Aetna IndividualUnderwritingGuide

8/3/2019 Aetna IndividualUnderwritingGuide

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Field Underwriting GuideAETNA ADVANTAGE PLANS FOR INDIVIDUALS,

FAMILIES AND THE SELF-EMPLOYED

13.02.002.1 FL CP (7/11)

This inormation is intended or brokers only.The Advantage plan disclaimer then goes on the next line. Aetna Advantage Plans orIndividuals, Families and the Sel-Employed are underwritten by Aetna Lie Insurance Company(Aetna) directly and/or through an out o state blanket trust or Aetna Health Inc. In some states,individuals may qualiy as a business group o one and may be eligible or guaranteed issue,small group health plans. To the extent permitted by law, these plans are medically underwritten andyou may be declined coverage in accordance with your health condition.

Florida


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Aetna Proprietary Inormation

This guide is designed to assist you in the process o

submitting applications or Aetna Advantage Plans.

It will provide inormation to help you and your clients

to complete the application thoroughly and correctly

and thereby expedite the processing time in the

Underwriting Department.

Review the application or completeness and accuracy, and ensure

that any necessary documents are attached prior to submitting it or

nal Underwriting.

The Medical Underwriting Risk Criteria section o this guide provides

a summary o health conditions commonly encountered in the

underwriting process. The underwriting risk criteria will assist you in

estimating the underwriting outcome, but nal determination will be

made by an Aetna underwriter. This guide is intended as a brie overviewonly and is not intended to be the source or underwriting decisions.

Aetna reserves the right to place the applicant in the appropriate risk

category, request additional inormation or decline coverage.

Coverage can not be guaranteed and no promises should be made to

the applicant(s) when the application is completed. The nal decision

will be based on enrollment requirements, health history and medical

underwriting risk criteria.

No requested eective date will honored prior to or on thesignature date.

This guide and underwriting risk criteria are subject to revision and

change at anytime without notice to you.

Introduction

Field UnderwritingGuide IndexAge and Family

Status Requirements 2

Residency Requirements 2

Terms o Coverage 3

Medical Underwriting

Requirements 3

Reasons Causing Underwriting

Processing Delays 4

Individual Medical

Underwriting: Overview 4

Declinable Conditions and

Medications 5

Medical Risk Criteria

or Agents 6Adult Male Build Chart 7

Adult Female Build Chart 8

Childs Build Chart 9

Percentage Rate Chart 10

Assistance with Underwriting

Questions 11

Underwriting and the

Appeals Process 11

Underwriting and the

Reconsideration Process 11

Alphabetical Index o

Medical Conditions 12-13

Aetna Advantage Plans

Risk Criteria 14-28

Body Mass Index (BMI)

Chart 29


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2Aetna Proprietary Inormation

Age and FamilyStatus Requirements

To qualiy or enrollment:

1. Applicant and enrolling spousemust be over the age o 18 and

under age 64 3/4

2. Dependent children o applicant

or enrolling spouse must be

under age 30

Eligibility o Newborns,

Adoptees and Foster Children:

1. Foster children do not qualiy

as a dependent on the Aetna

Advantage Plans.

2. Newborn babies, born to a subscriber

or enrolled spouse may be added to the

parents plan within 31 days o birth

without medical underwriting. I the

enrollment request is not submitted

within 31 days o birth, the newborn

child will be subject to the complete

medical underwriting process and must

meet all enrollment and underwriting

requirements.

3. A newly adopted child o a subscriber

or enrolled spouse may be added to theadopting parents plan within 31 days o

placement in the home or the purpose

o adoption, without medical

underwriting. The adopting parents must

provide evidence o the authorization to

control medical care. I the enrollment

request is not submitted within 31 days

o placement, the adoptee will be subject

to the complete medical underwriting

process and must meet all enrollment

and underwriting requirements.

ResidencyRequirements

To qualiy or enrollment

all applicants must be:

Legal resident within the state and Aetna

Advantage Plan Service Area.

Non-citizen Resident

Requirements:

Applicants or the Aetna Advantage Plans,

who are non-citizen residents o the

United States, must provide proo o legal

residency in the United States or a period

o six months immediately preceding the

application or coverage.

At least one o the ollowing items must be

submitted with the application as proo o

residency or a six month period:

1. Proo o rent or mortgage payments

within the United States or the past six

months

2. Verication o employment in the

United States or the past six months

3. Medical records rom a medical

oce or hospital in the United States,

indicating treatment within the United

States or the past six months

4. Receipts or utility bills, in the applicants

name, within the United States, or the

past six months

Items such as Passports, Visas, Drivers

Licenses and Social Security Cards do not

provide proo o the six-month residency

requirement and will not be accepted as

proo o continuous residency.

Foreign Exchange Students are not subject

to the six-month continuous residency

requirement, but are subject to the

complete medical underwriting process andmust meet all enrollment and underwriting

requirements. Foreign Exchange Students

applying or the Aetna Advantage Plans

must submit, with their application,

documentation o proo o enrollment in

the Foreign Exchange Student Program.


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Terms o CoverageThe Aetna Advantage Plans is intended to

be the sole coverage. Applicants who are

currently covered by another carrier must

agree to discontinue the other coverage

upon the eective date o this AetnaAdvantage Plan.

Coverage remains in eect as long as

the required premium charges are

paid on time and membership eligibility is

maintained. Coverage will be terminated i

the member becomes ineligible due to:

1. Non-payment o premiums

2. Residency requirements

3. Obtaining duplicate coverage

Pre-existing Conditions

Limitations:

A pre-existing condition is an illness

or injury or which medical advice or

treatment was recommended or received

within the six months preceding the

eective date o coverage.

For individuals age 19 and older: during the

rst 12 months ollowing a members

eective date o coverage, no coverage

will be provided or the treatment o a

pre-existing condition.

I the applicant had prior creditable

coverage within 63 days immediately

beore the signature date on the

application or is under the age o 19,

then the pre-existing conditions exclusion

o the plan will be waived.

MedicalUnderwritingRequirementsThe Aetna Advantage Plans are not

guaranteed issue plans. All applicants,enrolling spouse and dependents are

subject to medical underwriting to

determine eligibility and placement within

the appropriate risk level. Medical records

may be requested by the underwriter or

the purpose o evaluating

the underwriting risk.

Aetna oers multiple risk levels based on

the known and predicted medical risk

actors o each applicant. These levels are

represented in ten percent increments

beginning at 1.0 (standard rating level - norate up) through 2.5 (150% rate up).

Placement in Risk Categories:

Medical Underwriters will assess the risk

o all applicants through a review o all

inormation submitted on the application,

the health questionnaire, phone interviews

and medical records. Medical Underwriting

will assign risk points associated with

Medical Conditions, Build charts (BMI),

Tobacco and Medication usage. Based on

the assigned risk points, age and gender,the applicant:

1. May be enrolled in their selected plan

at the standard premium charge

2. May be enrolled in their selected plan at

a higher rate, based on the severity and

associated risk o the medical ndings.

3. Applicants age 19 and older may be

declined coverage based on signicant

medical risk actors

Reasons CausingUnderwritingProcessing DelaysAn application cannot be reviewed by

underwriting until all inormation hasbeen provided by the applicant(s) and

agent. Listed below are the most requent

omissions or errors that cause delays in

underwriting:

1. Answers to Health Questionnaire

missing or incomplete

2. No details provided or Health

Questionnaires with yes answers

3. Address inormation incomplete

4. Omitted height, weight, date o

birth or age on applicant and/or

dependents5. Missing signature o spouse and/or

dependents over age 18 or older

6. Missing name and address o physician

or providers in health history

7. Application not dated

8. Changes made to answers without

accompanying explanation or initials

9. Broker inormation incomplete or

agent number missing

10. Single check submitted with

multiple applications

11. EFT/Credit Card inormation incomplet

Situations which may result in the

application being closed without

underwriting include, but are not limited t

1. Applications which have been

completed in pencil

2. Submission o an outdated or expired

paper application

3. Multiple omitted items on the applicatio

4. Application not dated

5. Signature date is over 30 days old or is

post-dated

6. Missing signatures o applicant, spouse,

over-age dependents

7. No response to request or additional

inormation, such as medical records

or phone interviews

3 Aetna Proprietary Inormation


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Individual MedicalUnderwriting:Overview

Medical Underwriting:The process o reviewing and comparing

the medical history o applicants against

established underwriting risk criteria in

order to determine the appropriate level

o risk

Medical Underwriting Theory:

The Medical Underwriting process is

designed to identiy the potential medical

risk and cost or the conditions listed on an

application. These costs are predicted on

existing and anticipated uture:

n Hospitalizationsn Surgeriesn Medical Oce Visitsn Out-Patient Therapiesn Prescription Medicationsn Laboratory Testsn Radiological and Diagnostic Testsn Durable Medical Equipment

and Supplies

In our current culture, the cost o

prescription medications presents anincreased nancial risk component or

the treatment o acute and chronic

health conditions that do not require

hospitalizations and surgeries.

Obesity and smoking can present an

increased risk component in conjunction

with specic health conditions that are

complicated and/or exacerbated by such

conditions or behaviors. Conditions that

may be aected by obesity and smoking

include but are not limited to:

n Cardiac Conditionsn Hypertensionn Respiratory Conditionsn Gastric or Intestinal Conditionsn Back and Joint Conditions may present

The assigned risk category is based on the

level o severity and potential risk o the

listed health condition, phone interviews

and by review o medical records.

Adverse selection results when there is an

excessive coverage o high-risk candidates

in proportion to the coverage o low-risk

candidates. Through careul review and

proper rating o health risks, underwriting

guards against adverse selection.

Assistance with

Underwriting questions:

I you have specic questions about

a health condition, medication, etc,

and how these may be evaluated in

underwriting, you can submit send

your questions to our IndividualUnderwriting Mailbox.



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DeclinableConditions andMedications*Many health conditions present an extreme

risk due to the high cost o treatment andmedications. When such conditions are

listed on the application Aetna reserves the

right to decline coverage without urther

review o medical records*. Conditions that

will result in declination include, but are not

limited to the list to the right.

Medications Subject to Decline:

Some medications are costly and present an

increased underwriting risk. Applicants may

be declined based on the cost o their

prescription medications.* Dependents under the age o 19 will be

medically underwritten, and assigned theappropriate risk category.

Addisons Disease Klineelters Syndrome

AIDS Lupus Erythematosus, Systemic (SLE)

AIDS Related Complex (ARC) Lymphadenitis

Alzheimers Disease Mediterranean Anemiawithout Splenectomy

Amyotrophic Lateral Sclerosis Multiple Sclerosis

Aplastic Anemia Muscular Dystrophy

Ankylosing Spondylitis Myasthenia Gravis

Arteritis Myelobroisis

Arthritis, Rheumatoid Organic Brain Syndrome

Brights Disease Pacemaker or Implanted Debrilator

Bronchiectasis Pagets Disease

Buergers Disease Paraplegia

Burkitts Tumor Parkinsons Disease

Cardiomyopathy Pneumoconiosis

Cerebral Palsy (Inantile) Polyarteritis NodosaCirrhosis o Liver Polycythemia

Chronic Glomerulonephritis Polymyositis

Chronic Hepatitis Polyneuropathy

Chronic Obstructive PulmonaryDisease (COPD)

Portal Hypertension

Chronic Pulmonary Heart Disease Pregnancy

Chronic Renal Failure Psoriatic Arthropathy

Cooleys Anemia Pulmonary Heart Disease

Crouzons Disease Quadraplegia

Cushings, Syndrome Raynauds Syndrome/Phenomenon

Cystic Fibrosis Renal Failure, Chronic

Dermatomyositis Scleroderma

Emphysema Sickle Cell anemia

Encephalopathy Sjogrens Disease

Endocarditis Spina Bida

Esophageal Varicies Systemic Lupus Erythematosus (SLE)

Guillain Barres Syndrome Syringomyelia

Hemolytic Anemia Tay-Sachs Disease

Hemophilia Testicular Dysunction

Hemochromatosis Tetralogy o Fallot

Hodgkins Lymphoma Thalassemia Major

Human T-Cell Leukemia Virus Thrombotic Thrombocytopenia Purpura

Human T-Cell Lymphotropic Virus Transplant; Heart

Huntingtons Chorea Transplant; Liver

Hydrocephalus Transplant; Lung

IgG Deciency Uremia

Insulin Dependent Diabetes Mellitus Von Willebrands Disease


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Medical RiskCriteria or AgentsThe Risk Criteria section provides a summary

o conditions commonly encountered in

the medical underwriting process. The Risk

Criteria and Risk Level or each condition

includes the potential cost or treatment,

therapy and medications. The greater the

risk, the higher the Risk Level the applicant

would be assigned.

Risk is increased by actors such

as smoking, use o prescription

medications and height/weight.

In some situations, the listed condition itsel

may present only a minimal health risk,

but the treatment and/or use prescriptionmedications increase the overall cost risk.

Prescription medications which

exceed the acceptable cost range o

an assigned risk level may result in

a higher risk level being assigned or

declination.

Body Mass Index

Body Mass Index, (BMI) is a measure o

body at based on height and weight. The

BMI score is valid or both adult men and

women, as well as children. Research data

rom the National Heart, Lung and Blood

Institute has documented that BMI is a

reliable indicator o total body at which is

related to the risk o disease and death.

Aetna uses both BMI and Height/

Weight Ratio or the Applicants

age to determine the level o risk.

n BMI 43 and greater is an automatic

decline

n For Applicants with a BMI o 43 or lessthe Build Chart is used to calculate the

percentage increase or each Applicant.

How To Use The Build Chart:

1. Locate the appropriate chart or male,

emale or child.

2. Locate the applicants height in the let

hand column.

3. Follow that row to the right until it

intersects with the applicants weight

range.

4. Note the Level Number (Examples L0, L4).5. Reerence the appropriate chart Age

Band Chart or male, emale or child, or

the percentage increase to the premium.

Example: Male age 45 yearsn Height = 61n Weight = 310 lbs.n L5n Percentage Increase to Premium = 30%


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AdultMaleBuildC

hart

BMI43

AND

GREATER

IS

AN

AUTOMATIC

DECLINE

ForBMIbelow43;pleaseuseHeight/Weighttablebelowtoes

tablishratinglevel.

BodyWeightinPounds

Height

Ft./In.

Avg.

Wt.for

0pts

90

or

less

91-

105

106-

120

121-

135

136-

150

151-

165

166-

180

181-

195

196-

210

211-

225

226-

240

241-

255

256-

270

271-

285

286-

300

301-

315

316-

330

331-

345

346-

360

361-

375

376-

390

5

0

131

L4

L1

L1

L1

L1

L1

L2

L2

L3

L4

D

D

D

D

D

D

D

D

D

D

D

5

1

134

L4

L1

L1

L1

L1

L1

L1

L2

L3

L4

L5

D

D

D

D

D

D

D

D

D

D

52

137

L4

L1

L1

L1

L1

L1

L1

L2

L3

L3

L5

D

D

D

D

D

D

D

D

D

D

53

141

L4

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

D

D

D

D

D

D

D

D

D

54

145

L4

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

D

D

D

D

D

D

D

D

D

55

149

L4

L1

L1

L1

L1

L1

L1

L1

L2

L3

L3

L5

L6

D

D

D

D

D

D

D

D

56

153

L4

L4

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

D

D

D

D

D

D

D

D

57

157

L4

L4

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

L6

D

D

D

D

D

D

D

58

161

L4

L4

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

D

D

D

D

D

D

D

59

165

L4

L4

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

L6

D

D

D

D

D

D

510

170

L4

L4

L1

L1

L1

L1

L1

L1

L1

L1

L2

L3

L3

L4

L5

D

D

D

D

D

D

511

174

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

L6

D

D

D

D

D

60

179

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L3

L4

L5

D

D

D

D

D

61

183

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

L6

D

D

D

D

62

188

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L3

L4

L5

L6

D

D

D

63

193

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

L6

L7

D

D

64

199

L4

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L3

L4

L5

L6

D

D

65

204

L4

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

L6

L7

D

66

210

L4

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L3

L4

L5

L6

D

67

216

L4

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L4

L5

L6

L7

68

221

L4

L4

L4

L4

L4

L1

L1

L1

L1

L1

L1

L1

L1

L1

L2

L2

L3

L3

L4

L5

L6


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AdultFemaleBuildChart

BMI43

AND

GREATER

IS

AN

AUTOMATIC

DECLINE

ForBMIbelow43pleaseuseHeight/Weighttablebelowtoes

tablishratinglevel.

BodyWeightinPounds

Height

Ft./In.

Avg.

Wt.for

0pts

4 years ago,no recurrence

D D D D 60-80% 60-80%

Myeloid Leukemia; all treatment com-pleted > 6 years ago, no recurrence

D D D D 90% -D 90% -D

Recurrent cancer or metastatic disease D D D D D D

Cancer

Skin: Basal Cell

Removed > 3 months ago; in situ andall borders clear; no reconstructivesurgery required; no current treatmentor medications; current exam shows norecurrence

30% 30% 0-30% 0-30% 0% 0%

Removed < 3 months ago; in situ andall borders clear; no reconstructivesurgery required

90% 90% -D 50-90% 40-80% 30-40% 0-10%

Currently being medically treated 90% -D 90% -D 50-90% 40-70% 20-40% 10-30%

prescription medication IC IC IC IC IC ICCancer

Skin: Melanoma

Stage 1, borders clear, removed >1 year ; all cosmetic/reconstructivesurgery complete; no treatment or

medication or 1 year; current derma-tology exam conrms no recurrence

D D 50%- D 50%- D 10-20% 10-20%

Does not meet any o above criteria;metastatic melanoma

D D D D D D

Additional consideration or: smokingand reconstructive surgery

IC IC IC IC IC IC

Cancer

Skin: Kaposis Sarcoma

Once Diagnosed and related to HIVdiagnosis

D D D D D D

Cancer

Including:

Internal organsSystemic cancers

Most cancers that all within thesecategories are complex. The level oconsideration depends on originaldiagnosis; pathology reports; type andlength o treatment; treatment- reeperiod and recurrence rates

IC IC IC IC IC IC

Cerebral Palsy Over age 5 : mild impairment withspeech and movement (medicalrecords required or ull assessment

D D 50-90% 50-90% 20-30% 10-20%

Does not meet any o above criteria-Full medical records required

IC IC IC IC IC IC

Additional consideration or: inconti-

nence, wheelchair, requiring

IC IC IC IC IC IC

Physical/Speech/Occupational therapy

Cirrhosis o Liver Once Diagnosed D D D D D D

COPD

Chronic ObstructivePulmonary DiseaseEmphysema

Once Diagnosed D D D D D D

ColitisCrohns Disease

See Infammatory Bowel Disease

Aetna Advantage Plans Risk Criteria



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Listed Condition Risk Criteria Risk Level Approximate % Increase

Age0-22

Age23-29

Age30-39

Age40-49

Age50-59

Age60-65

ColitisCrohns Disease

See Infammatory Bowel Disease

Deaness Hearing aid present 0% 0% 0% 0% 0% 0%

Hearing aid recommended/

needs replacement

90%-D 90%-D 30-50% 20-50% 0-20% 0-20%

Cochlear implant, requiresmonitoring only

90%-D 90%-D 30-50% 20-50% 0-20% 0-20%

Does not meet any o the above cri-teria; potential surgical candidate;cochlear implant candidate

D D D D D D

Depression See Anxiety/Depression

Diabetes Mellitus Type II; Non Insulin Dependent or< 5 years: Controlled by diet or medi-cation; BMI less than 30; no smoking/tobacco use; no kidney, vision or

circulation problems; acceptablelaboratory test results

70%- D 70%- D 30-70% 30-70% 0-50% 0-50%

Type II; Non Insulin Dependentor 5 - 14 years: Controlled by dietor medication; BMI less than 30; nosmoking/tobacco use; no kidney, visionor circulation problems; acceptablelaboratory test results

D D 60%-D 60%-D 20-60% 20-50%

Does not meet any o the abovecriteria; smoker, amputation/peripheralvascular disease due to diabetes,complications o diabetes

D D D D D D

Additional consideration or: BMI,abnormal HgbA1C or asting blood

sugar levels

IC IC IC IC IC IC

Type I or Insulin Dependent D D D D D D

Diverticulitis Incidental nding, removed duringcolonoscopy exam within 1 year

0% 0% 0% 0% 0% 0%

Diverticulosis One attack; treated medicallywithin 1 year

0% 0% 0% 0% 0% 0%

Multiple attacks; treated medically

within 2 years

D D D D 60-70% 60-70%

Multiple attacks; surgically treated >

3 yrs ago

D D D D 40-50% 40-50%

Does not meet any o the abovecriteria

D D D D D D

Drug AbuseIllegal Drugs

No illegal drug use or over 5 years; nointravenous drug use ever; no therapy,treatment or mediations or 3 yearsexcept or ongoing attendance toNarcotics or Alcoholics Anonymous

D D 50-90% 50-90% 10-40% 10-30%

Inpatient admission within 5 years D D D D D D


D D D D D D




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Age

0-22

Age

23-29

Age

30-39

Age

40-49

Age

50-59

Age

60-65

Drug AbuseMarijuana/Cannabisuse only

No marijuana use or 1 or more years;no chronic respiratory conditions; notherapy, treatment or medications or 1year except or ongoing attendance toNarcotics or Alcoholics Anonymous

10% 10% 0% 0% 0% 0%

Marijuana use 6-12 months D D D 80%-D 80%-D 70%-D

1 inpatient admission within 2-5 yearsor marijuana abuse

30-40% 30-40% 10-30% 10-30% 0-10% 0%

DUI within 2 years D D D D D D

Drug AbusePrescription drugs

No abuse o prescription drugs or5 years; no therapy, treatment omediations or 3 years except ongoingattendance at Narcotics or AlcoholicsAnonymous

10-30% 10-30% 10% 0% 0% 0%

No abuse o prescription drugs or 5years; counseling or therapy within 3years; no mediations or 3 years

30-40% 30-50% 20-30% 20-30% 0-10% 0%

Does not meet any o the abovecriteria; still abusing prescriptiondrugs; two or more hospitaladmission in 10 years

D D D D D D

Ear InectionsOtitis Media

No hearing loss; one episode within 18months

0-10% 0-10% 0% 0% 0% 0%

No hearing loss; two episodes within18 months

40-60% 50-60% 20-50% 20-50% 0-20% 0%

No hearing loss; three episodes within18 months

90%-D 90%-D 50-90% 50-90% 0-20% 10%

Currently on antibiotics D D 30-70% 20-60% 10-30% 10-30%

Does not meet any o the above cri-teria

D D D D D D

Eating Disorders

Including:

AnorexiaBulimia

Age 15 or older; Medical Recordsrequired BMI must be greater than 16;normal laboratory test results; no car-diac conditions

IC IC IC IC IC IC

< Age 15; History within the past 5years

D

Does not meet any o the abovecriteria; BMI < 16

D D D D D D

Emphysema Once Diagnosed D D D D D D

Endometriosis Mild with no medication other thanover the counter NSAIDS within 5 years

D D 10-30% 10-30% 0-10% 0%

Mild with no medication other thanover the counter NSAIDS > 5 years

0-10% 0-10% 0-10% 0-10% 0% 0%

Currently being treated with Lupron/Danazol or Synarel

D D D 50% -D 30-70% 10-50%

Does not meet any o the above cri-teria; potential surgical candidate;Undiagnosed pelvic pain

D D D D IC IC




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Age0-22

Age23-29

Age30-39

Age40-49

Age50-59

Age60-65

Erectile Dysunction(ED) Impotence

Not a surgical candidate, cause nonvascular in nature

D D 90-D% 90-D% 10-50% 10-30%

Not a surgical candidate, causevascular in nature

D D D D 50-70% 40-60%

Does not meet any o the abovecriteria; potential implant or surgicalcandidate

D D D D D D

Fibroids andFibroma o Uterus

Post Surgical: Myomectomy with norecurrence

0% 0% 0% 0% 0% 0%

Post Surgical: Hysterectomy > 6months ago

0-10% 0-10% 0% 0% 0% 0%

Post Surgical: Hysterectomy 3- 6months ago

D 30% 20-40% 20-40% 10% 0-10%

Non-Surgical; stable < 5 cm with no

change in size or > 12 months

D D 50-60% 50-60% 10-30% 10%

Does not meet any o theabove criteria

D D D IC IC IC

Additional consideration or: size;type; location and stability o lesion

IC IC IC IC IC IC

Fibromyalgia Condition resolved; no symptoms,treatment or therapy or 1-3 years

0% 0% 0% 0% 0% 0%

Diagnostic work-up and testingcompleted; controlled with overthe counter (OTC) medications orprescription medication

D D 50%-D 50%-D 20-50% 10-50%

Diagnostic work-up and testingcompleted; controlled with > 3prescription medication

D D D D 40-60% 40-60%

Uses narcotic pain medication D D D D 40-60% 40-60%


D D D IC IC IC

Individual consideration or: BMI,physical/occupational or Chiropractictherpay

IC IC IC IC IC IC

Gallbladder Disorders

Including:

CholecystitisCholelithiasisCholangitis

Gallbladder surgically removedwithin one year; no complications;

no problems

0% 0% 0% 0% 0% 0%

Gallstones present, no symptoms,treated medically

0% 0% 0% 0% 0% 0%

Gallstones present, symptomatic D D D D D D

Does not meet any o the above crite-

ria; potential surgical candidate

D D D D D D

Graves DiseaseGoiter

See Thyroid Disorders




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Age0-22

Age23-29

Age30-39

Age40-49

Age50-59

Age60-65

General Health Adult: Aetna considers that applicantsover age 50 should have seen an M.D.at least once in the past 2 years.

Aetna will not process applicationso applicants 50 years or older thatdo not have a current History andPhysical with standard tests (BloodSugar, Cholesterol and Triglycerides)in the last 2 years.

Children Under Age 4: Well childcheckup documenting mile stonesand development will be required orall children under age 4

GERD(Gastro-esophagealRefux Disease)

Including:Acid reuxAcid indigestionHeartburn

Age 18 or over; all diagnostic testscompleted; using one prescriptionmedication; no smoking/tobacco use

or 12 months; no respiratory compli-cations; BMI less than 33

0-50% 0-50% 0-30% 0-20% 0-20% 0-10%

Age 18 or over; all diagnostic testscompleted; using two prescription

medication; no smoking/tobacco useor 12 months; no respiratory compli-cations; BMI less than 33

30% - D 30% - D 10-50% 10-50% 0-30% 0-20%

Does not meet any o the above criteria D D D D D D

Additional consideration or: obesity;previous use o prescription medication

IC IC IC IC IC IC

Graves Disease Goiter See Thyroid Disorders

Gout Occasional episodes; no more than 2-4

per year; no current medication; nojoint deormities or kidney stones

0% 0% 0% 0% 0% 0%

Currently taking prescriptionmedications

0-20% 0-20% 0-20% 0-10% 0-10% 0%

Does not meet any o the abovecriteria; > 4 episodes per year; jointdeormity or associated conditions

D D D D D D

Hasimotos Disease See Thyroid Disorders

Headache

Including:

MigraineVascular Migraine

Mild/ hormone related, up to 3 peryear; occasional medication needed(no Topamax)

0-40%- 0-40%- 0-40%- 0-40%- 0-10% 0-10%

Mild/ hormone related, greater than 6

per year; occasional medication needed(no Topamax)

10-50% 10-50% 0-50% 0-50% 0-30% 0-20%

Moderate to severe headaches, up to 3per year, uses prescription medications(non narcotic)

10-50% 10-50% 0-50% 0-50% 0-30% 0-20%

Moderate to severe headaches, greaterthan 6 per year, maintained on pre-scription medications (non narcotic)

70%-D 70%-D 30%- D

30-90% 10-40% 10-30%

Ongoing use o narcotic medication(Rx lled monthly)

D D D D 40-70% 40-70%

Does not meet any o the above criteria D D D D D D




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Age0-22

Age23-29

Age30-39

Age40-49

Age50-59

Age60-65

Heart Disease

Including:Angina

Coronary ArteryDiseaseIschemic Heart DiseaseMyocardialInarction (MI)Heart attack

History o Angina only; no surgeryrecommended; hypertension controlled< 135/90; PRN use o nitroglycerine;BMI less than 30

D D D D 70% -D 70% -D

History o angioplasty or coronaryartery bypass grats

D D D D 70% -D 70% -D

History o MI 1-5 years ago D D D 40% - D 20-50% 10-50%

Individual consideration or: obesity;multiple medications; multiple sur-geries; smoking; respiratory disease;hypertension

IC IC IC IC IC IC

Heart Disease

Including:ArrhythmiasDysrhythmias

Irregular heartbeatPalpitations

Pacemaker or debrillator recipient orcandidate

D D D D D D

Previous episode; currently maintainedon medication

D D D 70% -D 40% - D 40% - D

Individual consideration or: type;severity and treatment

IC IC IC IC IC IC

Individual consideration or: obesity;multiple medications; multiple

surgeries; smoking; respiratory disease;hypertension

IC IC IC IC IC IC

Heart Valve Disease

Including:

Mitral Valve DiseaseMitral Valve ProlapseMurmur

Benign murmur only; no regurgitation;no medications required (precautionaryantibiotics acceptable); no hyperten-sion; no other cardiac conditions; BMIless than 30

50-80% 50-80% 20-50% 20-50% 0-30% 0-30%

Asymptomatic; minimal regurgitation,normal EKG

D D D 80%-D 30-50% 30%

Individual consideration or: obesity;medications; multiple surgeries; smok-ing; respiratory disease; hypertension

IC IC IC IC IC IC

Medical Records required

Symptomatic or class II regurgitation D D D D D D

Heart Valve Disease

Including:

Aortic Valve DiseaseTricuspid Valve Disease

Normal heart unction; normal kidneyunction; no medications (precaution-ary antibiotics acceptable); no othercardiac conditions; no hypertension;BMI less than 30

50-80% 50-80% 20-50% 20-50% 0-30% 0-30%

Asymptomatic; minimal regurgitation,normal EKG

D D D 80%-D 30-50% 30%

Individual consideration or: obesity;medications; multiple surgeries; smok-ing; respiratory disease; hypertension

IC IC IC IC IC IC

Medical records required

Symptomatic or class II regurgitation D D D D D D

Herpes

Including:

Herpes Zoster(Shingles)

Outbreaks, treatment or symptomswithin 3 months

50-80% 50-80% 50-80% 30-60% 0-50% 0-30%

Ongoing suppressive therapy D D D 30-60% 0-50% 0-30%

Current eye or ear involvement D D D D 80%-D 80%-D




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Age0-22

Age23-29

Age30-39

Age40-49

Age50-59

Age60-65

Hepatitis Hepatitis A or E: single episode 6 ormore months ago; current normal LiverFunction Tests (LFTs); no treatment,

therapy or medications or 6 months

0-20% 0-20% 0-10% 0-10% 0% 0%

Currently has Hepatitis A or E D D 80%-D 80%-D 50-80% 50-80%

Hepatitis B or D: exposure only orimmunization; laboratory test resultspositive or Antibodies- negative orAntigens; current LFTs normal;no immune disorder symptoms;no treatment therapy or medicationor 1-2 years

50-80% 50-80% 50-80% 30-60% 0-50% 0-30%

Currently has Hepatitis B or D D D D D 80% - D 80% - D

Hepatitis C greater than 5 years ago,ully recovered with Negative tests

50-80% 50-80% 50-80% 30-60% 0-50% 0-30%

All other types o Hepatitis: Non-A,Non-B, G

D D D D D D

HerniaHiatalInguinalFemoralUmbilicalVentralIncisional

Single, asymptomatic hernia within thepast year, no surgical repair required

90% - D 90% - D 50-80% 50-80% 30-50% 0-20%

Single, asymptomatic hernia > 2 yearsago, no surgical repair required

0-10% 0-10% 0-10% 0% 0% 0%

Surgically repaired within 3 months 0-10% 0-10% 0-10% 0-10% 0% 0%

May be a surgical candidate; urthertesting required

D D D D D D

Herniated Disc See Back Problems

Herpes

Including:Herpes Zoster(Shingles)

Outbreaks, treatment or symptomswithin 3 months

50-80% 50-80% 50-80% 30-60% 0-50% 0-30%


Current eye or ear involvement D D D D 80%-D 80%-D

Herpes

Including:

Oral Herpes


Individual Consideration given orrequency o outbreaks

Herpes

Including:

Genital Herpes

No outbreaks or 2 years, ongoingsuppressive therapy

D D D 30-60% 0-50% 0-30%

Anal or Rectal Herpes D D D D D D

High Blood PressureHypertension

BMI less than 28; no smoking/tobaccouse or 12 months; blood pressure

controlled at 130/90 or less; normallaboratory test results; normal kidneyunction; no other cardiovascularconditions

IC 0-20% 0% 0% 0% 0%

BMI less than 28; no smoking/tobacco use or 12 months; bloodpressure controlled at 130/90 orless, single prescription medication;

normal laboratory test results;normal kidney unction; no othercardiovascular conditions

IC 0-50% 0-40% 0-40% 0-30% 0-30%




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Age0-22

Age23-29

Age30-39

Age40-49

Age50-59

Age60-65

High Blood PressureHypertension(continued)

BP controlled between 130/90 to140/100; medical records required

IC IC IC IC IC IC

BP controlled between 140/90 to

150/100; medical records required

IC IC IC IC IC IC

Individual consideration or: weight;BMI over 30; multiple medications;smoking; respiratory disease; elevatedcholesterol; other associated conditions

IC IC IC IC IC IC

High CholesterolHypercholestrolemiaHyperlipidemia

Individual consideration or: age;weight; blood cholesterol and lipid lev-els; smoking and multiple medications

IC IC IC IC IC IC

Normal blood cholesterol/lipid paneland on single prescription medication

IC IC 10-30% 0-20% 0-20% 0-20%

Hyperactivity

Including:

Attention DefcitDisorder (ADD)Attention DefcitHyperactivity Disorder

Age 5 - 18; maintained on singlemedication or at least 3 months;no other nervous, mental or

developmental disorders; no otherpsychotropic medications

30%- D

Age 18 or over; maintained onprescription medication

10-50% 10-50% 10-40% 10-40% 0-30%- 0-20%

Under age 5 D

Infammatory BowelDisorders

Including:

ColitisCrohns DiseaseRegional Enteritis

Surgical removal less than 2 yearsago; no stoma; does not requiresteroids or immunosuppressivemedications; no other treatment,therapy or medications

50%-D 50%-D 30-50% 30-50% 0-30% 0-30%

Same Criteria as above, with stoma D D D 50%-D 50%-D 50%-D

Medically managed, with up to 4attacks in the past 6 months

D D D 70%-D 60%-D 30-60%

Individual consideration or prescriptionmedication

IC IC IC IC IC IC

Infammatory BowelDisorders

Including:

Idiopathic ProctocolitisUlcerative Colitis

Surgical removal less than 2 yearsago; no stoma; does not requiresteroids or immunosuppressivemedications; no other treatment,therapy or medications

50%-D 50%-D 30-50% 30-50% 0-30% 0-30%

Diagnosed with Ulcerative Colitiswithin the past 3 years

D D D 70%-D 60%-D 30-60%

Diagnosed with Ulcerative Colitis > 3years ago

D D D 50%-D 50%-D 50%-D

Irritable BowelSyndrome (IBS)

Acute episode, ull resolved 0% 0% 0% 0% 0% 0%

Recurring, maintained on prescriptionmedication

50%-D 50%-D 30%-D 30-60% 0-50% 0-30%

Jaw DisordersTMJMalocclusionOther jaw disorders

Unoperated, asymptomatic with notreatment or > 2 years

30-50% 30-50% 20-50% 10-40% 0-20% 0-10%

Surgically corrected, no residual pain ororthodontic treatment within 2 years

50% 30-50% 20-50% 10-40% 0-20% 0-10%

Residual pain or requires orthodontictreatment

D D D D 50%-D 50%-D




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Age0-22

Age23-29

Age30-39

Age40-49

Age50-59

Age60-65

Kidney Stone(calculus)Ureter stone

2-3 episodes within 12 months 50-60% 50-60% 20-50% 20-50% 0% 0%

Currently on anti-stone medication 60% 60% 30-60% 10-40% 0-20% 0-10%

4 or more episodes within 12 months D D 80%- D 30-60% 10-30% 0-30%

Required lithotripsy 60-70% 60-70% 30-60% 20-40% 10% 10%

Potential surgical candidate; associatedconditions

D D D D D D

Knee Disorders

Including:ACL tearEusionPosterior Cruciate tearAnterior Cruciate tearAcute sprainsMedical ligament tearKnee cysts

Knee calcifcations

Surgically corrected 12 or more monthsago; no treatment ortherapy currently

50-60% 50-60% 30-50% 20-40% 10-20% 0-10%

Surgically corrected < 6 months age;no current treatment o therapy

D D D 50-100% 40-80% 30-50%

Not surgically corrected; medicallymanaged within the past 3 months;requires splint/brace and/or NSAIDS

D D D 50-100% 40-80% 30-50%

Not surgically corrected; medi-cally managed within 3 12 months;requires splint/brace and/or NSAIDS

50-60% 50-60% 20-50% 20-40% 10-20% 0-10%

Individual consideration given orphysical therapy, multiple surgeriesand other medications

IC IC IC IC IC IC

LupusLupus ErythematosusSystemic LupusDiscoid Lupus

Assessed by underwriter with ullmedical records

Systemic Lupus Erythematosus (SLE):Once diagnosed

D D D D D D

Muscular Dystrophy Once diagnosed D D D D D D

Multiple Sclerosis Once diagnosed D D D D D D

Obesity All applicants with a BMI greater than36 will be required to submit medicalrecords to include a history and physi-cal, height and weight, BP, Cholesteroland asting blood sugar within thepast 12 months.

BMI 43 or greater D D D D D D

Osteoporosis

Including:Osteopenia

Post menopausal; no ractures, asymp-tomatic, T score between - 2.5 and 1.0

0% 0% 0%

Individual consideration given orpain, causes other than menopauseand history o ractures

Diagnosed under age 45 IC IC IC 30-60% 30-50% 30-50%

Pancreatitis Recurrent or chronic, last episode > 3years ago

D D D 40-60% 40-50% 30-50%

Single acute episode; operated, ullrecovery; no treatment or medication >2 years ago

60-70% 60-70% 30-60% 30-60% 10-30% 10-30%

Individual consideration given orepisode within 2 years with ullmedical records

IC IC IC IC IC IC




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Age0-22

Age23-29

Age30-39

Age40-49

Age50-59

Age60-65

Pregnancy Pregnant applicant, spouse(domestic partner), or signicantother; in process o adopting or

surrogate pregnancy

D D D D D D

Prostate DisordersBenign ProstateHyperplasia (BPH)

PSA normal, no medication required D D D 40-60% 30-50% 30-40%

Individual consideration given orspecic medication Elevated PSA,biopsy normal

D D D 50-60% 50-60% 30-50%

Surgically corrected, no complications D D D 50-60% 50-60% 30-50%

Surgically corrected with complications D D D D D D

Prostate DisordersProstatitis

Single episode within the past 3months

80%-D 80%-D 80%-D 60-70% 30-50% 0-10%

Single episode within 3 12 months 50-60% 50-60% 30-50% 30-50% 0-10% 0-10%

Chronic or recurrent inection withinthe past year,

D D 30-50% 30-50% 0-10% 0-10%

normal PSA , no hypertrophy

Potential surgical candidate D D D D D D

Psoriasis Mild/Moderate; < 10% o skinsurace; treated with topical therapyor light therapy

10-30% 10-30% 10-30% 0-10% 0-10% 0-10%

Mild/Moderate; < 10% o skinsurace; treated with topical therapyand light therapy

50-70% 50-70% 20-50% 20-50% 0-20% 0-10%

Severe; > 10% o skin surace;treated with topical agents orlight therapy

50-70% 50-70% 20-50% 20-50% 0-20% 0-10%

Severe; > 10% o skin surace;treated with topical agents andlight therapy

90%-D 90%-D 50%-D 50%-D 30-50% 20-30%

Individual consideration given with useo systemic medication, methotrexate,Biologic Drugs such as Enbrel orAmevive with ull medical records

IC IC IC IC IC IC

Skin Conditions

Including:

EczemaDermatitisPoison OakFolliculitis

Acute episode: treated with OTCmedication or intermittent use oprescription cream, lotion, shampoo

or anti-histamine

0-20% 0-20% 0-20% 0-10% 0-10% 0%

Currently treated with multipleprescription medication

0-30% 0-30% 0-20% 0-10% 0-10% 0%

Condition lasting > 3 months IC IC IC IC IC IC

Related to immune disorder D D D D D D




29/32


Age0-22

Age23-29

Age30-39

Age40-49

Age50-59

Age60-65

Sleep Apnea - Adult

Including:Obstructive Apnea

Not a surgical candidate, wellcontrolled with over the countermedication and nasal strips

80%-D 80%-D 50-90% 50-90% 10-20% 10%

Not a surgical candidate, controlledwith CPAP/BIPAP

D D D 50-90% 40-60% 40-60%

Surgical candidate D D D D D D

Surgery completed > 1 year, norecurrence, no CPAP/BIPAP

0-20% 0-20% 0-20% 0-10% 0-10% 0%

Surgery completed, still requiresCPAP/BIPAP

D D D D 90%-D 90%-D

Smoking Smoking within the past 12 months isconsidered a smoker

0-10% 0-10% 0-10% 0-10% 0-10% 10-20%

A Blood Cotinine test within the past30 days is required to dispute smokingstatus

Thyroid DisordersHypothyroidism

Taking thyroid replacementmedication; stable or > 6 months

0-20% 0-20% 0-20% 0-10% 0-10% 0%

Taking thyroid replacementmedication; stable or 3- 6 months

0-20% 0-20% 0-20% 0-20% 0-10% 0%

Taking thyroid replacementmedication; stable or < 3 months

10-30% 10-30% 10-30% 0-10% 0-10% 0%

Cretinism

Thyroid DisordersHyperthyroidismGraves DiseaseMulti-nodular Goiter

Previously treated with surgery, PTUand MMI or radioactive iodine within 6months; stable on thyroid replacementmedication

80%-D 80%-D 50-90% 50-90% 10-20% 10%

Previously treated with surgery, PTU

and MMI or radioactive iodine

6 12 months ago; stable on thyroidreplacement medication

20-40% 20-40% 10-30% 10-30% 0-10% 0-10%

Goiter diagnosed > 2 years ago,unoperated

80%-D 80%-D 40-70% 40-70% 10-20% 10%


Thyroid DisordersHashimotos DiseaseThyroiditis

Asymptomatic less than 2 years, nocurrent treatment

0-20% 0-20% 0-20% 0-20% 0-10% 0%

On thyroid replacement rate ashypothyroidism

Potential surgical candidate D D D D D D




30/32


Age

0-22

Age

23-29

Age

30-39

Age

40-49

Age

50-59

Age

60-65

Ulcers

Types:GastricDuodenalPepticGastrojejunal

Single episodes, medically managed,no complications, ully resolved 1 year

40-60% 40-60% 20-50% 20-50% 10-20% 0-10%

Current diagnosis o Ulcer D D D D D D

Surgically repaired 1-4 years ago, norecurrence

40-60% 40-60% 20-50% 20-50% 10-20% 0-10%

Surgically repaired less thanone year ago

D D D 40-70% 40-70% 10-40%


Individual consideration given ormultiple attacks and smoking withull medical records

IC IC IC IC IC IC

Urinary Tract Inection Cystitis: Female; < 3 episodes,< 1 year ago

0% 0% 0% 0% 0% 0%

Cystitis: Female; 3-4 episodes< 1 year ago

0-20% 0-20% 0-20% 0-10% 0-10% 0%

Cystitis: Males; 1 UTI within past year 0% 0% 0% 0% 0% 0%

Cystitis: Males; > 1 UTI withinpast year

IC IC IC IC IC IC

Interstitial Cystitis asymptomatic,managed with prescription medication

IC IC IC IC IC IC




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