ABOUT THE PRODUCER’S GUIDE

Welcome! We are pleased you have selected to offer CoventryOne as one of your health care coverage options.

This Producer’s Guide to Medical Underwriting contains helpful answers and probable underwriting outcomes with regard to prior or existing health conditions in order to aid you in placing business with CoventryOne. It is intended only as a guide. Additional information may be available to medical underwriting that may result in a decision that is different than that presented in this guide. Therefore, this Producer’s Guide to Medical Underwriting should not be construed as a guarantee of underwriting action on any specific case. The medical underwriters’ experience and discretion is the ultimate determining factor of underwriting action toward issuance of an offer for coverage.

This guide does not provide product or inclusive state-specific information.

COVENTRYONE APPLICATION GUIDELINES

The following information is intended to highlight details of the application process most relevant to medical underwriting procedures, and should not be interpreted as a comprehensive explanation of the application process.

The applicant (or custodial parent/guardian if under age 18) and all dependents 18 years and older, must attest by signature that all statements and disclosures provided on the application are true and factual. Coventry does not accept agent-submitted applications that are not signed by the applicant(s) and agent, or those which are submitted by an unlicensed or non-appointed, non-contracted agent.

Applications are valid for 60 days from the date of the applicant(s) signature. All applicable sections must be completed, signed and dated. After 60 days from the application signature date, the application will be withdrawn from consideration and considered closed. A new application will be required after this 60 day period has expired. Coventry does not accept re-submission of the original application with updates to the signature dates.

Changes / corrections made to an application must be dated and initialed by the applicant.

The underwriting department will not accept incomplete applications. The agent will be informed that an incomplete application was received and that it must be properly completed and re-submitted before it can be processed.

Information on the application is considered to have been disclosed / provided by the applicant. The medical underwriters accept that the given answers are full, complete and have not been edited by the agent.

In the case of electronic applications, applications initiated by the agent must be sent to the client by email for electronic completion. E-signing on behalf of an applicant is illegal; if a client does not have access to email, a paper application should be used.

Completing the Application

Missing information slows the underwriting process. Make sure that for every “Yes” answer, there are corresponding details in the Medical Details Section and that medication information is provided. This often eliminates the need for telephone interviews, which results in quicker turnaround time and underwriting decisions.

Any of the following situations will result in an application being Rejected:

• Incorrect Application
• Missing Application Pages
• Missing Banking Information
• Missing Applicant Signature/s
• Missing Broker Signature
• Missing Date Signed

Top information most commonly missed for paper applications:

• Health questions not answered
• Details are not given for health questions with “yes” answers
• Physician information is missing
• Social Security number is not provided
• Specific medication names

Top information missed for online applications:

• Details are not given for health questions with “yes” answers
• Physician information is missing
• Specific medication names

Effective Dates

At the time of application, an applicant may request one of the following future effective dates depending on market:

• Date of underwriting approval
• 1^st or 15^th of the month following underwriting approval- depending on market
• Specific day following underwriting approval

Health History

ALL MEDICAL QUESTIONS MUST BE ANSWERED FOR EACH APPLICANT. Please provide detailed explanatory information for each “Yes” answer indicating to whom the response refers, treating physician, detailed diagnosis, onset and recovery date and treatment, including medications. Full provider information, including full name, address, and phone number is necessary. In most cases, answers to health-related questions are not to be obtained from a third party (except in the case of applicants under the age of 18), where a custodial parent or guardian is expected to provide the information on their behalf.

Tobacco Usage

Tobacco usage is defined as the use of tobacco, tobacco cessation products, or e-cigarettes(electronic cigarettes) in the past twelve (12) months.

Each eligible person must answer on the application that he/she has or has not used tobacco, tobacco cessation products in any form, or e-cigarettes(electronic tobacco) during the past consecutive twelve (12) month period.

ELIGIBILITY

Age

Issue Age

Applicants must be age 64 ½ and under as of the policy effective date and not eligible for Medicare.

Exceptions to this may vary by market:

• ID, UT & WY; the applicant may be older than 65 years if not eligible for Medicare
• GA; the applicant must be 63 ½ or under as of the policy effective date
• OH & PA; the applicant must be 65 or under as of the policy effective date

Maximum Issue Age of Dependents

Maximum issue age of a dependent child is 25 years.

Exceptions to this vary by state mandates that require coverage over age 25:

• FL under age 30
• IA up to age 99 if full-time student
• OH under age 28
• SD under age 29

Children-Only Health Coverage

CoventryOne only offers children-only coverage in a limited number of states as required by law. Applicants in these states must meet the state specific eligibility requirements and open enrollment dates in order to be considered. Contact your Market Representative for more information.

Pregnancy/Expectant Parent/Surrogate Parent/Adoption

CoventryOne does not offer to male or female applicants who are:

• Applicants who are currently pregnant
• Currently expecting a child with anyone
• An expectant or surrogate parent
• Applicants in the process of adopting a child

*Exception ID,UT & WY; will consider husband on single policy when wife is expecting

Applicants Age 55 or Older

Individuals age 55 or over who have not had a complete physical exam performed by a physician within the past three years will not be considered for coverage and their application will be withdrawn.

Residency Requirements

An applicant must be:

• A legal permanent resident of the United States or
• Have resided in the United States legally for at least 6 months and have established medical care with a physician within the United States.

*No short term temporary, or travel visas will be accepted. If a social security number cannot be provided, a copy of each applicant’s visa is required.

THE UNDERWRITING PROCESS

During the underwriting process, each applicant’s medical history is evaluated individually and action is taken based on the severity and prognosis of the disclosed condition(s).

Complete and accurate information is required. When reporting on a condition, applicants should consider the detailed questions that are part of the Health Condition Considerations portion of this guide. Further, medical disclosures should include:

• Specific diagnoses
• Onset and recovery date(s)
• Medications taken or prescribed and their start/end date(s)
• Details and results of all testing or treatment
• Any recommended (pending) testing, procedures, or follow-up visits.

Final rates may be based on information, including, but not limited to, that which is submitted or obtained via:

• The application
• Telephone interviews
• Medical records
• Claim history
• Prescription database searches, and / or
• Other requests for medical information not limited to the above

Medical Underwriting Telephone Interviews

When underwriting identifies the need for additional information or clarification of information disclosed on the application, the applicant may be contacted directly. Please note that all telephone interviews are recorded and retained for our records. Decisions will not be discussed during the telephone interview. The process is as follows:

• A call is made directly to the applicant (parent or guardian for applicants under age 18)
• If the applicant cannot be reached, a voice message is left for the applicant (if a recording device is available) with the following information:

Name of applicant;

Name of Coventry employee or representative the applicant is to contact, and;

Instructions describing how and when the applicant is to return the call.

Underwriting makes one follow up phone call if not reached on the first attempt

No mention of the requested medical information and/or condition in question is disclosed in the voice message. Medical Underwriting will not proceed with the application process until the telephone interview is completed.

If no response is received after 30 days from the application signature date, the application will be closed as incomplete.

Medical Records Request

CoventryOne has a contracted relationship with a medical records retrieval service in order to collect necessary medical record information for selected applicants. This partnership enables CoventryOne to gather medical records in a consistent and timely manner. The vendor will act on behalf of Coventry to obtain medical records from the appropriate provider(s).

You now have the option to help facilitate the underwriting process by including complete medical records with the submission of the application. These records will only be accepted if they are included with the initial submission of the application and will be at the applicant’s expense.

In other cases, if records are not submitted with the initial application as detailed above, Coventry Health Care will follow our existing records-gathering procedure and be responsible for any associated costs up to $75.

Medical records requests will be limited to five (5) years of medical history unless otherwise specified. Coventry Health Care will bear the burden of any costs associated with medical record gathering up to a maximum of $75 per record request. If a provider charges an amount higher than our pre-determined maximum, the difference in cost will be the burden of the applicant. Coventry reserves the right to require individuals to be responsible for medical records retrieval costs that fall outside of accepted business practices. Coventry will not request medical records from providers or facilities residing out of the United States. Coventry reserves the right to refuse records submitted directly from an applicant or agent.

Medical records are required by CoventryOne for the following situations:

• Any applicant age 55 and older (must have seen physician for complete physical exam within the past two 3 years)
• Individual medical conditions, as deemed necessary, based upon sound underwriting judgment and established underwriting practices
• Any time medical history is unclear or inadequate to make a precise determination of the risk

• Discovery of claims history as a previously covered member under a Coventry Health Plan.

BUILD CHARTS

Please refer to your market’s specific rate key for rate definitions. The adult build charts are for age 16 and older.

Applicants under age 16 who are underweight or overweight will be handled on a case by case basis including investigation as to any underlying conditions.

HEALTH CONDITION CONSIDERATIONS

The following probable underwriting actions are to be used as a general guide and should not be considered as a guarantee of coverage. Final rates and offers will be determined based on all pertinent details obtained through the application and prescription use history in addition to possible telephone interviews and medical records at the discretion of the underwriting staff.

We do not decline dependent applicants under age 19 or children-only applications where applicable and subject to state mandates. If a probable underwriting action listed below is “Decline” then the applicant will be offered with a Guaranteed Issue rate.

Exclusionary riders are only offered in situations where the condition would be declined. These riders are currently only available in the following states and a listing of the riders can be found on pages 21 & 22:

Arkansas Delaware Georgia Iowa Kansas

Louisiana Maryland Mississippi Missouri-KC Nebraska

North Carolina Ohio Oklahoma Pennsylvania North Carolina

Oklahoma Pennsylvania South Carolina South Dakota Tennessee

Please refer to your market’s specific rate key for rate definitions.

EXCLUSIONARY RIDER LISTING



An applicant requiring more than three exclusionary riders will be declined



Exclusionary riders are permanent unless otherwise state mandated



No exclusionary riders will be offered on applicants under age 19

Exclusionary riders are currently only available in the following states:

Arkansas Delaware Georgia Iowa Kansas

Louisiana Maryland Mississippi Missouri-KC Nebraska

North Carolina Ohio Oklahoma Pennsylvania North Carolina

Oklahoma Pennsylvania South Carolina South Dakota Tennessee

AUTO DECLINE MEDICATIONS

Any applicant taking one or more of the medications listed below within the past year will be ineligible for coverage.

This is not an all-inclusive list and is subject to change.

AUTO DECLINE CONDITIONS

Listed below are the most common conditions that result in a decline of coverage.

This is not an all-inclusive list and is subject to change.