Plan Documents & Eligibility

Optum Stop Loss Policy language does not contain an “Active at work” provision. Optum relies solely on the underlying Plan Document language to determine eligibility.

Optum's Stop Loss policy does not have the right to create or modify eligibility for an employer - that is defined by the Plan and Policyholder. If the current Plan Document is written in such a manner that it would provide coverage for furloughed employees, or employees on leave of absence, then Optum's Stop Loss Policy would follow the Plan Document.

If the current Plan Document language does not allow for these employees to be considered eligible, then Optum will require a Plan Document amendment stating the new eligibility requirements.

Optum is willing to accept an email correspondence that clearly outlines the plans intent in changing eligibility requirements. Optum will accept the eligible changes with an effective date no sooner than February 4, 2020 (the date the COVID19 ICD10 code became available).

However, Optum does request that formal plan amendment be provided with the same eligibility changes by either the renewal date or August, 1, 2020, whichever is the earliest date

Layoffs & Furloughs

Please see "Plan Documents & Eligibility" section above.

COBRA Extension Guidelines

We are responding to your inquiry on the DOL Guidance that was released on April 28, 2020. 

While the law is not completely set in stone, we are moving forward as if it will be final within the next few days. As a reinsurer, we are abiding by the provisions of the law as written that pertains to the following:  Disregard the “outbreak period” as it pertains to:

  • 30/60 day period to request special enrollment
  • 60 day period to elect COBRA
  • Due date for COBRA premium
  • Date for individuals to notify the plan of a qualifying event, or determination of disability
  • Date which individuals may file claims
  • Date in which individuals may file an appeal of an adverse benefit determination

We believe that assessing risk and the claim adjudication process may be more complex during this period, but we will follow the legislation as written.

Actively at Work & No Scheduled Shifts

Optum Stop Loss Policy language does not contain an “Active at work” provision. Optum relies solely on the underlying Plan Document language to determine eligibility.

Early Rx Refills

Policyholders that modify plan benefits to allow an early refill on one time per medication basis can do so at no impact to specific and aggregate premium.

To make these changes, the Policyholder will need to send Optum an email outlining their coverage decisions and the effective date of the changes. Optum will allow the effective date to be as early as February 4, 2020 (the date the COVID19 ICD10 code became available).

Optum will also need to receive a Plan Document amendment reflective of the change in this email no later than August 1, 2020, or prior to the renewal date.

Telemedicine & Virtual Visits

Policyholders that modify plan benefits to remove member copays as it relates to telemedicine during the COVID-19 pandemic may do so at no impact to specific or aggregate premium.

To make these changes, the Policyholder will need to send Optum an email outlining their coverage decisions and the effective date of the changes. Optum will allow the effective date to be as early as February 4, 2020 (the date the COVID19 ICD10 code became available).

Optum will also need to receive a Plan Document amendment reflective of the change in this email no later than August 1, 2020, or prior to the renewal date.

Cost Shares

If a policyholder makes the determination to cover the testing and treatment of COVID-19 without applying a deductible or coinsurance to the covered person, Optum will allow that modification to plan benefits at no change to premium rates.

As this is a change in plan benefits, we will require written communication in the form of a letter or email, with a plan document amendment to follow no later than August 1, 2020, or the end of the plan year, whichever comes first.

Special Enrollment Periods

Optum has many Policyholders that are requesting information on special open enrollment periods for employees that have not previously elected coverage and now are interested due to COVID-19 pandemic. Optum's current decision is that they would not be willing to accept these special enrollments under the Stop Loss Policy. Optum is continually monitoring regulatory updates and if legislation is provided that addresses such open enrollment periods, they will review and update our procedures as necessary.

Preauthorization Requirements for Scheduled Surgeries or Hospital Admissions NY State Law

Optum will support a Policyholder that choses to follow the legislation in New York concerning waiving the Preauthorization and Utilization Management requirement. By waiving these plan provisions it will not nullify an eligible claim under the plan and Stop Loss Policy. The Administrator of the plan is still responsible for reviewing and validating that charges are appropriate and that they are medically necessary pursuant to the provisions in the Plan Document.