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Aetna Proprietary Information 01/14 1

Medicare Supplement Insurance Applies to Medicare Supplement Policies underwritten by Aetna Life Insurance Company


The information included applies to Aetna Medicare Supplement insurance coverage underwritten by

Aetna Life Insurance Company (ALIC). Benefits and costs may vary depending upon the insurance

plan. Health insurance plans contain exclusions and limitations and are subject to eligibility

requirements. Neither Aetna Life Insurance Company nor any of its agents or Medicare Supplement

insurance policies are connected with or endorsed by the U.S. or state government, Social Security

or federal Medicare program.

Medicare Supplement Insurance policies underwritten by Aetna Life Insurance Company are available

on a Direct to Consumer basis as well as for sale by Internal Aetna Agents, Telesales and Select

National Distributors.

While this material is believed to be accurate as of the print date, it is subject to change.


Field Underwriting Guide Table of Contents

Introduction 4

Eligibility requirements 5

State-by-state eligibility grid 5

Definition of rating types 6

State-specific requirements for those under age 65 7

Effective dates 9

Open Enrollment 9

Guaranteed Issue rights 10

Application process delays 12

Payment and billing options 13

Contact Information 15

Agent responsibilities and checklist 16

Premium rate changes 18

Request for plan option change 18

Policy cancellation 19

Notification of member’s death to Aetna 19

Medical underwriting: Overview 19

Declinable conditions and medications 20

Other criteria for automatic declination 20

Previously declined applications 21

Medical underwriting process 21

Missing information 21

Medical records 22

Processing and pending timelines 22

Drug List Information 23


Introduction

This guide is designed to help you submit applications for the Aetna Medicare Supplement Plans

underwritten by Aetna Life Insurance Company (ALIC). It provides information to help you and

your clients to complete the application accurately to expedite the processing time in the

Underwriting department.

You should review the application for completeness and accuracy and make sure any necessary

documents are attached before you submit it.

The Medical Underwriting section of this guide summarizes common health conditions encountered in

the underwriting process. The medical underwriting risk criteria will help you anticipate the

underwriting outcome for policies not issued on a guaranteed-issue basis. The Underwriting

department will make the final decision.

This guide is intended as a brief overview only and is not intended to be the source for

underwriting decisions. Aetna reserves the right to request additional information or

decline coverage.

The final decision will be based on enrollment requirements, Medicare eligibility, health history and

medical underwriting risk criteria.

This guide and medical underwriting risk criteria are subject to revision and may change

at any time without notice.


Eligibility Requirements

To qualify for enrollment:

1. Applicants must be enrolled in Medicare Part A (Hospital Insurance) & Medicare Part B

(Medical Insurance) at the time of application.

2. Applicants must be age 65 or older (in some states, those under age 65 with a disability

and/or end-stage renal disease plans may be eligible).*

3. Applicants must live in the state in which Aetna Individual Medicare Supplement Plan

insurance policies are offered.

*Disabled individuals under age 65 may be eligible in the following states for the plans

specified:

State-by-State Plan Availability Grid

The charts below reflect Plan availability for Medicare Supplement Insurance Plans underwritten by

Aetna Life Insurance Company. Effective dates for recently approved states are shown below.

NOTE: The following information is provided for producers only and is not for distribution to Medicare

beneficiaries. This material provides a brief overview and is for informational purposes only. It

contains only a partial, general description of Aetna Individual Medicare Supplement Plan (Plan)

benefits, and rating, eligibility and state requirements. Please review Plan documents for a full

description of Plan eligibility, rating and state requirements and benefits. To view Plan documents, go

to AetnaMedicare.com. This document should not be used as or considered legal advice.

State Aetna Medicare

Supplement Plans

available to Medicare

beneficiaries age 65

and over

Rating Type

Alabama Plans A,B,F,G & N Attained Age

Arizona Plans A,B,F,G & N Issue Age

California Plans A,B,F,G & N Attained Age

Colorado Plans A,B,F,G & N Attained Age

Florida Plans A,B,F,G & N Issue Age

Georgia Plans A,B,F,G & N Issue Age

Illinois Plans A,B,F,G & N Attained Age

Indiana Plans A,B,F,G & N Attained Age

Iowa Plans A,B,F,G & N Attained Age

Kansas Plans A,B,F,G & N Attained Age

Kentucky Plans A,B,F,G & N Attained Age

Louisiana Plans A,B,F,G & N Attained Age

Maryland Plans A,B,F,G &,N Attained Age

Michigan Plans A,B,C,F,G & N Attained Age

Nebraska Plans A,B,F,G &,N Attained Age

Nevada Plans A,B,F,G & N Attained Age

New Jersey Plans A,B,C,F,G & N Attained Age

New York Plans A,B & F Community Rated


North Carolina Plans A,B,F,G & N Attained Age

Ohio Plans A,B,F,G & N Attained Age

Oklahoma Plans A,B,F,G & N Attained Age

Oregon Plans A,B,F,G & N Attained Age

Pennsylvania Plans A,B,F,G & N Attained Age

Rhode Island Plans A,B,F,G & N Attained Age

South Carolina Plans A,B,F,G & N Attained Age

Tennessee Plans A,B,F,G & N Attained Age

Texas Plans A,B,C,F,G & N Attained Age

Virginia Plans A,B, F, G & N Attained Age

West Virginia Plans A,B,F,G & N Attained Age

Wisconsin Base Plan with riders Attained Age

During the 6 month Open Enrollment Period (period of time when individual is first both enrolled in

Medicare and age 65 or older), all Plans offered are available on a Guaranteed Issue basis.

During the Guaranteed Issue Periods (loss of an Employer Plan, Loss of MA Plan or Medicare

Supplement Plan etc.) , Plans A, B, C (where available) and F are available on a Guaranteed Issue

basis.

All plans are guaranteed issue during the Medicare Advantage trial Periods.

State of WI does not allow standardized Plans mentioned above, the Base Plan with riders are Guaranteed Issue during the OE/GI events. If an individual applies for a rider after the policy is in effect and outside of GI, medical underwriting is required.

Definition of rating types:

▪ Community rated: For each Medicare Supplement Plan, the same monthly premium is

charged to all individuals in each Plan regardless of age. Premiums may increase due to

inflation and other factors, but not due to age.

▪ Issue-age rated: The premium is based on the age of the individual when the Medicare

supplement policy is purchased (issued). Premiums may increase due to inflation and other

factors, but not due to age.

▪ Attained-age rated: The premium is based on the current age of the individual (age

attained), so the premium increases as the individual gets older. Premiums may increase due

to age. There may also be increases for inflation and other factors.


STATE-SPECIFIC UNDER AGE 65 REQUIREMENTS

The following chart provides a brief overview of State rules that require Aetna to offer at least one

kind of Aetna Individual Medicare Supplement Plan policy to Medicare beneficiaries who are under

age 65. The chart describes the Aetna Individual Medicare Supplement Plans that each State

requires that Aetna offer, and the period(s) during which under age 65 Medicare beneficiaries are

eligible to enroll in these Plans.

Applicants who are under age 65 Medicare beneficiaries are eligible to enroll in the Aetna Individual

Medicare Supplement policy as shown in this chart. In all States that require coverage of Medicare

beneficiaries who are under age 65, beneficiaries are eligible to enroll in the policy during their 6-

month Open Enrollment (OE) period. Under aged 65 Medicare beneficiaries are only eligible to enroll

in the Plan during a Guaranteed Issue (GI) event if required under State law, as indicated in the

chart.

State

Aetna Medicare

Supplement Plans

available to Medicare

beneficiaries under age

65

State specific requirements –

when required to offer plan to Medicare

Beneficiaries under age 65

Alabama None No requirement

Arizona None No requirement

California Plans A, B, F & N -

No plans offered to under

age 65 Medicare

beneficiaries with End

Stage Renal Disease

During 6 month OE period and GI events

applicable to Medicare beneficiaries age 65

or over

Colorado Plans A, B, F, G & N

-----------------------

Plans A, B & F

During 6 month OE period

------------------------------------------

For other GI events required by the

State

Florida Plans A, B, F, G & N

-----------------------

Plans A, B & F


------------------------------------------


State

Georgia Plans A, B, F, G & N

-----------------------

Plans A, B & F


------------------------------------------


State

Illinois Plans A, B, F, G & N

-----------------------------

----

Plans A, B, F & G


------------------------------------------


State

Indiana None No requirement

Iowa None No requirement

Kentucky Plans A, B, F, G & N Always medically underwritten

Louisiana Plans A, B, F, G & N

-----------------------

Plans A, B & F


------------------------------------------


State

Kansas Plans A, B, F, G & N

------------------------

Plans A, B & F


---------------------------------------

GI events applicable to Medicare


beneficiaries age 65 or over

Maryland Plan A only

------------------------------------------

Plan A only

During 6 month OE period,

including loss of coverage under the

Maryland Health Insurance Plan

(MHIP) For other GI events required by the

State

Michigan Plans A & C During 6 month OE period; enrolled

in Medicare due to disability

Nebraska None No requirement

Nevada None No requirement

New Jersey Plan C only

----------------------------------------

Plan C only

During 6 month OE period – Limited

to individuals age 50-64

------------------------------------------


State – Limited To individuals

age 50-64

New York Plans A, B & F Eligible to enroll in same plans

available to age 65 and over Medicare

beneficiaries at any time. This means

that there are no restrictions on when

an under age 65 Medicare beneficiary

can enroll in Aetna Individual

Medicare Supplement Plans.

North

Carolina

Plans A & F

-------------

Plans A & F


------------------------------------------


State

Ohio None No requirement

Oregon Plans A, B, F, G & N

----------------------------------

Plans A, B & F


------------------------------------------


State

Oklahoma Plan A only

------------------------------------------

Plan A only


------------------------------------------


State

Pennsylvania Plans A, B, F, G & N

----------------------------------

Plans A, B & F


------------------------------------------


State

Rhode Island None No requirement

South

Carolina

None No requirement

Tennessee Plans A, B, F, G & N

----------------------------------

Plans A, B & F


------------------------------------------



State

Texas Plan A only

--------------------------------------------

Plan A only


------------------------------------------


State

Virginia None No requirement

West Virginia None No requirement

Wisconsin Basic Plan plus riders

--------------------------------------------

Basic Plan plus riders


------------------------------------------


State

Effective dates

The requested effective date must be included on the enrollment application. Applicants may choose

an effective date ranging from the 1st-28th of the month. Effective date must be on or after

application signature date. Paper applications that have the first of the month hardcoded, can be

revised by crossing off the “first”, substituting it with the correct effective date, initialed by the

applicant.

Effective dates must coordinate with the expiration date of the existing policy if the policy is being

replaced. All existing policies should remain in force until the replacement application is approved

and issued by the underwriter.

Applications will be accepted 6 months* prior to the effective date for individuals applying during an

Open Enrollment period. Applications will be accepted 90 days in advance of the requested effective

date for individuals applying during a guaranteed Issue event and for underwritten applications.

*In New York and Wisconsin, applicants can apply for coverage no sooner than 3

months prior to turning 65 and in West Virginia no more than 30 days prior to

enrollment in Medicare Part B.

Open Enrollment

Open Enrollment lasts six months and begins on the first day of the first month in which an

individual is both age 65 or older and is enrolled in Medicare Part B.

During Open Enrollment, carriers cannot discriminate in pricing by health status, claims experience,

receipt of healthcare, or medical conditions. They must accept all eligible applicants; there is no

medical underwriting.

All plans that Aetna offers in a state must be available to any individual in that state who applies

during his/her Open Enrollment (OE) Period.

Some states require coverage on a Guaranteed Issue basis during the Open Enrollment period for

individuals under age 65 entitled to Medicare due to disability. This can be found in the “STATE-

SPECIFIC UNDER AGE 65 REQUIREMENTS” chart included below.

Individuals who enroll during the six-month Open Enrollment period may be subject to Pre-existing

Condition Limitations.


Effective 7/1/13, Pre-existing Condition Limitations no longer apply to Aetna Medicare Supplement

Plans.

Guaranteed Issue requirements for eligible persons

For a specified time, an individual who has lost other health coverage and submits evidence of the

date of termination or disenrollment from the prior coverage may be eligible for a Medicare

Supplement policy on a guaranteed issue basis. During this time, carriers cannot discriminate in

pricing, by health status, claims experience, receipt of health care, or medical conditions. They must

accept all eligible applicants and carriers can not medically underwrite.

The applicant must submit evidence of the date of termination or disenrollment from the prior

coverage with the enrollment application, or can send it to Aetna at:

PO Box 14399

Lexington, KY 40512-9701 Fax 1-877-380-2777 (Do not fax premium checks)

Events that require Guaranteed Issue* of a Medicare Supplement

Plan:

1) Loss of an employer plan** that provides benefits that supplement the applicant’s

Medicare benefits because the plan terminates or ceases to provide the supplemental

benefits (involuntary loss of coverage).

2) Loss of a Medicare Advantage (MA) or a Program of All-Inclusive Care for the Elderly

(PACE), due to the following:

Certification of the plan was terminated

Plan was discontinued in the applicant’s area

Applicant no longer eligible for the plan because he or she moved out of area, or the

plan is terminated for all residents in the area

Plan/organization materially misrepresented plan provisions when marketing it

3) Enrolled in a Medicare risk contract health care prepayment plan, cost contract or

Medicare Select plan, or similar organization due to the following:

o Certification of the plan was terminated

o Plan was discontinued in the applicant’s area

o Applicant no longer eligible for the plan because he or she moved out of area, or the

plan is terminated for all residents in the area

Plan/organization materially misrepresented plan provisions when marketing it

4) Loss of a Medicare Supplement policy because of:

o Bankruptcy/insolvency of organization

o Other involuntary termination or enrollment in the plan

o Issuer substantially violated a material provision of the policy

o Issuer or agent materially misrepresented the policy provisions when marketing the

policy


5) Applicant was enrolled under a Medicare Supplement Policy and terminated it. The

applicant then enrolled as a first-time member under a Medicare Advantage, PACE

program or Medicare Select policy and terminated the plan during the first 12 months of

enrollment.

6) When first enrolled in Medicare Part A at 65, the applicant also enrolled in a Medicare

Advantage or PACE program, and disenrolled from that plan within 12 months of the

effective date.

To be eligible for Guaranteed Issue, individuals must apply no later than 63 calendar days after

current coverage ends. If the person loses employer-sponsored coverage, the application should be

made 63 days from date the coverage ends, or the date the individual receives notice of termination

or claim denial.

*New York State is Guaranteed Issue all the time for all plans. The application does not include a

section for health questions.

Involuntary loss of an Employer Plan that supplements Medicare results in a Guaranteed Issue event

in all States. The following States require Guaranteed Issue for loss

of an Employer Plan that is primary to Medicare because the individual leaves the plan (voluntary):

CO, IL, IN, KS, LA, NV, NJ, OH, PA, TX, WI.

Although all plans must be guaranteed issue during the 6 month Open Enrollment period,

Plans G and N are not required as GI for the normal guaranteed issue events. The following chart

outlines the requirements for ALIC Medicare Supplement insurance.

State Plan G Plan N AZ, CO, GA, IL, MD, MI, NV, NC, PA, SC, TX, VA

Guaranteed issue for GI

events mentioned above and

Open Enrollment

Medically underwritten

outside of 6 month Open

Enrollment Period

AL, FL, IN, IA, KS, KY, LA, NE, NJ, OH, OK, OR, RI, TN, WV



Enrollment Period



Enrollment Period

CA Guaranteed issue for GI


Open Enrollment

Guaranteed issue for GI


Open Enrollment

NY N/A N/A

WI N/A N/A

The exception to the chart above is that Guaranteed Issue applies for #5 and #6 listed

above (trial period for Medicare Advantage):

Plans G and N were not filed and will not be offered in New York. For the State of WI, the Base Plan with riders are Guaranteed Issue during the OE/GI events.

If an individual applies for a rider after the policy is in effective and outside of GI, medical underwriting is required.

Examples of documentation required for proof of Guaranteed Issue:


Loss of group coverage – copy of disenrollment (creditable coverage) letter. Letter should

include the applicant’s name, address and date of termination.

Medicare Advantage (MA) Plans – Disenrollment / notification, including MA plan leaving their

service area, letter from MA plan indicated date of disenrollment, applicants name and

address.

Applicant leaving Medicare Advantage (MA) area – letter from the MA plan indicating the

disenrollment is due to move from the area or a copy of documentation indicating applicant’s

prior address.

Loss of a Medicare Supplement Plan – Proof of the Company’s insolvency, misrepresentation

etc.

Applications that are submitted outside on an Open Enrollment or Guaranteed issue period must be

medically underwritten*. The Individual must complete the Health Questions section of the

enrollment application.

The “smoker rate” applies to any individuals who applies outside of the Open Enrollment/Guaranteed

issued period and indicates that they smoke or have used tobacco during the time period indicated

on the application.

The “smoker rate” applies in Florida for any individual who indicates that they smoked or have used

tobacco during the time period indicated on the application. This is not limited to underwritten

applications like other states.

Application process delays/declinations Our intent is to make the application process as smooth as possible for you and your clients.

We cannot process an application until we have all the necessary information from the applicant and

agent.

Here are the most frequent omissions or errors that cause delay in underwriting/processing:

1. Failure to provide the Medicare Claim Number (HICN)

2. Failure to provide Medicare Parts A and B effective dates

3. Failure to submit correspondence to validate eligibility for Open Enrollment or Guaranteed

Issue

4. Incomplete address information

5. Missing or incomplete answers to health questionnaire

6. Missing date of birth or age for the applicant

7. Missing Social Security Number for the applicant

8. Application not signed and/or dated


9. Changes made to answers without accompanying explanation or initials

10. “White out” or “Liquid Paper” used without initials

11. Broker information incomplete or agent number missing. (Agent SS# will be blacked out on

the copy of the application that is sent with the policy).

12. Application completed in pencil

13. Submission of an outdated or expired application form

14. Multiple omitted items in the application

15. Signature date is postdated or more than 30 days old

16. The applicant did not know he/she applied for coverage.

17. The applicant is unwilling to complete a phone interview when applying outside of an Open

Enrollment or Guaranteed Issue Period.

18. The Health Questions section of the application is completed for individuals who are applying

during an Open Enrollment or Guaranteed Issue event.

19. If discovered that the Agent who signed the application did not speak with the applicant.

20. Applications submitted with check from third party payer that has no family

(spouse/partner/child) or business relationship (business owner, employer/retiree of the

business)

Important notes when completing applications:

- Billing Address: If the applicant wants to provide a billing address that is different than the

residence address, they should be instructed to call Aetna after receiving the policy at 1-888-

624-6290 or submit the request in writing to PO Box 1188, Brentwood, TN 37024.

- Notice or Policy Lapse: Whether or not the State enrollment application includes the section

to assign someone as a third party designee in the event a policy may lapse, the applicant

should be told that after they receive their policy, they should call 1-888-624-6290 for the

appropriate form required for this designation.

Payment and billing options

Individuals can choose to be billed monthly, quarterly, semi-annually or annually. The initial

premium payment is required with the enrollment application. The exception is New York where the

premium is not required with the application.

The initial premium payment for California is limited to the first month’s premium. Do not submit

more than one month’s premium with California applications.

In addition to the various premium modes available, there are three billing methods available:


EFT (Electronic Funds Transfer) payment option: The Electronic Fund Transfer (EFT)

payment option allows for premium payment to be drafted from the member’s checking or

savings account.

o Applicants can apply for EFT as part of the Med Supp enrollment application.

If an applicant would like to apply for EFT payments at a later date, they can complete the

EFT payment option form included in the enrollment packet or on aetnamedicare.com

o Go to: http://www.aetnamedicare.com/plan_choices/supplement_state_select.jsp

o Then select your state, click on the “Enrollment” tab, then “Apply” and then choose the

link to the form under the Electronic Funds Transfer (EFT) and Credit Card Option Program

Credit card (MasterCard or Visa) payment option: The Credit Card payment option

allows for premium payment to be drafted from the member’s Visa or

o MasterCard account.

The credit card payment Option form is included in the enrollment packet or on

aetnamedicare.com

Go to: http://www.aetnamedicare.com/plan_choices/supplement_state_select.jsp

Then select your state, click on the “Enrollment” tab, then “Apply” and then choose the link to

the form under the Electronic Funds Transfer (EFT) and Credit Card Option Program

Important information regarding the credit card premium payment option:

Submit the completed Medicare Supplement application documents WITHOUT the credit card

form to:

Aetna Life Insurance Company, P.O. Box 14399, Lexington, KY 40512-9701

Advise the applicant to call Policyholder Services at 888-624-6290 two business days after

submitting the application to get the necessary information needed to complete the credit

card authorization form. Policyholder Services will provide them with their pending Policy

Identification Number and the actual premium amount.

Ask the applicant to send the completed credit card form (and not the application documents)

to:

Aetna Life Insurance Company

P.O. Box 14389

Lexington, KY 40512-4389

Use one form for each applicant. (Husband and wife CANNOT be listed on the same

form.)

Only VISA and MasterCard credit cards will be accepted.

Credit card form must include the wet signature of the Cardholder and Signature

Date.

http://www.aetnamedicare.com/plan_choices/supplement_state_select.jsp



If the credit card holder is NOT the applicant/proposed Insured, then the Cardholder’s

relationship to the applicant MUST be included on the form to ensure payment is

applied to the appropriate application.

All credit card transactions will appear as “Aetna Ind. Medicare Supp” with the

phone number “888-624-6290” on the bank transaction.

Credit card transactions can have a Bill Day from the 1st to the 28th of the month.

Credit card details provided should be active (i.e.: Credit Card expiration date should

be in the future).

Applicant should NOT use a credit card which expires within 30 calendar days after the

date of the application.

Credit card information WILL NOT be accepted (and will be destroyed) if sent

through phone, fax, or email.

Direct Billing: Individuals are sent an invoice for premium payment due and pay, using a

check or money order.

The premium for all plans will be $2 higher per month for policyholders who choose the

monthly direct billing option. The $2 additional premium does not apply to policies when

premiums are paid on a quarterly, semi-annual or annual basis or if paid monthly through

the Aetna Electronic Funds Transfer (EFT) or Credit Card Payment option program.

With the exception of California, the rates shown in the Outlines of Coverage are the EFT rates. The

$2 must be added to individuals who pay on a monthly direct billed based, the rates shown in the

California Outline of Coverage are the monthly direct billed rates. The rate for California is

discounted by $2 for individuals who pay other than monthly direct billed.

Draft Dates.

Initial premium for EFT will be drafted on the date the policy is issued

Initial premium for Credit Card will be drafted on the date the policy is issued

Initial premium submitted via check will be processed when received

A 31-day grace period is allowed for payment of premiums. The policy will be cancelled at the end of

the 31-day grace period if the premium has not been paid during this time.

CONTACT INFORMATION

Aetna Customer Service 1-888-624-6290

TTY/TDD 711 Monday- Friday 8:00-8:00 CST

Submit applications, including initial premium payment to:

Aetna Life Insurance Company PO Box 14399


(See instructions above for credit cards)


Correspondence Aetna Life Insurance Company

PO Box 1188 Brentwood, TN 37024

Claims


Brentwood, TN 37024

Overnight Delivery for Applications Aetna Life Insurance Company

101 Yorkshire Blvd. Lexington, KY 40509

Renewal Premium Payments

(do not send initial premium to this address)


Atlanta, GA 30374-2085

Agents questions on commissions status, etc. 888-624-6290. Agents can view application status and commission statements at:

www.aetnaseniorproducts.com

Agent responsibilities and checklist

Before submitting application, review it for the following information:

Applicant’s personal information. Is it complete and correct?

Medicare Parts A and B information

Guaranteed-Issue questions answered

Proof of prior creditable coverage (termination notice, HIPAA certification, etc.)

Plan selection information

Statement of health questions (if applicable)

Release authorization

Agent information

Application includes a street address, not a PO Box

If mailing address is not the same as the applicant’s, make sure a contact name is included

with the billing address


First month’s premium is attached – Attach check made payable to: Aetna Life Insurance

Company, OR a completed application along with the Aetna Electronic Funds Transfer (EFT)

or Credit card Payment Application. Note: New York applicants are not required to pay the

first month’s premium with the application. Do not take more than one month’s premium for

California, even if request quarterly, semi-annual or annual billing.

Include completed/signed Notice of Replacement Form for any application that is for a

replacement of a Medicare Supplement or Medicare Advantage Plan.

Complete / sign checklist for Illinois** and Kentucky sales. EFT or Credit card

payment option forms are completed if premiums requested via credit card or EFT.

o **IL Checklist is not required for Applications taken from a Call Center

Mail application to:

Aetna Life Insurance Company Overnight Delivery

PO Box 14399 Aetna Life Insurance Company

Lexington, KY 40512-9701 101 Yorkshire Blvd.

Lexington, KY 40509

You can fax the information, but only if the applicant is enrolling in the Aetna Electronic Funds

Transfer (EFT) at the time of the application.* The form can be found on

http://www.aetnamedicare.com/plan_choices/supplement_state_select.jsp, and in the enrollment

kit. The program permits premium payment by automatic deduction from the applicant’s checking or

savings account. Fax to: 1-855-291-0553

*If an applicant has given you a check for the initial premium, please DO NOT submit the

application via fax. It will not be processed. Instead, mail the application and the check

to the address above for application submissions.

PLEASE NOTE: Applications received without premium payment will not be processed until

the initial premium is received. To avoid delays in application processing and closure of

the application due to non-payment of initial premium, please make sure that the

applicant is aware that premium must be submitted. To avoid delays, it is suggested that

the applicant enroll in the EFT program at the same time the application for Medicare

Supplement Insurance is submitted.

Enrollment forms for the credit card payment option (Visa or MasterCard) may be submitted by mail

only. The form can be found at:


Credit Card premium payment application forms must be mailed to:

PO Box 14389


To check the status of an application or for member services, call:

1-888-624-6290; TTY/TDD 711, or go online at:

www.aetnaseniorproducts.com




Premium rate changes existing business Increases/changes to Aetna’s Individual

Medicare Supplement Plans occur annually on the individual’s policy anniversary date. All individuals

are notified by letter in advance of any premium rate increase in accordance with the state-specific

notification requirements.

Premium rate changes new business

State specific premium rate changes are applied to new applications based on the application

signature date.

Example: Rate increase implemented effective 1/1/14:

- If application is signed before 12/01/13 for a 1/1/14 effective date, the 2013

rate will apply

- If the application is signed on or after 12/01/13 for a 1/1/14 effective date, the

2014 rate will apply

Request for policy exchanges (upgrades, downgrades, pre-to post-MIPPA)*

Following applies to Individual Medicare Supplement plans underwritten by Aetna Life Insurance

Company.

Any request to exchange a current policy to another Aetna Medicare Supplement policy

requires that the member complete a new enrollment application. Medical underwriting is

required for upgrades and pre to post-MIPPA plan exchanges.

The premium rate applicable to the new policy will be at the member's current

age. The exception is Florida where the premium will be the current premium

but at the age the policyholder was first enrolled in an ALIC Individual

Medicare Supplement Plan.

*If the member is still within the 6 month Open Enrollment or applicable Guaranteed

Issue period, medical underwriting is not required, however a new enrollment

application is required. Medical underwriting is required for Plans G and N outside of

the Open enrollment as indicated in the Medical Underwriting Guidelines. The Plan

Option change may be approved or denied based on the risk criteria stated in the

Medical Underwriting Guidelines.

The States of California and Oregon require that beginning each year on an individual’s

birthday and lasting for 30 days thereafter, an individual enrolled in a Medicare supplement

policy may cancel the their current Medicare supplement policy and enroll in another Medicare

supplement policy of the same or lesser value. This includes replacing a pre-MIPPA plan by a

post-MIPPA plan considered the same or of lesser value. The individual may apply within the

30 day period prior to and 30 days following his/her birthday and elect an effective

date up to 90 days past his/her birthday. Applications will not be accepted if signed prior to

the applicant’s birthday. This applies to internal as well as external replacements.

Within the free-look period – Policy exchanges are permitted on a Medicare Supplement

policy effective as of the original issue date of the policy. This requires a new application.

Underwriting needs to review the new application and entire case file. Any necessary

underwriting requirements are ordered for approval or declination of an upgrade. These

requests are handled by the New Business department.


After the free-look period – Policy exchanges are permitted on a Medicare Supplement policy

as described above. A new application must be taken and fully underwritten if applicable as

described above. The change will be effective the next premium due date after Underwriting

approval. Underwriting needs to review the new application and entire case file. Any

necessary underwriting requirements are ordered for approval or declination of an upgrade.

Any premium shortage may be requested as a delivery requirement. The policy must be

maintained on its anniversary date billing cycle

The new/reissued policy reflecting the benefit change, a copy of the signed application

requesting the increase and an acknowledgement letter are sent to the policyholder, with a

carbon copy to the writing agent of record

If the request is declined, coverage will remain as originally approved, with a letter sent

explaining this (letter is mailed from the Underwriting Department).

Policy cancellation

30-day “free look” period

The policyholder may request cancellation for a full refund within the 30-day “free look” period.

Notification of policyholder’s death A death certificate is required to cancel a policy when a policyholder has died. Aetna must receive

proof of the death (obituary or copy of the death certificate) in order to send a premium refund.

Medical underwriting: Overview

Medical underwriting is the process of reviewing and comparing the medical history of an applicant

against established underwriting risk criteria in order to determine the appropriate level of risk.

The medical underwriting process is designed to identify the potential medical risk and cost for the

conditions listed on the application. These costs are predicted based on existing and anticipated

future:

Hospitalizations

Surgeries

Medical office visits

Outpatient therapies

Laboratory tests

Prescription medications

Radiological and diagnostic tests

Durable medical equipment and supplies

Medical underwriting

When an applicant does not have Guaranteed Issue rights and is not applying during Open

Enrollment, the application will be medically underwritten. Medical underwriting staff will review all

the information submitted on the application, including medical records when necessary.


Applications are underwritten up until the time the policy is issued and the first premium paid. If a

declinable health condition emerges between the time the application is taken and the time of policy

issuance, the application will be declinable.

Telephone interviews are required on all underwritten business.

Power of Attorney will not be accepted on any underwritten application.

Any “yes” answer in the Health Questions section of the application will automatically disqualify the

applicant. This does not apply to the question regarding smoking.

Once the medical underwriting process is completed, applicants will be enrolled in the plan they

selected, or will be declined coverage based on significant medical risk factors.

Declinable conditions and medications

Many health conditions present an extreme risk because of the high cost of treatment and

medications. When such conditions or medications are listed on the application and the applicant is

not in the Open Enrollment or Guaranteed Issue period, Aetna reserves the right to decline coverage

without further review of medical records.

Applicants answering “yes” to the health questions on the enrollment application will typically be

turned down for enrollment in the Aetna Individual Medicare Supplement Plan. Applications are not

declined solely based on smoking status, however smoking premium rate adjustment of 1.10 will be

made in all states (excluding NY).

Conditions and medications in this category include, but are not limited to the

conditions/medications included on pages 19 and 22.

Additional Underwriting information

Common reasons for decline:

Any type of further evaluation, diagnostic testing or surgery that has not been performed.

Any condition listed under the Health Questions section of the enrollment application

Macular Degeneration (wet) requiring injections within the past 12 months.

Atrial Fibrillation currently being treated with medication.

Diabetes with hear or artery blockage at any time.

History of prostate cancer with a detectable PSA reading.

Aneurysms that have not been surgically removed.

Osteoporosis with fracture 9any type)

Lung or respiratory disorders; use of oxygen or a nebulizer within the past 24 months

including hospital/in home use).

Lung or respiratory disorder with tobacco use.

Other criteria for denial of coverage

Other risk conditions and situations that may result in denial:

Applicant has not obtained coverage under Medicare Part A and/or Part B

Applicant answered “Yes” to “Are you currently hospitalized, residing in a nursing home,

enrolled in a hospice program, or expecting to enter a hospital or nursing home within the

next 6 months”


Applicant answered “Yes” to the health questions included on the enrollment application

Applicant awaiting surgery, recommended to have surgery, or is a surgical candidate

Documented signs and symptoms requiring treatment, but no definitive diagnosis provided

Applicant is recommended to have further diagnostic testing

Applicant has been referred to a specialist for a consultation not yet completed

Applicant has been recommended to have a prosthesis replaced or modified

Multiple suicide attempts documented, or single suicide attempt within the past 10 years

Applicant has been taking medications listed on declinable conditions and medications list

Previously declined applications

An applicant who has previously been declined coverage can submit a new application. The

underwriter will review the new application along with the reason for the previous denial to ensure:

No conditions previously disclosed have been omitted from the new application.

If the previous denial was for a condition that will always result in a decline, the same result

will occur.

If the previous denial was for a condition that is now resolved or reduced in risk, the

underwriting process will be followed.

Medical underwriting process

If an applicant meets all eligibility criteria for enrollment in the Aetna Individual Medicare

Supplement Plan, Aetna will accept and enroll the applicant in the plan under the following

circumstances:

The applicant is eligible for Guaranteed Issue or is applying during an Open Enrollment

period.

The application is complete and the underwriting review process determines the applicant is

eligible based on medical history.

Missing information

When information on the health history is incomplete or unclear, the underwriter will make a follow-

up call or send a letter to the applicant for clarification. Some examples include:

Health statement questions answered “No,” but medications or provider information is listed

in the “Details” section

Unclear or unanswered questions regarding treatments or medications listed on the

application

Dates or services not provided

End dates of treatment not provided


Medical records

At times, medical records may be requested as part of the risk selection process. It is up to the

underwriter to make the final determination whether medical records are required by using:

Health history provided on the application

Underwriting guidelines

Assessment of overall risk based on sound medical underwriting judgment

Processing and pending timelines

The goal of the underwriting team is to process applications in a timely manner.

To achieve this goal, the team has established time lines around functions and responsibilities:

Underwriters will complete initial review of application with decision to accept, decline or pend for

further information within 6-8 business days assuming applications were received in good order

with no missing information or billing details.

Applications with missing information will be pended for 10 business days.

We will again follow-up with applicants and pend application.

Closed and Incomplete letters will be sent on day 60.

If medical records are requested, the application is pended up to 20 business days. When Aetna

receives the medical records, the underwriting process will be completed within 6-8 business

days.

Applications will be closed out within 60 days of receipt if additional information

required to process the application is not received.


Drug list information

Drug list information is provided to assist agents in completing Medicare Supplement insurance

applications.

Simple and concise list of the most commonly prescribed medications for declinable conditions.

Applicants may be unaware of a condition listed on the application, but prescribed medication

may indicate the condition exists and are not eligible for coverage with the company. Medications

include oral drugs, inhalers, injections, and infusions.

New drugs for these conditions are regularly introduced and may not be included but may be

unacceptable. Any questions concerning questionable medications should be directed to the

Underwriting Department

Because of the nature of some medications, individuals taking them will be declined, regardless

of the severity of the condition.

Some medications can be given for multiple conditions; medications are unacceptable when they

are prescribed for any of the conditions listed next to the drug. When applicant is prescribed a

medication that has multiple uses, the condition for which it is prescribed must be furnished.

Medications listed alone, are unacceptable for any condition.

The following drug list information has been arranged alphabetically by medication. This should be

helpful in finding the medication prescribed.

lower case: generic name

Upper Case: brand name


Drug list information –

*specific conditions

Akineton: treatment of Parkinson’s Disease

Amantadine: treatment of Parkinson’s

Disease

Artane: treatment of Parkinson’s Disease

atenolol + blood thinner: treatment of atrial

fibrillation, arrhythmia, irregular heartbeat

baclofen: treatment of Multiple Sclerosis

Calan + blood thinner: treatment of atrial


Carbidopa: treatment of Parkinson’s disease

Cardioquin + blood thinner: treatment of

atrial fibrillation, arrhythmia, irregular

heartbeat

carvedilol: treatment of cardiomyopathy,

heart disorder

clopidogrel: treatment of Peripheral Vascular

Disease

Coreg: treatment of cardiomyopathy, heart

disorder

Coumadin: treatment of atrial fibrillation,

arrhythmia, irregular heartbeat

Covera + blood thinner: treatment of atrial


Digitek: treatment of atrial fibrillation,


Digoxin: treatment of atrial fibrillation,


Dopar: treatment of Parkinson’s Disease

Efudex: treatment of cancer

Furosemide (40mg): treatment for

congestive heart failure, heart disorder

Hydromorphone: treatment of chronic pain

Inderal + blood thinner: treatment of atrial


InnoPran +blood thinner: treatment of


heartbeat

Isoptin + blood thinner: treatment of atrial


Lanoxicaps: treatment of atrial fibrillation,


Lanoxin: treatment of atrial fibrillation,


Laradopa: treatment of Parkinson’s Disease

Lasix (40 mg): treatment for congestive

heart failure

Levodopa: treatment for Parkinson’s Disease

Lioresal: treatment for multiple sclerosis

Lodosyn: treatment of Parkinson’s Disease

Lopresor + blood thinner: treatment of


heartbeat

Metoprolol + blood thinner: treatment of


heartbeat

Mirpex: treatment of Parkinson’s Disease

Plavix: treatment of peripheral vascular

disease

Pramipexole: treatment of Parkinson’s

Disease

Propranolol+blood thinner: treatment of


heartbeat

Quinidex + blood thinner: treatment of


heartbeat

Quinidine + blood thinner: treatment of


heartbeat

Quinora + blood thinner: treatment of atrial



Requip: treatment of Parkinson’s Disease

Ropinirole: treatment of Parkinson’s Disease

Sinemet: treatment of Parkinson’s Disease

Symmetrel: treatment of Parkinson’s Disease

Tenormin +blood thinner: treatment of


heartbeat

Toprol + blood thinner: treatment of atrial


Trihexyphenidyl: treatment of Parkinson’s

Disease

Verapamil + blood thinner: treatment of


heartbeat

Verelan + blood thinner: treatment of atrial


Warfarin: treatment of atrial fibrillation,



Drug List

abatacept

Abilify

acamprosate

Actigall

Actimmune

adalimumab

Adriamycin

Adrucil

Agrylin

*Akineton for: Parkinson’s

Disease

alefacept

alemtuzumab

Alferon

Alkeran

*amantadine for:

Parkinson’s Disease

ambenonium

Amevive

amiodarone

anagrelide

anakinra

Anandron

anastrazole

Antabuse

Aranesp

Arava

Aredia

Aricept

Arimidex

aripiprazole

*Artane for: Parkinson’s

Disease

*atenolol + blood thinner

for: atrial fibrillation,

arrhythmia, irregular

heartbeat

auranofin

Aurolate

Avinza

Avonex

azathioprine

AZT (azidothymidine)

Azilect

*baclofen for: Multiple

Sclerosis

benztropine

Betapace

Betaseron

bethanechol

Bexxar

bicalutamide

Blenoxane

bleomycin

bromocriptine

bumetanide

Bumex

busulfan

Busulfex

*Calan + blood thinner



heartbeat

calcium acetate

Campath

Campral

capectabine

*carbidopa for:

Parkinson’s disease

*Cardioquin + blood

thinner for: atrial

fibrillation, arrhythmia,

irregular heartbeat

*carvedilol for:

Cardiomyopathy

Casodex

CeeNu

Cellcept

Cerespan

Cerubidine

chlorambucil

chlorpromazine

cilostazol

cisplatin

*clopidogrel for: Peripheral

Vascular Disease

clozapine

Clozaril

Cogentin

Cognex

Comtan


Cordarone

*Coreg for: Cardiomyopathy

Heart Disorder

Cosmegen

*Coumadin for: atrial


irregular heartbeat

*Covera + blood thinner



heartbeat

cyclophosphamide

cyclosporine

cytarabine

Cytosar

Cytoxan

dactinomycin

Dantrium

dantrolene

darbepoetin alfa

daunorubicin

Demadex

Demerol

didanosine

dideoxyinosine

Didronel

*Digitek for: atrial


irregular heartbeat

*digoxin for: atrial


irregular heartbeat

Dilaudid

Disipal

disulfam

docetaxel

dofetilide

Dolophine

donepezil

*Dopar for: Parkinson’s

Disease

doxorubicin

dronedarone

Droxia

Duragesic

Duvoid

edrophonium

*Efudex for: Cancer

Eldepryl

Eligard

Eloxatin

Emcyt

Enbrel

Endocet

Enlon

entacapone

epoetin alfa

Epogen

ergoloid mesylates

erythropoietin

Eskalith

etanercept

etidronate

etoposide

Eulexin

Exelon

Exvoxac

Faslodex

Femara

fentanyl

filgrastim

flecainide

floxuridine

fluorouracil

fluphenazine

flutamide

Forteo

foscarnet sodium

FUDR

fulvestrant

*Furosemide (40 mg) for:

Congestive Heart Failure,

Heart Disorder

galantamine

gamma interferon

gefitinib

gemtuzumab

Gengraf

Geodon

Gleevex

gold sodium thiomalate

goserelin


Haldol

Haloperidol

Hizentra

Humira

Hydergine

Hydrea

*Hydromorphone for:

chronic pain

hydroxyurea

imatinib

Imuran

*Inderal + blood thinner



heartbeat

infliximab

*InnoPran + blood

thinner for: atrial


irregular heartbeat

interferon alpha 2a

interferon alpha 2b

interferon beta

Intron A

Invega

Iressa

*Isoptin for: atrial


irregular heartbeat

Kadian

Kemadrin

Kineret

*Lanoxicaps for: atrial


irregular heartbeat

*Lanoxin for: atrial


irregular heartbeat

*Laradopa for: Parkinson’s

Disease

*Lasix (40 mg): for:

Congestive Heart Failure,

Heart Disorder

leflunomide

lenalidomide

letrozole

Leukeran

leuprolide

*levodopa for: Parkinson’s

Disease

*Lioresal for: Multiple

Sclerosis

Lithane

lithium

Lithobid

*Lodosyn for: Parkinson’s

Disease

lomustine

*Lopressor + blood

thinner for: atrial


irregular heartbeat

loxapine

Loxitane

Lupron

Lysodren

Matulane

mechlorethamine

Megace

megestrol

Mellaril

melphalan

memantine

Mepergan

meperidine

mercaptopurine (6MP)

mesoridazine

Mestinon

methadone

Methadose

methotrexate

*metoprolol + blood

thinner for: atrial


irregular heartbeat

Mexate

*Mirapex for: Parkinson’s

Disease

Mithracin

mitomycin

mitotane

Moban

molindone

morphine

MS Contin

Multaq

Mustargen


Mutamycin

mycophenolate mofetil

Myleran

Mylotarg

Myochrysine

Myotonachol

Mytelase

Namenda

Nardil

Navane

Nebupent

Neoral

neostigmine

Neulasta

Neupogen

Nilandron

nilutamide

olanzapine

Oncovin

Opana

Orencia

oxaliplatin

oxycodone

Oxycontin

Pacerone

paclitaxel

paliperidone

pamidronate

papaverine

Parlodel

Pavabid

pegfilgrastim

Peg-Intron

Pentam

pentamidine

pentoxifylline

Pentoxil

Percocet

perphenazine

phenelzine

Phoslo

Platinol

*Plavix for: Peripheral

Vascular Disease

Pletal

plicamycin

*pramipexole for:


Pradaxa

Prednisone

procarbazine

Procrit

procyclidine

Prograf

Prolixin

propafenone

*propranolol + blood

thinner for: atrial


irregular heartbeat

Prostigmin

Purinethol (6MP)

pyridostigmine

quetiapine

*Quinidex + blood

thinner for: atrial


irregular heartbeat

*quinidine + blood

thinner for: atrial


irregular heartbeat

*Quinora + blood thinner



heartbeat

rasagiline

Razadyne

Rebetol

Rebif

Remicade

Reminyl

*Requip for: Parkinson’s

Disease

Retrovir

Revlimid

Rhythmol

ribarvirin

Ridaura

Rilutek

riluzole

Risperdal

risperidone


rivastigmine

Roferon-A

*ropinirole for: Parkinson’s

Disease

Roxanol

Roxicet

Roxicodone

Sandimmune

selegiline

Serentil

Seroquel

*Sinemet for: Parkinson’s

Disease

sotalol

Stelazine

Symbyax

*Symmetrel for:


Tabloid

tacrine

tacrolimus

Tambocor

Taxol

Taxotere

*Tenormin + blood

thinner for: atrial


irregular heartbeat

Tensilon

teriparatide

Teslac

testolactone

tetrabenazine

thioguanine

Thioplex

thioridazine

thiotepa

thiothixene

Thorazine

Ticlid

ticlopidine

Tikosyn

*Toprol + blood thinner



heartbeat

torsemide

tositumomab

Trelstar LA

Trental

trifluoperazine

*trihexyphenidyl for:


Trilafon

triptorelin pamoate

Tylox

Urecholine

Urso

ursodiol

Velban

VePesid

*verapamil + blood

thinner for: atrial


irregular heartbeat

*Verelan + blood thinner



heartbeat

Viadur

Videx

vinblastine

vincristine

*warfarin for: atrial


irregular heartbeat

Xeloda

Xenazine

Zelapar

zidovudine, AZT

ziprasidone

Zoladex

zoledronic acid

Zometa

Zyprexa


The above list is not all-inclusive. Many of these medications have generic forms and new

medications are introduced frequently.

Documents

Medicare Supplement Insurance Applies to Medicare ...web1.healthplanone.com/HP1_Vendor_Docs/Medicare/... · on a Direct to Consumer basis as well as for sale by Internal Aetna Agents,