qualifying event and will
only pass the application to Aetna if valid.
• Death of insured
- Request a copy of the termination letter from the insurance
carrier or a copy of the death certificate from the applicant.
THIS INFORMATION IS INTENDED FOR BROKERS ONLY. Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna
Life Insurance Company. Aetna Health Plans (HMO/HNO) are underwritten by Aetna Health Inc. (“Aetna” refers to Aetna Life and/or Aetna Health Inc.).
In some states, individuals may qualify as a business group of one and may be eligible for guaranteed issue, small group health plans.
www.aetna.com
©2014 Aetna Inc.
73.03.022.1 (3/14)