Due to the fact that we are more then just a source for the latest health reform updates, I wanted to break from the daily grind of writing about the Washington Health Insurance Reform Debate and instead write a quick post about Aetna’s new health insurance underwriting criteria for individual insurance as it pertains to doctor’s visits to complete undewriting.
For more on health insurance underwriting please visit our main health insurance section.
The following is from a broker update emailed to our office to help expedite the underwriting process. It pertains to the fact that Aetna requires some kind of health history when submitting an application. Specifically, Aetna requires that individuals that haven’t seen a doctor for a few years must then go and get a physical.
We want to clarify Aetna’s underwriting requirements when a doctor’s visit is needed in order to underwrite an applicant(s). The doctor’s visit must be performed by a Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner/Certified Registered Nurse Practitioner (NP/CRNP) or Physician Assistant (PA).
Aetna Individual and Family Health Insurance Plans Age/timeline requirements
Newborn through age 17: The application must include a doctor’s visit within the past 3 years. If there is no doctor’s visit, a current medical exam (within the last 6 months) and physical is required. The only exception to this policy would be a newborn, under 31 days old, or a newly adopted child who is being added to a policy without underwriting.
Age 18 through age 30: The application must include a doctor’s visit within the past 5 years. If there is no doctor’s visit, a current medical exam (within the last 6 months) and physical is required. A physical must include height, weight, and a blood pressure reading.
Age 31 through age 49: The application must include a doctor’s visit within the past 5 years. If there is no doctor’s visit, a current medical exam (within the last 6 months) and physical is required. A physical must include height, weight, a blood pressure reading and lab results for blood sugar and cholesterol.
Age 50 and older: The application must include a doctor’s visit within the past 2 years. If there is no doctor’s visit, a current medical exam (within the last 6 months) and physical is required. A physical must include height, weight, a blood pressure reading, and lab results for blood sugar and cholesterol.
If the Underwriter determines (either through outreach to an applicant in a phone interview or by review of medical records) that the applicant has not had a doctor’s visit within the required timeframes, the underwriter will close the application.
The underwriter will document what information is required to be considered for enrollment and a written letter will be sent to the applicant to advise that their application has been closed.
Example: A 50 year old applicant applies for coverage with no medical history. A telephone interview is conducted and at that time, the applicant confirms that he/she has not seen a physician in over 5 years.
At that time, the clinician performing the telephone interview will advise the applicant during the conversation that “To proceed with underwriting your application, the results of a current physical exam is required. This includes but is not limited to: height; weight; blood pressure; lab results for cholesterol and fasting blood sugar; and past medical history. Your application can be continued if you submit this documentation to the underwriting department within the next 30 days. You may fax this information to (866)223-2041.” The applicant should identify on the fax that this is a “Request to reopen their application” and they should include their closed letter.
