Florida Health Insurance

BLUE CROSS AND BLUE SHIELD OF FLORIDA and HEALTH OPTIONS FIELD UNDERWRITING GUIDELINES FOR MEDICALLY UNDERWRITTEN INDIVIDUAL PRODUCTS

This manual is the property of the Individual Medical Underwriting Department, Blue Cross and Blue Shield of Florida and Health Options. The contents are considered proprietary information and are not to be shared with unauthorized personnel or the public.

It has been provided to assist you in the overall underwriting process. This manual contains guidelines only. Final underwriting decisions are the responsibility of the Home Office, Individual Medical Underwriting Department.

“Blue Cross and Blue Shield of Florida and Health Options does not refuse to insure any individual solely because of race color, creed, marital status, sex, national origin or for any reason prohibited by law. The Company does not refuse to insure any individual solely because of their residence, age, lawful occupation or mental or physical handicap unless there is a reasonable relationship between the residence, age, lawful occupation, or mental or physical handicap of the individual and the risk to be undertaken by the Company by issuing the insurance.”

BLUE CROSS AND BLUE SHIELD OF FLORIDA and HEALTH OPTIONS

FIELD UNDERWRITING GUIDELINES

FOR THE UNDER AGE 65 INDIVIDUAL MEDICALLY UNDERWRITTEN PRODUCTS

Introduction

The selection of quality, high persistency business is vital in order for Blue Cross and Blue Shield of Florida and Health Options (hereto referred as “The Company”) to continue to make outstanding products available on an individual basis. It is through the efforts of the writing agent that this high quality of business can be obtained. The Company relies on the agent to carefully select risks and to supply the facts needed so that we may classify applicants properly, fairly and quickly. The agent must report any personal observations or facts bearing on the insurability of the risk, even if it is expected that The Company will get the facts from another source such as a previous application, claim or prescription history, medical records, tele-interview or a paramedical examination.

The Company should have a feeling of confidence when an agent recommends an applicant, and the agent can gain our confidence if he/she has a record of submitting good business. The success and continuation of the sale of our policies is dependent upon the individual agent and the use of common sense underwriting.

These Field Underwriting Guidelines have been provided as a reference tool for the BCBSF sales agent. The Company expects each agent to use this manual as a guide before submitting an application for a proposed insured.

UNACCEPTABLE APPLICATIONS

Applications should not be written for individuals who:
1. Live in a non-operational service area for the product being sold. (See Florida and Operational County Residency Requirements section of these Administrative Guidelines.)
2. Applicants with an ineligible occupation, (Pleaser refer to the Ineligible Occupation section of these Administrative Guidelines)
3. Are about to be seen by a physician or about to enter a hospital, sanitarium, rest home, prison or other institution, or who are sick, infirm, or otherwise not healthy at the time of the application.
4. Have a medical appointment scheduled within the next 30 days, including appointments for routine physicals, until after the physician has been seen and all test results are known (generally two weeks after the exam).
5. Recently had or anticipate testing or surgery and have not been released from the physician’s care.
6. Are pregnant women, spouses of pregnant women, pregnant dependents, or prospective fathers until after delivery and released from the physician’s care (generally, after the six-week check-up). NOTE: Prospective fathers include married and single individuals. Child-only applications may be completed for other dependent children.
7. Are dependent children under 6 weeks of age on a family application and/or who have not had their first well child examination after release from the hospital. (See Dependent Eligibility Requirements section of these Administrative Guidelines.)
8. For BlueOptions and BlueChoice, is a child under the age of 1 year when the child will be the proposed insured on a Child Only application (See A Minor Child as the Applicant section of these Administrative Guidelines). The minimum age for child only contracts for DIV, Essential, and BlueCare is 3.
9. Is a dependent child, over the age of 30, on a family application. (See Dependent Eligibility Requirements section of these Administrative Guidelines.)
10. Are currently receiving Social Security Disability and/or early Medicare benefits, or unable to work due to disability or receiving Workers’ Compensation or disability income benefits.
11. Are an eligible employee currently enrolled for group coverage through Blue Cross and Blue Shield of Florida or Health Options. (See Replacement of Blue Cross Blue Shield of Florida/Health Options Group Coverage section of these Administrative Guidelines.)

12. Reside in Florida less than six full consecutive months of the year. (See Florida and Operational County Residency Requirements section of these Administrative Guidelines.)
13. Are a Non U.S. citizen who has been in the United States for less than six full consecutive months, or are visiting the United States on a temporary basis. (See Non United States Citizens section of these Administrative Guidelines,)
14. Have been medically rejected for coverage by Individual Medical Underwriting in the past year, unless otherwise instructed by the Individual Medical Underwriting Department that a new application may be completed. (See Appeals Process and Procedures section of these Administrative Guidelines.)
15. Have been previously rejected by Individual Medical Underwriting due to outstanding information needed to determine insurability. A new application should not be completed until authorized by the Individual Medical Underwriting Department after review of the outstanding information. Please Note: If an application was closed due to an incomplete tele-interview, the applicant may re-apply, however, they must be willing to complete the tele-interview. (See Appeals Process and Procedures section of these Administrative Guidelines.)
16. Refuse to provide their social security number (See Social Security Number Requirement section of these Administrative Guidelines.) Social Security Numbers are for internal use only. Contracts are assigned a policy number.
17. Are unable to sign or e-sign his or her application for whatever reason (other than a minor child under the age of 18 in which case the parent is required to sign). A power-of-attorney is not acceptable.
18. Will become age 65 as of the proposed effective date of coverage.
19. Are applying for the HMO product and have health history requiring a Medical Exclusionary Rider; this type of applicant is unacceptable for the HMO product.
Please refer to the Medical Histories Guidelines section of this manual when assessing the medical eligibility of the applicant(s).

Unacceptable Electronic or IST Applications

Applications should not be submitted electronically for individuals who:

1. Have an existing individual health insurance with BlueCross Blue Shield of Florida and wants to upgrade/change existing product/plan (example to a richer benefit) the existing policy. (Upgrade/Change)
2. Have an existing individual health insurance with BlueCross Blue Shield of Florida and wants to include another family member, spouse or dependent. (Add-On)
A paper application must be submitted in these situations.

APPLICATION COMPLETION

The application is the primary basis on which The Company relies before issuing an Individual Insurance Contract or an HMO Membership Agreement. Every question on the application is critically important. The writing agent should ask each question separately, in full, and then record with care the answers exactly as given by the applicant. Keep in mind that the application is a legal contract. Therefore, it is extremely important that full disclosure of all medical history be provided on the application for all applicants.

In addition, Underwriting will obtain claims history and prescription medication usage in the review process. Medical records obtained/furnished and/or claims data that may be on file with BCBSF/HOI cannot be made part of the contract and should not be used as a substitute for obtaining and recording complete medical history on the application.

Failure to properly disclose complete and accurate information could result in an inappropriate underwriting action, or rejection of the entire application if discovered during the underwriting process

Undisclosed health history discovered after issue could also result in serious problems at the time of a claim and could result in possible rescission or cancellation of the contract.

Complete names and addresses of all doctors and hospitals, and dates consulted should be provided. Please be sure to obtain health history for all dependent children and provide it on the application. This should include the name of the pediatrician, date last seen and reason seen. (See also Application Completion and/or Medical Histories section of these Administrative Guidelines.)

If, during the visual examination of the applicant(s), the height and weight or other health history appears different than provided by the applicant, re-question him or her and provide the details. If you still feel the information is inaccurate please note this information in the “Agents Notes” or “Agent Remarks” section of the application. Note: On a paper application, the Agent will provide additional comments in the Agent Remarks. On an electronic or IST application, the Agent will provide additional comments in the Agent Notes. (Includes telephonic applications)

During the process of completing the application, the agent should refer to the Medical Histories Guidelines section of this manual. If the applicant has medical history that would result in a Medical Exclusionary Rider or a Rate Modification, the underwriting action should be discussed with the applicant during the interview process. If the condition indicates a DEC, in the Medical Histories Guidelines section of this manual, an application should not be taken.

Insurance Products Only:
• A complete physical examination by a family physician (established patient/physician relationship with multiple visits) within the past two years is usually sufficient for underwriting purposes even though blood and urine testing may not have been done. Examples of this may include but are not limited to: annual gynecological check-ups; post-pregnancy exams; regular exams for blood pressure treatment; etc. Keep in mind, when determined to be necessary, the Individual Medical Underwriter may order a paramedical examination, at no expense to the applicant. • Employment; FAA; Immigration; exams by a family member; DOT, and exams for other insurance companies are generally not sufficient and/or available for underwriting purposes and will not be requested by the Individual Medical Underwriting Department. • Also, brief notes from the examining physician that the patient is in good health are not sufficient.
Insurance and HMO Products:
An applicant with significant health history, such as: a heart disorder, heart murmur, neurological disorder, seizure history, cancer history, anemia, colon disorder, etc. cannot be considered unless a current medical evaluation/examination by their physician has been performed within the previous 12 months. In these situations, a paramedical examination is not sufficient for an underwriting assessment. This current examination, performed by the applicant’s physician, should generally include:

1. Documentation with evaluation of the significant health history and an overview of all past and current health history, and 2. A current medical evaluation and the results of all testing deemed appropriate by the physician within the previous 12 months.
There are three methods in which to submit an application. Note: It is illegal to complete a paper application and subsequently key the data collected into the IST Application when the applicant is unavailable to e-sign. This action will result in counseling and or job termination.

Electronic or IST application (includes Online, Web conferencing and telephonic applications): This is the preferred method of application submission. All applicants 18 and older must be present to validate the information provided on the application and e-sign the application.

Paper Application: Handwritten applications must be completed in a legible manner. The applicant and spouse (if applying) should sign the application at the time of completion. All applicants 18 and older must be present to validate the information provided in the application and sign the medical authorization.

INELIGIBLE OCCUPATIONS

Aerial Photographer
Hazardous Materials
Armed Forces
Helicopter Pilot
Asbestos and Toxic Worker
Law Enforcement or Police
Athletes (Pro or Semi Pro)
Mining
Circus, Carnival or Rodeo Worker
Off-Shore Oil Worker
Crop Duster
Race Car Driver
Demolition
Security Guard (Armed)
Drilling
Sky Diving Instructor
Diving Professional
Timber, Wood Cutters and Loggers
Explosives
Underwater or Caisson Workers
Fire Fighter
Wild Animal Trainers
Fishermen & Crew including Commercial Fishing

Revised October 2005. Revised December 2006. Revised July 2009. Revised December 2009.

SOCIAL SECURITY NUMBER REQUIREMENT

Please keep in mind that Social Security numbers are required for all applicants, including dependents. Health ID numbers will be assigned as contract numbers; however, Social Security Numbers are still required. If an applicant does not have a social security number, an electronic or IST application (includes telephonic applications) cannot be taken. If not eligible for a Social Security Number, please submit a paper application.

Note: To submit an electronic or IST application (includes telephonic applications) the data entry of a Social Security Number is required. If a Social Security Number is not entered, an error message will appear. It is imperative that a valid Social Security Number is entered. An invalid or incorrect Social Security Number may result in the rejection of the application.

NON UNITED STATES CITIZEN

To be eligible for coverage the applicant must meet the following guidelines:

• Must be a legal resident of the United States for a minimum of six full consecutive months. • Must intend to remain in the United States for a full two-year period. • Must be a permanent resident of the State of Florida. • Must have current valid documentation for underwriting review. • If the applicant has any significant health history, the applicant must have established a physician/patient relationship with a doctor in the United States.
Documented Residents –Electronic (IST) or paper applications

A copy of their valid Visa, Resident Alien Card or Employment Authorization Card must also be submitted with the application.
(Can be attached at the time of submission using the Attachment Type “Visa/Permanent resident Card”.)

Resident Alien cards are given for permanent residency status while VISAs are generally given for a specific time frame depending upon the reason the VISA is being issued. Some VISAs are considered more likely to help secure a Resident Alien Card while others are considered temporary. All VISAs are issued with an expiration date. If a client has received an extension on their VISA expiration date, the underwriter may request a copy of their I-94 form showing the new expiration date. The VISA must be valid as of the effective date of the policy.

Additionally, while it is preferred that the applicant has established a physician/patient relationship with a United States physician so that medical records may be obtained if desired by the Underwriter; it is not required provided the applicant does not have a significant health history. In this situation, the application may be written and a Paramedical Exam may be ordered by Underwriting.

Note: If you are submitting a paper application, a Paramedical Exam Disclosure Statement must be taken for applicants that will be required to complete a Paramedical Examination. (Please refer to the Paramedical Examinations section of these Administrative Guidelines)

Undocumented Residents –Paper applications only

Complete the application with applicant following normal paper process and the required steps below:

• Applications must include the mandatory supplemental form
• Indicate the country of citizenship on the supplemental form.
• The Agent/Applicant must provide two forms of valid identification: [A valid, unexpired government-issued identification, one of which must be a passport or national identity card with a photograph; OR one valid unexpired government-issued identification (either a passport or national identity card with a photograph) and one alternate form of communication in the form of a utility bill, tax identification information, etc…]
• “Undoc” should be indicated on the first page of the application to improve cycle time.
If the form and/or the valid identification are not received, processing will be delayed or the application will be rejected.

Please be aware, not all Visa types are acceptable for coverage. If an applicant is rejected for an unacceptable Visa they are not considered undocumented and are not eligible for consideration under the documented or undocumented guidelines.

Additionally, while it is preferred that the applicant has established a physician/patient relationship with a United States physician so that medical records may be obtained if desired by the Underwriter; it is not required provided the applicant does not have a significant health history. In this situation, the application may be written and a Paramedical Exam may be ordered by Underwriting.

Note: If you are submitting a paper application, a Paramedical Exam Disclosure Statement must be taken for applicants that will be required to complete a Paramedical Examination. (Please refer to the Paramedical Examinations section of these Administrative Guidelines)

FLORIDA & OPERATIONAL COUNTY RESIDENCY REQUIREMENTS

For an Insurance Product, the primary applicant’s residence address must be in the State of Florida, and in an operational county for the product for which they are applying, for more than six full months of the year. If the primary applicant is a student, they must attend a college or university in the State of Florida
A dependent may only be considered for coverage as a dependent on a family contract if they are a full or part time student, OR if they reside in the State of Florida.

Benefits may be limited for services rendered outside the state of Florida or the Continental US and it is important to make the applicant aware of this.

Note: If the applicant is not a full or part-time student, please indicate the occupation of the applicant. For dependent children who do not reside with the Primary Applicant, see the Dependent Eligibility Requirements section of these Administrative Guidelines.

SPLIT POLICIES

The Company prefers that all family members be enrolled under one contract. However, to assist applicants in achieving the most appropriate coverage to meet their needs, applications for family members may be split in any manner desired, except same product, same deductible.
• Different products for each family member or different deductibles within the same product for each family member are acceptable. • Separate applications with separate premium payments are required and separate underwriting for each will occur. • The applications will not be linked together and will be processed as they are approved. • Different effective and billing dates are likely.
Note: It is not recommended that split policies be written in a situation where the family is replacing other coverage, as we will not coordinate effective dates nor paid-to-dates between the family members. .

For in-force policies, family members may split off and roll to the same or a higher deductible within the same product without underwriting. Also, in some circumstances, the family member may roll to a different insurance product without underwriting. These change requests are handled through the Enrollment, Membership and Billing Department. If a family member desires a lower deductible or richer product, a plan change application and underwriting is required. (See Changes To An Existing Contract section of these Administrative Guidelines)

DEPENDENT ELIGIBILITY REQUIREMENTS

Eligible dependents are a spouse/domestic partner, unmarried natural child(ren), adopted child(ren) or stepchild(ren).

Spouse/Domestic Partner

Applicants that are legally married can include their spouse as an eligible dependent for all products. Applicants applying for Blue Options can include their domestic partner as an eligible dependent. (See Domestic Partners Guidelines section of these Administrative Guidelines). If the spouse’s last name is different from the primary applicant, note the reason why they are different in the Agent Notes/Remarks section of the application.

Children

Children up to age 30 may be covered if they are a Florida resident or a full or part-time student attending an accredited college or university.

Dependent children are medically assessed for the Under 65 Medically Underwritten products the same as adult applicants. It is impossible to determine a newborn child’s insurability for coverage when they have not yet established a relationship with a Pediatrician/Physician. Therefore, dependent children, under 6 weeks of age and who have not had their first Well Child examination after release from the hospital, cannot be considered for coverage on a family application. If existing coverage is available, the parent(s) should be encouraged to add the newborn child to the current contract until the child is eligible for the Under 65 Medically Underwritten products. Keep in mind; the majority of contracts include a provision to add newborn children, without evidence of insurability, if enrolled within a specified time period (generally 30 to 60 days).

A Child(ren) applying as a dependent, but who does not reside with the applicant on a primary basis, must still be a resident of the state of Florida and live in an operational county for the product for which they are applying, for more than six full months of the year or a full or part-time student attending an accredited college or university. The zip code of the child’s residential address must be noted in the appropriate section of the application if different from the primary applicant. These children should be identified in the Agent Notes/Remarks section of the application. If a minor child under the age of 19, it should also be noted whom they reside with, why they reside there and how familiar the primary applicant is with the child’s health history. The parent with whom the minor child resides must be interviewed for answers to all questions. Indicate the name, relationship and date of interview in the Agent Notes/Remarks section of the application.

Electronic or IST application: All applicants 18 and older must be present to validate the information provided on the application and e-sign the application. Note: For telephonic applications, the applicant may e-sign using a link sent via email.

Paper Application: All applicants 18 and older must be present to validate the information provided in the application and sign the medical authorization.

The following applies to the Insurance Products only:

Foster child(ren) or child(ren) in court ordered custody or legal guardianship of the primary applicant may be covered to the end of the calendar year in which they reach the age of 18 as a dependent. .
Electronic or IST Applications (includes telephonic): A copy of the court ordered custody document must be submitted as an attachment with the application using attachment type “Guardianship/Custody Papers”.
Paper Applications: A copy of the court ordered custody document must be submitted with the application.

The following applies to the HMO product only:

The HMO product does not consider foster children or children in a court ordered custody or legal guardianship arrangement as eligible dependents on a family contract.

All Products: Qualified Dependents of Domestic Partner. (See Domestic Partner Guidelines of these Administrative Guidelines)

The following requirements are necessary in order to qualify as a dependent Domestic Partner:

1. Both individuals are each other’s sole Domestic Partner and intend to remain so indefinitely; and
2. Individuals are not related by blood to a degree of closeness (example, siblings) that would prohibit legal marriage in the State of Florida; and
3. Both individuals are unmarried, at least 18 years of age, and are mentally competent to consent to the Domestic Partnership; and
4. Both individuals are financially interdependent and have resided together continuously in the same residence prior to applying for coverage under the Contract and intend to continue to reside together indefinitely.
Please ensure that the above criteria and eligibility is met prior to the completion of a Domestic Partner application. If needed, the applicant may be required to provide proof of eligibility during the underwriting process.

If a dependent Domestic Partner’s children are to be covered as well, the following criteria and eligibility requirements must be met:

The child(ren) must meet and continue to meet eligibility requirements as outlined in the Dependents Eligibility Class and Extension of Eligibility for certain Dependent Children subsections of the contract and one of the following must apply.

1. The above listed child(ren) resides with the couple and the Domestic Partner is responsible for the child(ren)’s well being; or
2. The Domestic Partner is required to provide coverage for the child(ren) by court order; or
3. The child(ren) qualifies as the Domestic Partner’s dependent(s) for tax purposes under the federal guidelines.
The parent must also apply and be approved on the same contract (as primary or dependent); otherwise the child(ren) must be written as separate child only-applicants.
If the parent is declined, the child(ren) is no longer eligible and must apply on a child only application(s). Proof of dependent child(ren) eligibility may be requested during the underwriting process.

DOMESTIC PARTNER GUIDELINES

CHILD ONLY APPLICATION

(A MINOR CHILD APPLYING AS THE APPLICANT)

1. A minor child at 1 year of age or older for BlueChoice and BlueOptions; or 3 years of age or older for DIV, Essential or BlueCare may be considered for coverage as the Applicant. It is unacceptable to submit a Child Only application for a child under 1 year of age for BlueChoice and BlueOptions or under 3 years of age for DIV, Essential or BlueCare. 1
2. A Child-Only application should not be completed for a dependent child 18 years or older, as this applicant is considered a legal adult and must sign his or her own application.
3. When an application is taken on more than one minor child from the same family, separate applications should be taken on each child applying for coverage.

4. The parent or legal guardian must be interviewed for answers to all questions on the application. When a child does not reside with the parent applying for the coverage, the parent or legal guardian with whom the minor child resides must be interviewed to verify answers to all medical history questions. Indicate the name and relationship of the interviewee, and date of the interview in the Agent Notes/Remarks section of the application.
5. The parent or legal guardian must sign or e-sign the application. If the child resides with a legal guardian, a copy of the court order naming the guardian must be submitted at the same time as the paper application. For electronic applications the court order must attached as a document at the same time the electronic application is submitted. Also, include a statement explaining why the child does not reside with the natural parents in the Agent Notes/Remarks section of the application.

Children should have an established pediatrician whereby they have received immunizations and well child exams. This, and all other health history, should be noted on the application for each child applying for coverage. Blank applications on children are not acceptable.

1 Child Only minimum age reduced to age 3 for Insurance and HMO applications signed 6-15-01 and later.
Child Only minimum age reduced to age 1 for BlueOptions and BlueChoice effective February 1, 2006.
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SMALL GROUP REFORM IMPACT ON INDIVIDUAL HEALTH COVERAGE

Florida Senate Bill 1914 was enacted in 1993 and governs the participation of a small business owner (employees 1-50) in the contribution of premium payment and administrative support for the payment of premiums for an individual’s non-group health coverage. This legislation stipulates that:

1. A small business owner (employees 1-50) cannot contribute to an individual employee’s individual medical contract, and 2. A small business owner (employees 1-50) cannot provide administrative support for the billing of an employee’s individual medical contract and if coverage is approved, all premium billing will be sent to the primary contract holder. The exception to this is a List Billing arrangement enacted by Florida legislation in 2005 (HB 811).
Note: A Premium Validation Statement is required for paper applications.

REPLACEMENT OF EXISTING INSURANCE

STATUTORY OBLIGATIONS AFFECTING THE INSURANCE PRODUCTS ONLY:
The State of Florida defines Replacement of Accident or Sickness insurance as coverage that is permanent and the applicant is forfeiting their available benefits. It is not considered replacement of Accident or Sickness insurance, under the statutory language, when prior coverage benefits are no longer available to the insured (example reaching limiting age, exhaustion of COBRA benefits, or coverage that is temporary or short-term that is not considered creditable coverage).

To further meet the State of Florida statutory requirements, the application contains the state-required language. This section of the application was also developed to meet the underwriting needs for any case in which prior coverage is proposed to be replaced (even if not defined under the State of Florida definition of replacement). Therefore, in any possible replacement situation, the agent is to complete this section of the application.

Note: A Replacement or Existing Insurance Form is required for paper applications.

Insurance and HMO products:
If other insurance is to be given up, it is extremely important that the applicant understand the full significance of this action. Replacement of existing coverage should be considered only when it is in the best interest of the applicant. The applicant should be advised to take advantage of any benefits they may be eligible for under COBRA, Conversion or the HIPAA/IPAA statutes.

Please inform the applicant it can take up to 60 days for an underwriting decision to be made. The applicant should be advised not to lapse existing coverage that can be continued before the Blue Cross and Blue Shield of Florida or Health Options contract is issued or an offer is made.

If an applicant is replacing Blue Cross and Blue Shield coverage from another state, it is important that the agent make clear to the applicant that Blue Cross and Blue Shield of Florida and Health Options are different entities from their current Blue Cross and Blue Shield Plan.

Please emphasize to the applicant:
• That they are applying for a medically underwritten product that is not a conversion or COBRA product. • That they are not applying for coverage available due to the HIPAA/IPAA legislation. • That they are not applying for guaranteed issued coverage. • That the product for which they are applying is medically underwritten. This means there are no statutory limitations that preclude the Individual Medical Underwriting Department from imposing Exclusionary Riders and/or Rate Modifications, and/or excluding a member on a family application, or declining the entire application on our individual underwritten products.
IMPORTANT It is the agent’s responsibility to notify the Individual Medical Underwriting Department, if the applicant makes a premium payment on their current coverage while their application is in the underwriting process. The agent’s notification should indicate the new paid to date of the current coverage so that the effective date for the proposed coverage will be advanced accordingly, upon issue, provided this date is not more than 90 days from the application date.

Requests for effective date changes will not be approved once the contract has been issued. For additional information see the Portability section of these Administrative Guidelines. If replacing Blue Cross Blue Shield of Florida or Health Options coverage, refer to Replacement of Blue Cross Blue Shield of Florida/Health Options Group Coverage section of these Administrative Guidelines.

Conversion and Guarantee Issue (GI) policies are also available. These policies have specific eligibility requirements, which must be met. They are solely written by the Direct Sales Center agent. Applicants interested in these products of insurance should be advised to contact the Direct Sales Center at 1-800-876-2227.

REPLACEMENT OF BLUE CROSS BLUE SHIELD OF FLORIDA/HEALTH OPTIONS GROUP COVERAGE

An individual application may be written on a BCBSF group eligible employee that was either never enrolled or who has cancelled off of their BCBSF group contract (example the individual is eligible for the BCBSF group coverage but chooses not to be covered). This does not permit the writing of an individual application on an employee who is presently covered under a BCBSF group plan unless their employment has terminated with the employer and the group coverage will cancel within the next billing period.
If BCBSF or HOI group coverage is active and the employee is applying for the individual product due to anticipated termination of employment within the next 60 days, a letter from their employer indicating the anticipated termination date must be faxed to your team faxination number at the time of application. If terminating employment due to a job change, the applicant’s new date of hire and place of employment, as well as, occupational duties must be furnished in the Agent Notes/Remarks section of the application. (See Ineligible Occupations section of these Administrative Guidelines.)

Please be aware that BCBSF cannot, due to system limitations, issue an individual product if the BCBSF/HOI group coverage or COBRA is active on our membership system, even when the client knows that their group coverage is no longer in force. This pertains to all individual policies including Temporary Insurance Protection (TIP), BlueOptions, BlueChoice, Dimension IV, Essential & BlueCare coverage.

Group coverage cancellation can only be accomplished by the applicant’s previous employer who must notify their Group Personal Service Representative (PSR) in the BCBSF/HOI Group Membership & Billing Department.

If the applicant is covered under COBRA coverage, the cancellation is handled through both the COBRA administrator and previous employer. To expedite the processing of the cancellation, the applicant must notify their COBRA administrator.

Please keep in mind that unlike group coverage, these are medically underwritten products with no guarantee of issuance. If current coverage can be continued, the applicant should not be instructed to cancel any prior coverage. The Individual Medical Underwriter will advise when a final decision has been made so that the writing agent can instruct the applicant of the cancellation process for the BCBSF/HOI Group coverage.

PORTABILITY OF PRE-EXISTING CREDIT

This section applies to the Insurance Products only.

Senate Bill 910, Portability of Insurance, passed by the Florida Legislature, became effective October 1, 1996. This Senate Bill only applies to the insurance products. This statute does not apply to persons who are enrolling into an HMO product. This statute requires that credit of or toward the contractual 24-month pre-existing period be given if the benefits of the prior coverage were similar to or exceeded the benefits of the new coverage. This coverage is considered to be creditable if no more than 62 days have passed from the termination date of the prior coverage to the effective date of the proposed insurance product.

In order to comply with this statute, all applicable Certificate(s) of Creditable Coverage must be faxed to your team faxination number at the time the application is submitted. In some instances, the Certificate of Creditable Coverage may not be available. In these situations, the prior health insurance information should be added to the replacement of existing insurance section of the application. Credit of or toward the 24 months pre-existing limitation clause will not be given if the appropriate proof of creditable coverage is not submitted with the underwritten insurance product application. Be sure that either a Certificate of Creditable Coverage is submitted or all coverage is noted appropriately for all prior creditable coverage up to 24 months.

Note: If a paper application is submitted, a Prior Concurrent Coverage affidavit is required.

Please bear in mind that Senate Bill 910 only requires that insurers give credit for prior creditable coverage, upon issue. This statute does not:

• limit BCBSF’s ability to impose Medical Exclusionary Riders or Rate Modifications on our individual insurance products.
• limit BCBSF’s ability to exclude a member on a family application or to decline the entire application.
• limit BCBSF’s ability to medically underwrite individual product applications.

The process of tele-interviewing has become an industry standard and has been incorporated into BCBSF underwriting practices. Calls may be made to the applicant(s) during the underwriting process for medical history details where medical records are not initially deemed necessary. Tele-interviewing has proven to reduce cycle-time by reducing Attending Physician Statement (APS) ordering rate, reduce requests for information from the agent, improve agent satisfaction, resolve data discrepancies, elicit undisclosed health history and verify application information.

Tele-interviews are conducted by nurses and physicians using medical history scripts approved by BCBSF. Claims history and prescription medication usage may be questioned during the interview. Occasionally, 3-way calls are made to the consumers’ physician to obtain additional medical history, laboratory or test results.

Agents should not call the vendor for the status of a file.

If a member calls regarding a contact number for tele-interview completion, the phone number is 1-866-317-6610. If the applicant refuses to complete the tele-interview, or if the tele-interview is not completed within 45 days, the application will be declined.

You may submit a new application after the declination for an incomplete tele-interview if the applicant desires coverage. Applicant needs to be advised a tele-interview will be ordered and applicant must be willing to complete the tele-interview.

TELE-INTERVIEWS PARAMEDICAL EXAMINATIONS

A Paramedical Examination, when determined to be necessary, will be ordered by the Individual Medical Underwriter at no expense to the applicant. The examination will include check of height, weight, blood pressure and pulse. In addition to routine urine and fasting blood testing, testing for nicotine, cocaine, pregnancy, hepatitis, and HIV will be done. Blood will not be drawn on children under age 12. The examination will also include completion of a medical history questionnaire.

For Insurance Products:

If an applicant is applying for an underwritten insurance product and has not had a complete physical examination within the past two years and does not have a patient/physician relationship with a medical doctor, a paramedical examination may be required.

For HMO Product:

A current paramedical examination is required for each applicant age 18 and older when applying for the HMO product. However, at the Underwriter’s discretion, medical records may be ordered prior to scheduling a paramedical examination. Additionally, at the Underwriter’s discretion, a paramedical examination may be ordered for children under the age of 18.

For Insurance and HMO Products:

Although a paramedical examination may be ordered, this should not be used as a substitute for acquiring and recording the applicant’s past and present health history on the application. BCBSF continues to rely on the agent to carefully select risks and to supply the facts needed for assessment of the applicants properly, fairly and quickly. If an applicant has a patient/physician relationship with a past or existing health history, the information should be included in medical history section of the application. If significant health history is noted on a paramedical examination that was not disclosed in the medical history section of the application, rejection of the entire application could result

PARAMEDICAL EXAMINATIONS CONTINUED

A Paramedical Examination Disclosure Statement was designed to aid the writing agent in informing applicants that Individual Medical Underwriting may require a paramedical examination. It provides the applicant with details that explain why the paramedical examination is necessary and tells the applicant what type of testing will be done. The agent should explain the examination process to the applicant(s) prior to having them sign or e-sign the application.

Note: The Paramedical Examination Disclosure Statement is part of the electronic or IST Application (includes telephonic applications), however, when utilizing a paper application this form is a separate document.

When taking an underwritten application for an applicant that appears will require a Paramedical Examination, the writing agent is responsible for:

1. Explaining to the applicant(s) that a paramedical examination may be ordered and what the paramedical examination includes.
2. Explaining to the applicant that they may be contacted by the paramedical examination service, within the next week or so, to schedule the examination, providing that the Individual Medical Underwriter does not order medical records first.
3. Explaining to the applicant that they will need to fast for a minimum of 4 hours prior to the scheduled paramedical examination.

PARAMEDICAL EXAMINATIONS CONTINUED

The following information will outline what happens after the Underwriter reviews the application and determines that a paramedical examination is necessary.

The Individual Medical Underwriter will contact the paramedical examination service.
The branch office located closest to the applicant’s home will be assigned the request. An examiner will contact the applicant(s) to schedule an appointment for the examination(s), the urine specimen and the blood sample. Applicant(s) must have the examination performed in the State of Florida and preferably in the county where they reside. If examinations need to be done in another county, please provide where and why in the Agent Notes/Remarks section of the application. If, due to travel plans, the applicant will be unavailable for a paramedical examination, the agent should postpone taking the application until their return.
The paramedical examination service will send the examination results to the Individual Medical Underwriting Department. The blood and urine sample(s) will be sent to the laboratory service for analysis.
The laboratory service will then send the blood and urine results to the Individual Medical Underwriting Department for review.
The examination and laboratory results are generally received in the Individual Medical Underwriting Department within 7 to 10 days from the examination date.
The agent will be able to receive status information via accessBlue. It will indicate when the examination and laboratory work were ordered and when the examination and laboratory results were received in the Individual Medical Underwriting Department.
It is advantageous for the paramedical examination(s) to be scheduled and completed as quickly as possible. However, should the paramedical service report difficulties in scheduling the required examination, the Individual Medical Underwriter will notify the writing agency and request the agent’s assistance.

If the applicant refuses to complete the examination, or if the examination is not completed within the usual underwriting time period, the application will be declined.

Agents can view the status of vendor requests, such as requests for medical records or paramedical examinations via accessBlue.

It is important that the agent inform the applicant there is no coverage between the application date and the effective date of the contract, if approved. In addition, any change in the applicant’s health history, after completion of the application, can be used in the underwriting assessment.

When the application has been completed and the initial premium collected, the writing agent is to sign and date the Cash/Conditional receipt. The applicant’s copy of the completed receipt is to be given to the applicant at the time the premium is collected.

CASH receipt:

1. It is required that two months’ initial premium be collected.
2. However, if the applicant chooses to pay their subsequent premiums via the Automatic Payment Option (APO), form 9499, only one month’s premium is required at the time of application. The completed APO form and voided check is required at the time the application is submitted to Individual Medical Underwriting.
3. In replacement of existing coverage situation, if coverage is approved, the effective date of the contract will be coordinated with prior coverage termination/paid to date providing it is not prior to the application date and no more than 90 days from signature date. If the prior coverage terminated after the signature date and prior to issue, the effective date will be the date final action is taken by underwriting. The Underwriter will verify the current paid to date of the replacement coverage at the time of final action. Therefore, effective date changes will not be granted once the contract is issued
4. In a non-replacement situation, if coverage is approved, the effective date of coverage will be assigned by the Individual Medical Underwriter and will be the first available billing date (1st, 8th, 15th, 23rd), which occurs after the date of final Underwriting approval.

CASH RECEIPTS-INSURANCE PRODUCTS (NON HMO) PAPER APPLICATIONS ONLY

CONDITIONAL receipt:

1. It is required that two months’ initial premium be collected.
2. In replacement of existing coverage situation, if coverage is approved, the effective date of the contract will be coordinated with prior coverage termination/paid to date providing it is not prior to the application date.
3. In a non-replacement situation, if coverage is approved, the effective date of coverage will be the date the application is signed.
4. The effective date cannot be more than 90 days from the signature date.

5. The Underwriter will verify the current paid to date of the replacement coverage at the time of final action. Therefore, effective date changes will not be granted once the contract is issued.

CONDITIONAL RECEIPTS-INSURANCE PRODUCTS (NON HMO) PAPER APPLICATIONS ONLY

CASH RECEIPTS-HMO PAPER APPLICATIONS ONLY

THE FOLLOWING APPLIES TO THE HMO PRODUCT ONLY:

The only available receipt for the HMO product is the HMO CASH RECEIPT-Paper Applications Only.

It is important that the agent inform the applicant that there is no coverage between the application date and the effective date of the HOI contract, if approved. And, any change in the applicant’s health history, after completion of the application, can be used in the underwriting assessment.

When the application has been completed and the initial premium collected, the writing agent is to sign and date the HMO Cash receipt. The applicant’s copy of the completed receipt is to be given to the applicant at the time the premium is collected.

The HMO CASH receipt:
1. It is required that two months’ initial premium be collected.
2. However, if the applicant chooses to pay their subsequent premiums via the Automatic Payment Option (APO), form 9499, only one month’s premium is required at the time of application. The completed APO form and voided check is required at the time the application is submitted to Individual Medical Underwriting.
3. In a non-replacement situation, if coverage is approved, the effective date of coverage will be assigned by the Individual Medical Underwriter and will be the first available billing date (1st, 8th, 15th, 23rd) following the required confirmation period*, which occurs after the date of final Underwriting approval.
4. In replacement of existing coverage situation, if coverage is approved, the effective date of the contract will be coordinated with the prior coverage paid-to-date providing the paid-to-date is at least 10 days in the future*.
5. There is no coverage between the application date and the effective date of the contract.
6. Effective date changes will not be granted once the contract is issued.
*Florida Statute requires that a seven-day confirmation period for all approved underwritten HMO policies be provided. This allows the consumer to confirm their desire to enroll in the HMO product. The HMO product does NOT carry a 10-day free look. The confirmation requirement will advance the effective date by 10 days.

(See also REPLACEMENT OF EXISTING INSURANCE section of these Administrative Guidelines.)

When completing an electronic or IST application (includes telephonic applications) if not replacing the applicant may choose between the underwriter selecting the effective date once underwriting is complete, or choosing the effective date from one of the available billing dates (1st, 8th, 15th, 23rd). If replacing coverage as of the application signature date, the effective date is always coordinated with the termination date of the prior coverage.

It is important that the client understands that there is no coverage between the application date and the effective date. Any change in their health history prior to their effective date can be used in determining their eligibility.

The Effective Date is applied using the following guidelines:

In a non-replacement situation, the effective date must be a billing date (1st, 8th, 15th or 23rd). The applicant may select an effective date, however, the date must be within 45 days of the application signature date. If the applicant allows BCBSFL to select the effective date, BCBSFL will assign the effective date no greater than 45 days from the application signature date.

If replacement, the effective date must be within 90 days of the application signature date.

In a replacement of existing coverage situation, the effective date will be coordinated with the “paid to“ date or termination date of prior coverage provided that date is not before application date and within 90 days.

Under no circumstances can the effective date be prior to the application date.

ELECTRONIC OR IST APPLICATION EFFECTIVE DATE ASSIGNMENT OVERVIEW
ELECTRONIC OR IST APPLICATION EFFECTIVE DATE ASSIGNMENT FOR ALL PRODUCTS-EXCLUDING HMO

Agent will collect binder information in the electronic or IST application. Upon approval of the application, monies will be collected. Below is further detail on the process based on the payment type:

Credit Card
Agent enters credit card information in IST. CBPP performs basic validation procedures:

IF Valid: Application goes to Siebel and Underwriting.
IF Invalid: Error message appears and app cannot be submitted.

If application is approved, CBPP begins process to collect monies and application is sent to EM&B for enrollment.

Any questions or concerns regarding payments/money after the application has been submitted for enrollment needs to be directed to ASC.

ANSWERS TO FREQUENTLY ASKED QUESTIONS BROCHURES

The Answers to Frequently Asked Questions brochures were designed to be reference material for the applicant after the application has been completed. Therefore, at the point the sale has been closed and the application completed, the applicant should be provided with the appropriate Q & A brochure, depending upon the product selected. The information provided in these brochures should be discussed with the applicant.

These brochures were not designed to replace the role of the agent in explaining or assisting with the medical underwriting and enrollment processes.

For Insurance Products:
Form 18388 has been provided for the underwritten insurance products.

For the HMO Product:
Form 18143 has been provided for the underwritten HMO product.
CHARGE UPON APPROVAL
ELECTRONIC APPLICATIONS ONLY

ADDITIONAL UNDERWRITING INFORMATION AFTER SUBMISSION OF THE APPLICATION

After submission of an application and prior to contract placement, if the writing agent learns of information that should have been recorded on a pending application but was not recorded, he/she should contact the Individual Medical Underwriting Manager immediately.

The Individual Medical Underwriting Manager should also be immediately contacted if the writing agent learns of a claim, treatment, or change of health history after the application was taken and prior to placement of the contract.

Complete details should be provided which should include, but are not limited to:

1. Date of first symptom.
2. Diagnosis.
3. Type of treatment received.
4. Full name and address of provider first consulted.

RATE MODIFICATIONS

The Individual Insurance and HMO products are marketed with the objective of providing broad health care coverage to as many applicants as possible. However, firm guidelines must be followed in order to make these superior health care plans available on an individual basis with reasonable premium levels. Therefore, every application for the Under 65 Individual Medically Underwritten Products (BlueOptions, BlueChoice, BlueCare, DIV and Essential) is carefully reviewed by the Individual Medical Underwriter.

Blue Cross Blue Shield of Florida has developed flexibility for our customers when choosing a health plan through the utilization of medical exclusionary riders and/or product ratings when underwriting an individual application. Riders and/or ratings create coverage/premium options to members with specific health related conditions.

The majority of applicants and their dependents will qualify for coverage at standard rates. However, when an individual does not qualify for coverage at the standard rate, a counter offer of coverage may be made offering the coverage at a higher premium rate. The offer of coverage with a Rate Modification applies to all of the Individual Underwritten products (HMO and Insurance). In some instances it may be necessary to impose a rate modification and a medical exclusion rider for the same condition if maintenance prescription drugs are being taken.

At the present time, there are four substandard risk ratings (SRR) approved for the individual underwritten products:

• SRR I equates to 25% additional premium • SRR II equates to 50% additional premium • SRRIII equates to 75% additional premium • SRRIV equates to 100% additional premium
The Individual Medical Underwriter will make the final determination of the amount of the rating imposed after a comprehensive review of the application and any requested medical records, tele-interviews and/or paramedical examination.

RATE MODIFICATIONS CONTINUED

ISSUE PROCESS – CONTRACTS ISSUED WITH A RATE MODIFICATION:

Advance notice will be sent to the Agent when a rate modification is applied. This notification is sent via the Message Center for electronic or IST applications (includes telephonic applications) and fax for paper applications.

1. At the time of the Underwriting final decision, an advance notice will be sent to the writing agent advising of the Rate Modification and the reason for this action.
2. The issued contract will be endorsed with the Rate Modification, which also indicates the condition requiring the additional premium rating. Also, additional details are provided for the applicant in the document titled: “An Important Notice Regarding Your Health Insurance Policy”, which is included in the issue package.
3. The agent should explain the reason for the Rate Modification(s) and that the additional premium charge(s) is required due to the condition indicated on the Rate Modification endorsement(s). It should also be explained that the rating is a permanent part of the contract. (See Appeals Process and Procedures section of these Administrative Guidelines). It should be emphasized that this action has no effect on the contract benefits.
There is no requirement to return the Rate Modification endorsement(s). Payment of premium as billed indicates the applicant’s acceptance of the counter offer of coverage with the Rate Modification(s).

MEDICAL/MEMBER EXCLUSIONARY RIDER

THIS SECTION APPLIES TO THE UNDERWRITTEN INSURANCE PRODUCTS ONLY

Medical Exclusionary Rider: In some situations, coverage may be offered to an individual with a counter offer of coverage resulting in a condition or body part being excluded from all benefits under the contract. Medical Exclusionary Riders will be used when the nature of the condition(s) indicates the potential for recurrence, treatment, or likelihood of surgery.

Imposing Medical Exclusionary Riders to a contract enables the Company to provide coverage for other than the ridered condition. Generally, coverage will not be offered with more than three Medical Exclusionary Riders imposed on one person. However, coverage offered to a family may include Medical Exclusionary Riders on one or more family members, depending upon each individual’s health history. In some instances it may be necessary to impose a rate modification and a medical exclusionary rider for the same condition.

The agent should explain the reason for the Medical Exclusionary Rider(s). It should be emphasized that the underwriting action is necessary for the pre-existing condition as an alternative to declining the applicant. The agent should also explain how the Medical Exclusionary Rider(s) affects the contract benefits.

The wording used in the Medical Exclusionary Rider is pre-established according to the condition and the potential risks of related conditions. The wording of an exclusionary rider cannot be changed. Requests to change rider wording of the Medical Exclusionary Rider will not be considered. We must be consistent with the action taken on all applicants with similar health histories.

Member Exclusionary Rider: There are situations when a person applying for coverage on a family application is so seriously impaired that it is not possible to issue health coverage to them. In these instances, a family member is declined but coverage is offered to the remaining family members. When this underwriting action is necessary, the contract is issued with a Member Exclusionary Rider (INSURANCE PRODUCTS) or an Exclusionary Rider of Person (HMO PRODUCT).
Note: Member Exclusions are applied when a family member is declined but coverage is offered to the remaining family members. When this underwriting action is necessary, the contract is issued with a Member Exclusionary Rider (INSURANCE PRODUCTS) or an Exclusionary Rider of Person (HMO PRODUCT). (See Member Exclusionary Rider, section of these Administrative Guidelines).

ISSUE PROCESS – CONTRACTS ISSUED WITH MEDICAL/MEMBER EXCLUSIONARY RIDER(s) for Electronic or IST and Paper see below:

Electronic or IST Applications: (Includes Telephonic Applications)
An automated Agent Communications is sent prior to the policy being issued with a Medical and/or Member Exclusionary Rider/Amendment. Below is a summary of the messaging that will be received. A letter and a copy of the Medical and/or Member Exclusionary Rider are sent to the applicant.

• Immediate Automated Agent Communication is sent with Awaiting Signed Rider Status Change Final Action is pending our receipt of the Exclusionary Rider and/or Amendment form(s), which must be signed and dated by the proposed primary Contract Holder. If this document(s) is not received by the due date of this notice the file will be closed and considered refused.

Note: The exclusion rider/amendment and related documents will be attached to the Agent Communication in the Message Center; this will help you in communicating with the applicant. The most efficient method to return a signed rider is through the Message Center via accessBlue. The Agent will be required to print the rider/amendment, have the applicant sign the document, the signed document will need to be scanned and attached in the Message Center. Doc type used for the attachment should be “signed rider”.

Using any other method to submit a rider will significantly delay the processing of the application. Please remember to change the status of the Agent Communication to “responded” when a rider is attached. If the status is not changed to “responded”, the message will continue to appear and follow up messages will be sent. If you are acknowledging a communication and not responding, please do not include attachments. Note: A letter and copies of the rider(s) are also sent to the consumer via U. S. Postal Service.

• Automatic email notification to applicant (utilizing the email address supplied on the application) is sent 5 days after Awaiting Signed Rider Status Change Message: We have previously communicated our underwriting decision regarding your application for health coverage with Blue Cross and Blue Shield of Florida, Inc. Your coverage has been approved contingent upon our receipt of the signed and dated rider/amendment forms. As of this date, these very important documents have not been received within our Home Office and we will soon consider our offer of coverage refused and close our file. If you have not yet mailed the signed and dated rider/amendment forms back to us, please take this time to complete this very important step now. If you have questions about our offer, please contact your writing agent. Thank you for your interest in Blue Cross and Blue Shield of Florida, Inc.

• Past due automated Agent Communication is sent 14 days after original communication (If no Signed Rider Received) This is a PAST DUE REMINDER.
Final Action is pending our receipt the Exclusionary Rider and/or Amendment form(s), which must be signed and dated by the proposed primary Contract Holder. If this document(s) is not received by the due date of this notice the file will be closed and we will consider our offer refused.
Note: If the signed rider is not returned by the due date indicated in the Agent Communication, the application will be refused.

MEDICAL/MEMBER EXCLUSIONARY RIDER CONTINUED

Paper Applications:
1. At the time of the Underwriting final decision, an advance notice will be sent to the writing agent advising of the Medical and/or Member Exclusionary Rider(s) and the reason for this action. 2. The contract package is also mailed and includes a copy of the unsigned rider. The applicant should sign the enclosed rider and return the rider document in a prepaid envelope provided in the contract package. 3. If the signed rider is not returned, a follow up correspondence will be sent to the Agent and the applicant that includes a copy of the signed rider.
Note: If the signed rider is not returned by the due date indicated in the Agent Communication, the application will be considered refused, the policy terminated as the effective date and the initial premium will be refunded.

Medical exclusionary riders/amendments cannot be issued on an HMO agreement. If a medical condition requires a Medical Exclusionary Rider, the applicant will be declined for HMO. The writing agent should refer to the Medical History section of these guidelines when assessing the medical eligibility of the applicant. For additional information, see the Unacceptable Applications section of these Administrative Guidelines.

MEDICAL and/or Member EXCLUSIONARY RIDER CONTINUED

CANCELLATION DUE TO NON-RECEIPT OF APPROPRIATELY SIGNED/DATED RIDER FORM(S)

If the appropriately signed and dated rider form(s) is not received in the Individual Medical Underwriting Department within 10 days, the application offer will be considered refused.

REJECTION OF ENTIRE APPLICATION

There are some health conditions that result in an applicant being so heavily impaired that the issuance of coverage is not possible. If an applicant’s health history and/or condition is indicated as a decline (DEC) in the Medical Histories Guidelines section of this manual, an application for coverage should not be taken.

Due to the complexities of multiple impairments that do not lend themselves to a reliable standardized classification, each applicant’s situation must be separately and individually considered. While the applicant’s condition(s) individually may be ratable or riderable, the combination of the conditions could render the applicant uninsurable for the product for which they applied. Under certain circumstances, an alternative offer may be made. This requires the completion of a paper application.

When an application contains inadequate, understated or incomplete health history, the Underwriter is unable to assess the risk and it becomes questionable whether there is additional undisclosed health history. Applicants and family members with significant health history that was not disclosed on the application may result in the entire application being rejected. A rejection of this nature prevents the applicant and/or family members from applying for any underwritten product for a minimum of one year, even if subsequent details or medical records are submitted for review.

If coverage cannot be issued, a letter is sent to the applicant, with a copy to the agent, explaining the reason for the rejection.

An applicant who has been medically rejected for coverage may not re-apply for one year, unless otherwise indicated in the Agent Advance Notification. Please refer to the Appeals Process and Procedures section of these Administrative Guidelines.

Note: If there is no significant change in the applicant’s health history and the condition is indicated as DEC in the Medical Histories Guidelines, an application for coverage should not be taken.

APPEALS PROCESS AND PROCEDURES

We realize there are situations that pose challenges for the agent when placing a policy that has been issued on a non-standard basis. An underwriting decision should not be appealed unless additional medical information is submitted from the applicant’s physician. In addition, Appeals cannot be worked until Enrollment is finalized and a signed rider received. However, this does not apply to rejections due to significant undisclosed health history, in which reconsideration cannot be given for 12 months. Please remember that the passage of Senate Bill 910, Portability of Insurance, does not affect the ability of the Medical Underwriting Department to impose medical exclusionary riders and/or ratings on coverage or reject individuals applying for individual medically underwritten products of insurance. (Refer to the Inappropriate Appeals section of these Administrative Guidelines.)

This section is provided to guide the agent through the appropriate appeal process.

An appropriate appeal must be submitted in writing and must include:

1. All related additional medical records, and
2. All office notes including physician’s assessment, and
3. All laboratory and test results along with supporting medical documentation for the testing.
4. If an applicant is declined due to multiple conditions, all conditions must be addressed in the appeal information. Appeals from multiple physicians should be submitted at the same time.
5. If an applicant is declined due to symptoms for which a firm cause/diagnosis has not been established, a physician’s assessment to include a final cause/diagnosis and treatment plan is required.
6. The properly signed and dated Medical or Member Exclusionary rider(s) must be received prior to processing any change request for a paper application. (example Effective Date, Rate Removal, Product/Deductible changes etc.).

Medical Rejections Based Upon Paramedical Examination Laboratory Results

In the advance rejection notice, the Individual Medical Underwriter will indicate the laboratory values that are outside the normal clinical range. If the Underwriter indicates these values require a permanent rejection, an appeal of the decision should not be submitted.

APPEALS PROCESS AND PROCEDURES CONTINUED

When further consideration can be given (not a permanent rejection), the following requirements are needed:

1. Repeat normal laboratory results for all laboratory values indicated as outside the normal clinical range.
2. Complete office notes from the physician seen for the repeat laboratory testing.
3. The notes must include the physician’s assessment for the cause of the unacceptable test results.
4. If unacceptable results are determined to be the result of illness, the records should indicate a diagnosis and indication that treatment has been completed, and that the applicant has been released from care.

INAPPROPRIATE APPEALS

A policy should never be placed under the premise that the underwriting action can be changed through the appeal process. Similarly, an applicant that has been declined for coverage should not be given false hope that the rejection action can be overturned.

While the underwriting area is willing to reconsider an action based on a justified appeal; inappropriate appeals are time consuming and result in decreased customer satisfaction. We rely on our agents to effectively control inappropriate appeals.

Examples of inappropriate appeals are:
1. Brief notes from any provider.
2. Corrections to the medical records or appeals based solely on a statement by the applicant or agent without supporting medical documentation.
3. Applicants and family members rejected for significant health history that was not disclosed on the application. A rejection of this nature prevents the applicant and/or family member from applying for any underwritten product for a minimum of one year, even if subsequent medical records are submitted for review.
4. Request to rewrite a medical rejection less than one year from the decision unless otherwise noted on the Advance Rejection Notice.
5. Appeals of an Underwriting decision for which action is clearly noted in the Medical Histories Guidelines section of this manual. If these guidelines indicate a rider, rating or rejection for a specific condition, requests that we not take the action indicated will not be considered. We must be consistent with the action taken on all applicants with similar health histories.
6. Repeat laboratory test results alone, without a physician’s assessment, are not sufficient for appeal review.
7. If the Advanced Rejection Notice indicates a permanent rejection due to medical records reviewed and/or paramedical laboratory results, an appeal of this decision should not be submitted.
8. An appeal requesting a change in the wording used in the Medical Exclusionary Rider. This wording is pre-established according to the condition and the potential risks of related conditions and the Underwriter must be consistent with the action taken on all applicants with similar health histories. The wording of a Medical Exclusionary rider cannot be changed. Requests to change rider wording of the Medical Exclusionary Rider will not be considered.

RATE MODIFICATION AND/OR EXCLUSIONARY RIDER REQUEST FOR REMOVAL TO AN EXISTING, PLACED, CONTRACT

Rate Modifications and Medical Exclusionary Riders are PERMANENT as long as the coverage is kept in-force. However, we may consider removal of a Rate Modification and/or Medical Exclusionary Rider on an individual basis under the following situations:

1. The coverage has been in-force for a minimum of two years, and
2. The Rated and/or Ridered condition is not permanent and no longer exists, and
3. There have been no symptoms or treatment for the condition Rated or Ridered within the previous 24-months (see Note below), and
4. The condition Rated or Ridered does not require periodic medical treatment or evaluation.
5. Ratings for Maintenance Prescription Drugs: As with all Rate Modifications, the rating for maintenance prescription drugs is considered a permanent rating. However, consideration for possible removal of the rating can be given after one year of discontinuation or change of the medication, as recommended by a physician.

NOTE: Certain conditions such as, but not limited to, polyps, ulcer, etc., require a Medical Exclusionary Rider for a minimum of five years. Some Medical Exclusionary Riders and Rate Modifications may be necessary for even longer periods of time or may be permanent. The agent should always refer to the Medical Histories Guidelines section of this manual for time frames on specific conditions.

RATE MODIFICATION AND/OR EXCLUSIONARY RIDER REQUEST FOR REMOVAL TO AN EXISTING, PLACED, CONTRACT CONTINUED

In order for consideration of removal of a Rate Modification and/or Exclusionary Rider, after meeting the requirements in numbers 1-5 on the previous page, the following must occur:

1. The contractholder specifically requests removal of the Rate Modification and/or Exclusionary Rider, in writing, and
2. The written request is accompanied with current medical documentation from the physician familiar with the member’s health status. This medical documentation must include the physician’s office notes and results of any laboratory or other testing performed within the previous 24 months. A brief note from the provider will not be sufficient.
3. The medical records must be furnished at the expense of the Contract Holder.
4. In the case of the Rate Modification due to maintenance prescription drugs, in addition to 1, 2, and 3 above, discontinuation of the medication for a minimum of one year, as recommended by a physician.
Only an Individual Medical Underwriter can approve the removal of any Exclusionary Rider or Rate Modification.

Written notification of the final underwriting decision will be sent to the appropriate person. If an Exclusionary Rider or Rate Modification is removed, the change is generally effective on the current paid to date of the contract.

CHANGES TO AN EXISTING CONTRACT

PLAN or PRODUCT CHANGES (UPGRADES, PRODUCT CHANGES AND ADD-ONs CANNOT BE SUBMITTED ELECTRONICALLY. A PAPER APPLICATION MUST BE TAKEN.

ADDING OR REMOVING THE OPTIONAL MATERNITY BENEFIT

The optional maternity benefit endorsement can be added or deleted without evidence of insurability. Benefits under the maternity benefit are subject to a 10-month waiting period and with an additional premium rate. To add or delete the optional maternity benefit to an existing contract, a written request from the member should be sent to the Under 65 Membership and Billing Department.

NOTE: The Essential Product and BlueOptions Plans 30-41, 70-73 do not offer the optional Maternity Endorsement.

CHANGES TO AN EXISTING CONTRACT CONTINUED

For Insurance Products Only

EFFECTIVE DATE CHANGES IN NON-REPLACEMENT SITUATIONS:

Effective dates are assigned based on the applicant’s choice at the time of application. Requests for effective date changes in a non-replacement situation will not be considered.

For Insurance Products Only

EFFECTIVE DATE CHANGES IN REPLACEMENT SITUATIONS:

It is the agent’s responsibility to inform the Individual Medical Underwriter when the client has paid another premium on their existing contract while the application for BCBSF coverage is in the Underwriting process. It is also the agent’s responsibility to verify the paid to date of the existing contract with the applicant if requested to do so by the Individual Medical Underwriter, prior to policy issue.

The effective date is determined based upon the type application and receipt (paper only) selected at the time of application and the paid to date of the coverage being replaced. Please remember that the only advanced effective date will be the date that coincides with the termination date of the replaced coverage. In any replacement situation, the effective date cannot exceed 90 days from the application date.

In that it is the agent’s responsibility to inform the Individual Medical Underwriter of any change in paid to dates, as well as to verify the paid to date of existing coverage if requested to do so prior to policy issue, a change in a policy effective date should not be necessary. Therefore, requests for effective date changes after issue are not routinely allowed.

CHANGES TO AN EXISTING CONTRACT CONTINUED

For Insurance Products Only

EFFECTIVE DATE CHANGES IN REPLACEMENT SITUATIONS:

While requests for effective date changes after issue are not routinely allowed, we realize there may be situations in which termination of the prior coverage may be out of the member’s control. In these situations, an exception for an effective date change may be considered to coincide with the termination date of the prior coverage. In order to consider an effective date change, as an exception, the agent must provide:

1. A signed and dated statement from the Contract Holder explaining the reason for the requested effective date change, and
2. A Certificate of Creditable Coverage providing the termination date of the prior coverage. If this is not available, a statement from the prior carrier providing the termination date of the replaced coverage will be sufficient.
A request for an effective date change will not be considered if only the following documentation is submitted:

1. Cancelled checks or copies of cancelled checks.
2. Prior coverage billing statements.

For the HMO Product:

During the Underwriting process, at the time of the Underwriter’s final decision and prior to issue, the agent is requested to verify with the applicant the termination date of the previous coverage. It is the agent’s responsibility to verify this information and respond to the Underwriter within the allotted response period.

Requests for effective date changes after the HMO product has been issued will not be honored. The HMO product allows for access to coverage upon the contract effective date. Remember that capitation has been paid to the Primary Care Physician as of the coverage effective date.

CHANGES TO AN EXISTING CONTRACT CONTINUED

This section applies to the Underwritten INSURANCE PRODUCTS only

CHANGE IN SMOKING STATUS

A member who was rated as a smoker (tobacco user) at the time of contract issue may request the non-smoker rate after they have discontinued all tobacco products for a minimum of 12 consecutive months. In order to be considered for the non-smoker rate, the member must not have used any tobacco products or medication for smoking cessation for a period of 12 consecutive months, and they cannot currently be under treatment, or have been treated, for any tobacco related diseases.

A request for the non-smoker rate must be submitted to the Individual Medical Underwriting Department in the following manner:

1. The request must be made in writing by the Insured, and
2. The written request must be accompanied with the results of a negative urine cotinine test (test for nicotine) obtained at the expense of the Insured, and
3. The written request must be accompanied with documentation from the Insured’s physician that the Insured has not smoked or used tobacco products for at least one year.
Upon receipt of the above requirements, and in reviewing this request, claims histories will be utilized, as treatment for any tobacco related diseases (example cancer of the mouth, throat, lungs; emphysema, etc.) will be taken into consideration. Written notification regarding the Underwriter’s decision will be provided to the Insured, as well as the writing agent.

If the non-smoker rate is approved, it will become effective on the contract paid to date after receipt of the request and necessary medical information.

PLEASE REMEMBER: THE NONSMOKER RATE IS NOT APPLICABLE TO THE HMO PRODUCT.

CHANGES TO AN EXISTING CONTRACT CONTINUED

CREDIT OF OR TOWARD THE 24-MONTH PRE-EXISTING PERIOD

This section applies to the Underwritten INSURANCE PRODUCTS only

The credit of or toward the 24-month pre-existing period of the underwritten insurance products is in accordance with Senate Bill 910, Portability of Insurance. Request for consideration for credit of or toward the 24-month pre-existing period must include supporting documentation, for all insured family members, of the prior coverage and the effective date and termination date of this coverage. A Certificate of Creditable coverage is the best form of this documentation.

We recognize that there will be situations where Certificates of Creditable Coverage are not available. In these situations, the required documentation must be submitted on the Prior/Concurrent Coverage Affidavit for all insured family members with full details as indicated on the form. The Prior/Concurrent Coverage Affidavit must be signed and dated by the Contract Holder as well as the writing agent. (paper application only)

Coverage is considered creditable if the prior benefits are similar to, or exceeds the benefits of the BCBSF contract, and there has been no more than a 62-day lapse in coverage. Most TEMPORARY OR SHORT TERM POLICIES ARE NOT CONSIDERED CREDITABLE. A copy of the contract indicating it is creditable must be submitted.

Note: BlueOptions Temporary coverage is considered creditable coverage. Please refer to Other Products of Insurance section of these Administrative Guidelines.

If the coverage replaced does not meet the requirements set forth in Senate Bill 910, credit of or toward the BCBSF 24-month pre-existing period will not be given.

Please keep in mind: Senate Bill 910 is not applicable to the HMO Product. It is inappropriate to request credit of or toward the HMO 24-month pre-existing period and these types of requests should not be submitted.

CHANGES TO AN EXISTING CONTRACT CONTINUED

ADDING A DEPENDENT
Adding a Dependent to an existing contract cannot be submitted on an electronic or IST application (includes telephonic applications). A paper application must be completed.

Dependents to be added to an existing contract are subject to evidence of insurability unless the dependent to be added is a newborn child, less than 60 days old, or an adopted child who is within the 60-day period immediately following the date of adoption.

To add a newborn child who is less than 60 days old or to add an adopted child during the 60-day period immediately following the date of adoption to an existing contract, a Membership Change Request must be completed by the contract holder and submitted to the Under 65 Membership and Billing Department.

Dependents, other than those outlined above, are subject to complete medical underwriting and evidence of insurability. A new application for an add-on dependent should be completed in the following manner:

1. The proper underwritten application must be used. In other words, if the existing contract is the HMO product, the writing agent must use the currently approved application form for this product. If the existing contract is one of the underwritten insurance products, the writing agent must use the currently approved application form for these products.
2. The front of the application should clearly be indicated as “Add-on”.
3. The current adult subscriber/contract holder information should be recorded in Part I: Enrollment Information Questions 1 though 6 of the application.

4. The information for the dependent(s) proposed to be added should be recorded in Part I: Enrollment Information Questions 7 through 11 and Questions 13 through 14 of the application.
5. The Part II: Medical History questions of the application should be completed only for the dependent(s) proposed to be added.
6. The answers to Part III: Supplemental Information of the application should be recorded for the dependent(s) proposed to be added.

CHANGES TO AN EXISTING CONTRACT CONTINUED

Adding a Dependent to an existing contract continued

7. Part IV: Additional Information questions should be answered, signed and dated by the existing adult contract holder.
8. There are two required signature fields in Part V: Authorizations/Acknowledgements section of the application. The existing adult contract holder must sign and date the Cancellation Provision. The date and signature of the existing adult contract holder and spouse, if proposed to be added, are required under the “PLEASE READ AND SIGN THE APPLICATION” language.
9. The For Agent Use Only section should be completed in the usual manner.
10. All appropriate forms (i.e. Premium Validation Statement, Replacement of Existing Insurance form, etc.) must be submitted and must be signed by the add-on dependent proposed to be added. However, if the add-on dependent proposed to be added is a dependent child, all signatures must be that of the current adult subscriber/contract holder.
11. All applicants over the age of 18 must sign the authorization for release of medical records, including dependent children.
12. Collection of premium at the time of application is currently not required for add-on applications.
13. The Home Office will assign the effective date for the add-on applicant, if approved for coverage, and the contract holder’s premium statements will be reflected accordingly.

Examples of Inappropriate Add-On Applications are:

A. An add-on application submitted for a contract that is not in-force.
An add-on application submitted prior to approval of coverage for the primary Contract Holder will be contractually rejected. Once the application on the primary Contract Holder is approved and placed, an add-on application may be submitted (this includes request for product changes currently in underwriting or BAF’s submitted for primary contract holder).

ELECTRONIC OR IST APPLICATION QUICK REFERENCE GUIDE
(Includes Telephonic Applications)

#
Do (√)

Don’t (X)
#
Do (√)

Don’t (X)
1
Application

1.1
Enter all information correctly. Example: SSN, payment information, provider details, Agent comment.
Do not key in erroneous data when completing the application. Example: SSN, Payment information.
1.2
For HSA, select family plan for family and select Individual plan for individuals.
For HSA, do not select family plan for Individual and vice versa.
1.3
Ensure that eligible applicants e-sign electronic or IST application. For Telephonic Applications, the applicant may e-sign using a link sent via email.
Do not e-sign on applicant’s behalf.
2
Underwriter Communication in Message Center of accessBlue

2.1
Respond promptly to communications received from Underwriters.
Do not delay in responding the communications received from Underwriters.
2.2
Scan all signed documents and send through message center in accessBlue.
Do not fax the signed documents.
2.3
When sending in a signed rider through message center: Select document type of “Signed Rider”.
Do not select a document type other than “Signed Rider” when sending signed rider through message center.
2.4
Once all required information is completed and attached, change the status of the communication to “Responded”.
Do not forget to change the status of the communication to “Responded” once all required information is completed and attached. Do not use the status of “Acknowledged”.
2.5
In case of vendor requests: Encourage Applicant to promptly complete the Tele-Interview and/or complete the paramedical examination.
Do not delay a Tele-Interview.
Do not delay a paramedical examination.
Do not delay supporting the request to get medical records.
3
Application Types

3.1
Submit only New Business through Electronic/IST. (Includes Telephonic Applications)
Do not submit requests for upgrades, product changes or add-ons with the electronic or IST application. (Includes Telephonic Applications)

TABLE OF CONTENTS

PAGE

OVERVIEW………………………………………………………………………………………………… 2-4
UNDERWRITING ACTION KEY………………………………………………………….. 4
UNDERWRITING QUESTIONS FOR ALL APPLICANTS …………………………………. 5
ADDITIONAL MEDICAL QUESTIONS – CONDITION SPECIFIC………………………. 6-10
BRAIN OR NERVOUS SYSTEM…………………………………………………………. 6
CARDIOVASCULAR SYSTEM………………………………………………………….… 7
DIGESTIVE SYSTEM………………………………………………………………………… 8
ENDOCRINE SYSTEM ……………………………………………………………………… 8
GENITOURINARY SYSTEM………………………………………………………………. 9
MUSCULOSKELETAL SYSTEM ………………………………………………………… 9
RESPIRATORY SYSTEM…………………………………………………………………… 10
TUMOR……………………………………………………………………………………………. 10
LIST OF MEDICAL CONDITIONS AND PROBABLE UNDERWRITING ACTION…. 11-42
LIST OF UNACCEPTABLE MEDICATIONS….…………………………………….….. 43
HEIGHT AND WEIGHT OVERVIEW ………………………………………………………………. 44-46
HEIGHT AND WEIGHT TABLE……………………………………………………………….…….. 47

MEDICAL HISTORIES GUIDELINES

For Insurance and HMO products:

This Medical Histories section is to be used in the evaluation of medical histories presented by applicants for medically underwritten individual policies. This guide is intended to help the agent determine the usual underwriting action of the Individual Medical Underwriting Department for listed health impairments. It is intended for use as a guide. Only the Individual Medical Underwriting Department has the authority to accept applications, issue coverage, or change any of the underwriting guidelines in this manual.

This guide includes only generally recognizable conditions and is not totally inclusive of all medical conditions since it would otherwise be too lengthy and too technical to be of use. It does not necessarily reflect the ultimate decision of the Individual Medical Underwriter. Each applicant will be considered individually on the basis of all medical and underwriting information. In some situations, the probable final action indicated in this guideline may be subject to review of medical records, such as an Attending Physician Statement or Paramedical Examination obtained by, and at the discretion of the Individual Medical Underwriting Department.

Based on the overall evaluation of a condition; specifically, the severity, duration, any complications, type of treatment, and any related conditions, it may be necessary to impose both a Medical Exclusionary Rider and a Substandard Risk Rating in order to offer coverage. Due to all the variables involved, these situations cannot be indicated in these guidelines. Therefore, this guide should not be interpreted as a guarantee of underwriting action on any specific case.

For the Insurance products only:

The medically underwritten insurance products can be offered in a variety of ways, all of which are dependent upon the applicant’s health history. One way that the medically underwritten insurance product can be offered is on a Standard basis. This offer means that the underwriting decision allows for the applicant to be enrolled into the product with no exclusions, other than those referenced in the contract language. Contracts issued on a Standard basis are subject to the Pre-Existing clause of the contract unless portability of coverage applies. For further information, see Portability in the Administrative Guidelines section of this manual.

The second offer of coverage allows for the issuance of the insurance product with a Medical Exclusionary Rider(s). The Medical Exclusionary Rider excludes coverage for health care services for a specified body part or condition. This action allows us to provide coverage for most of the applicant’s health care needs rather than decline the applicant entirely. This is in addition to any applicable pre-existing period of the contract. Contracts issued with a Medical Exclusionary Rider(s) are subject to the Pre-Existing clause of the contract unless portability of coverage applies. For further information, see Portability in the Administrative Guidelines section of this manual.

The third offer of coverage allows for the issuance of the insurance product with a Rate Modification(s). The Rate Modification does not exclude otherwise covered benefits, as outlined in the contract language. The Rate Modification is used for certain conditions in which a Medical Exclusionary Rider is not appropriate (i.e. elevated or abnormal lipids, elevated blood pressure, build, and etc.). The Rate Modification does not waive any applicable pre-existing period of the contract. Contracts issued with a Rate Modification(s) are subject to the Pre-Existing clause of the contract unless portability of coverage applies. For further information, see Portability in the Administrative Guidelines section of this manual.

The fourth offer of coverage allows for the issuance of the insurance product with both a Medical Exclusionary Rider(s) and a Rate Modification(s). In some situations, the condition or body part excluded by a rider may also require a rating due to the individual’s use of related prescription drugs. While the rider excludes coverage for the health care services provided to treat or care for a specified body part or condition, it does not exclude benefits for the prescription drug(s) taken for the excluded condition or body part. The Rate Modification is used to cover the cost of any applicable maintenance drugs. Contracts issued with a Medical Exclusionary Rider and a Rate Modification(s) are subject to the Pre-Existing clause of the contract unless portability of coverage applies. For further information, see Portability in the Administrative Guidelines section of this manual.

For the HMO product:

The HMO product cannot be issued to an applicant who demonstrated a health history requiring a Medical Exclusionary Rider. This is necessary due to the overall product design that allows access to contract benefits, without restriction, when rendered by a Primary Care Physician (PCP). An HMO application is not to be taken for any individual who has a health history requiring a Medical Exclusionary Rider. This type of applicant is unacceptable for the HMO product. Please refer to the list of medical conditions and probable underwriting action provided in this section when assessing the medical eligibility of the applicant(s).

The HMO product can be issued with a Rate Modification due to health history that may require higher
utilization of medical services. The Rate Modification may also be imposed due to the applicant’s use of maintenance prescription drugs. The Rate Modification does not affect the contractual pre-existing period when benefits are rendered by a Specialist.

For the Insurance and HMO products:

Due to all the variables involved, all situations cannot be indicated in these guidelines. Therefore, this guide should not be interpreted as a guarantee of underwriting action on any specific case. It is not the intent of Blue Cross and Blue Shield of Florida and Health Options to provide coverage to applicants who are progressively ill. The term “complete recovery,” as used in the following guide, presupposes a complete and uneventful restoration of health, uncomplicated by residuals.

The following key to the guide should be used to interpret the abbreviations:

STD Standard – acceptable without limitations.
R Rider – no benefits will be provided for the impairment described in the rider.*
SRR I a Substandard Risk Rating of 25% additional premium.**
SRR II a Substandard Risk Rating of 50% additional premium.**
SRR III a Substandard Risk Rating of 75% additional premium.**
SRR IV a Substandard Risk Rating of 100% additional premium.**
DEC Decline – no coverage can be offered.
IC Individual Consideration will be given for the listed impairment. This consideration involves obtaining additional underwriting information before a final decision can be made by the Underwriter.
UFC Underwrite for Cause.

During the process of completing Part II: Medical History questions of the application, the agent should refer to this Medical Histories section. If the applicant has a medical history that would result in a Medical Exclusionary Rider or Rate Modification, the underwriting action should be discussed with the applicant during the interview process. If the condition indicates a DEC, an application should not be taken.

FOR THE PURPOSES OF THIS SECTION OF THE MANUAL, “HMO” REFERS TO BLUECARE. “MAJOR MED” REFERS TO BLUEOPTIONS, STANDARD & LOW COST PLANS, BLUECHOICE AND DIV. “HOSP & SURG” REFERS TO BLUEOPTIONS HOSPITAL & SURGICAL AND ESSENTIAL PRODUCTS. “BO RC” REFERS TO BLUEOPTIONS ROUTINE CARE PRODUCTS.

* * Note: No more than two (2) Medical Exclusionary Riders can be imposed per person. If the medical history
requires three or more Medical Exclusionary Riders, final action will result in declination of coverage. Medical
Exclusionary Riders apply to the Insurance products only.

** ** Note: Substandard Risk Ratings apply to the Insurance and the HMO products.

UNDERWRITING INFORMATION

UNDERWRITING QUESTIONS

The most important step in the underwriting process is accurate and detailed answers to all questions on the application, especially the Part II: Medical History questions. The following will help you to provide the necessary information. Always include this information where there is a “yes” answer to a medical history question.

FOR ALL HISTORIES – Always include complete name (first and last), address, zip code, and telephone number of the attending physician (and specialty, if known).

⇒ When was a doctor last seen? Provide dates (month and year) and reason for the office visit.
⇒ What tests were done? Provide date and test results.
⇒ What did the doctor call the ailment or disorder?
⇒ Was medication prescribed? If yes, the name of the medication and dosage. (This can
usually be obtained from the prescription bottle.)
⇒ Is medication still being taken? If not – when stopped?
⇒ Are there still symptoms or episodes? How often? Include dates.
⇒ Is there any residual impairment?
⇒ Were any other doctors seen? If yes, repeat the questions.

ADDITIONAL MEDICAL QUESTIONS

Use these questions in addition to the usual questions to provide further underwriting information.

BRAIN OR NERVOUS SYSTEM

Epilepsy, Seizures or Fainting Spells

1. Describe type of seizure, name of epilepsy, or fainting spells.
2. What were the dates of first episode and last episode?
3. How often do symptoms occur? Give dates.
4. What studies have been done? Give dates and results.
5. How treated? Give name and dosage of medication. Give date physician last seen.
6. Give name(s) of all physician(s) seen, specialty and date last seen.

Mental and Emotional Histories Including Anxiety, Depression and Any Form of Counseling

1. Give full name of diagnosis, if known.
2. How was condition treated and by whom? Any hospitalization? When, where and how long?
3. Was counseling received? Provide date of first and last visit and frequency of visits.
4. Have they been released from care?
5. What medications were taken? Give name(s) and dosage. Is any medication taken currently? Give name(s) and dosage. When was medication discontinued?
6. Was there any disability or restrictions of activities? Provide details.
7. Give name(s) of all physician(s) seen, specialty and date last seen.

CARDIOVASCULAR SYSTEM

Blood Pressure

Note: If blood pressure is controlled with medication, applicant must have consulted attending physician within the past 12 months. A prescription will usually not be re-filled without ongoing monitoring.

1. What is date of last evaluation?
2. Is medication taken? Give name and dosage. When was medication first prescribed (month and year)?
3. How often is blood pressure checked and by whom?

Chest Pain

1. Give dates of episodes.
2. What was the cause and/or final diagnosis? (If cause or final diagnosis not determined, an application should not be submitted.)
3. Dates of any ECG (EKG), Stress Test and Echocardiogram and the results. Include all follow-up testing.
4. What other studies were done and what were the results of each?
5. Has applicant been hospitalized? (Place, date, Name of Physician in charge.)
6. What is the current treatment, including medications? Provide name and dosage.
7. Are activities restricted?
8. Give name(s) of all physician(s) seen, specialty and date last seen.

Heart Murmur

1. When was murmur diagnosed?
2. Name type of murmur, location, and grade if known.
3. How was it diagnosed? What tests were done and dates?
4. Name of Physician that did the test and name of Physician that checked it most recently. Give date(s).
5. Are there any restrictions of activities?

DIGESTIVE SYSTEM

Stomach, Intestine, Colon

1. Give diagnosis.
2. Was a biopsy or culture done? If so, provide results.
3. Was it treated? Type of treatment? Date of last symptoms?
4. When was medication last taken? Give name and dosage.
5. Was there any bleeding? Was transfusion required?
6. Was any hospitalization required? When and for how many days?
7. Was any surgery performed? Give type, reason and dates.
8. Was any follow-up testing performed? If so, give type of test, dates and results.
9. Give name(s) of all physician(s) seen, specialty and date last seen.

ENDOCRINE SYSTEM

Hypoglycemia

Note: Diabetes, Glucose Intolerance, Hyperglycemia, or a Sugar Disorder are uninsurable
conditions.

1. When was Hypoglycemia first diagnosed?
2. Is it controlled by diet?
3. What was the date and result of the latest blood sugar test? Was it done after fasting?
4. Give name(s) of all physician(s) seen, specialty and date last seen.

Thyroid

1. Is applicant hyperthyroid (overactive) or hypothyroid (underactive)?
2. Are nodules present?
3. Is a goiter present or has one been diagnosed?
4. How was condition treated? Medication or surgery? Give dates.
5. What medication is taken? Give name and dosage.
6. What symptoms did applicant have?
7. Give name(s) of all physician(s) seen, specialty and date last seen.

GENITOURINARY SYSTEM

Kidney, Bladder or Urinary Tract Disorders

1. What was the diagnosis?
2. How many episodes have occurred? Give dates.
3. What tests were done and what were the results?
4. How was disorder treated? Give name of any medication(s) and dosage.
5. Is applicant still taking medication? Give name and dosage.
6. If a kidney stone (urinary stone) was diagnosed is it present, was it passed or removed? How was it removed? Also, give number of occurrences.
7. Give name(s) of all physician(s) seen, specialty and date last seen.

MUSCULOSKELETAL SYSTEM

Arthritis

1. Give type of arthritis (rheumatoid, osteo, gouty, etc.)
2. Indicate location or joint involved.
3. What was the date of most recent arthritic episode?
4. What activities are restricted and how often? How disabling is it?
5. Type treatment received? (physical therapy, chiropractic manipulations, or massage)
6. If medication taken, provide name(s) and dosage.

Back and Neck

1. What was the diagnosis?
2. What areas of the back and neck are/were affected?
3. Any disability including missed work? Provide date of first and last symptoms.
4. Were any X-ray, MRI, CAT scan, or other testing done? If so, provide name, date and results.
5. How was the condition treated, including therapies? For how long? Still receiving treatment and/or medication? Give details, including name and dosage of all medications.
6. Give name(s) of all physician(s) seen, specialty and date last seen

RESPIRATORY SYSTEM

Allergies, Asthma, Emphysema, Bronchitis and other Respiratory Disorders

1. What was the diagnosis?
2. How many attacks occur per year? What was the date of the last attack?
3. How disabling are the attacks? How many days lost from work or school?
4. What medication(s) are used for control? Give name and dosage.
5. Was a nebulizer prescribed? If yes, provide complete details.
6. Are any drug injections required? How often? Give name, dosage and frequency.
7. What tests were done and what were the results?
8. Has any emergency room visit or hospitalization been required? When, how many times and for how long? Give details.
9. Give name(s) of all physician(s) seen, specialty and date last seen.

TUMOR

Tumor, Polyp, Cyst

1. What was the diagnosis? (Give technical name or pathology diagnosis, if known.)
2. Where was growth located? Where and what organ?
3. When was it removed and how? (Surgery, burned off, radiation, chemotherapy?)
4. Was any treatment or follow-up needed after it was removed? Provide test name, date and results.
5. Give name(s) of all physician(s) seen, specialty and date last seen.

UNDERWRITING GUIDELINES BY PLAN AND CONDITION:
Below is a listing of common conditions and underwriting action by a designated plan. Columns A through E to the right of each condition provide a designation of the Underwriting Action by plan. Please review the table below to determine the plan or plans associated in each grouping.

Column A:
BlueCare

Column B:
BO Plans 3, 4, 5, 10, 11, 12, 13, 16, 17, 30, 31, 32, 33, 36, 37, 38, 39, 40, 41, 95, 96, 97, 98
BlueChoice Plans 1 & 2 (all deductibles)
Dimension IV (all deductibles)
Blue Select Plans 105, 113, 116, 117, 205, 213
BO PEP GEN III Plans 503-505, 510-513, 595-598, 620-625, 640-643, 660-662

Column C:
BO Plans 34, 35, 50, 51 / Blue Select Plan 152 / BO PEP GEN III Plans 626, 627, 663

Column D:
BO Plans 70, 71, 72, 73
Essential Network Hosp/Surg / Essential Traditional Hosp/Surg
Miami Dade Blue Plan 1 / BO PEP Hosp/Surg 570-573 (effective 08/01/09)

Column E:
BO Plans 81, 82 /Blue Select Plan 181
BO PEP GEN III – My Basic Plan 581, 582 (effective 08/01/09)

CONDITION/PLAN

A
B
C
D
E
CONDITION/PLAN

A
B
C
D
E
ABNORMAL GLUCOSE

Not diagnosed as Diabetic, Glucose intolerance, hyperglycemia or metabolic syndrome- need subsequent normal 2-hour glucose tolerance test (GTT) and physician’s assessment.

IC
IC
IC
IC
IC