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Frequently Asked Questions

 

Does Symetra have an actively-at-work provision? No.
Does Symetra have late entrant or act of war exclusions? No. Our stop loss policy does not have exclusions for late entrants or those actively at war.
Does Symetra have coordination of benefit reductions? No.
What are the transplant limitations and exclusions? There are no exclusions or limitations for transplants.
Will Symetra laser or carve-out any claimants when quoting new business?
On rare occasion, Symetra may provide this option if it is determined that a laser is needed because of a known claimant's condition or claim potential and the policyholder is in agreement.
Will Symetra ever laser a claimant at renewal? Symetra will not introduce a new laser at renewal unless specifically requested by the policyholder or administrator.
What is Symetra's renewal process?





Groups are typically reviewed for renewal by utilizing information through 10 months of the open policy period. The group's demographics, geographical break-out, managed care networks, policy, and Specific deductible level are some of the items used to develop a Specific manual rate along with the group's reimbursement history. For Aggregate coverage, the prior period, open period and running 12 months of first-dollar-claims data is reviewed and an attachment point is determined.
Does Symetra require the Specific level to be within a certain percentage of the Aggregate? Symetra's standard Specific deductible is within a range of zero to 15 percent of expected claims, depending on case variables.
Does Symetra offer special types of policies such as 24/12, 18/12, etc.? The following options are available for both Specific and Aggregate: incurred and paid (12/12); run-out (12/15, 12/18, etc); run-in (15/12, 18/12, 24/12) and paid.
When a case is written on a paid basis, is there a run-in limitation on the amount and/or the time? For new business there may be limits imposed on the dollar amount of run-in claims allowed. Typically on renewals there are no run-in limitations on a paid policy.
What is the minimum size group for Aggregate only? Symetra will consider Aggregate-only quotes on a case-by-case basis.
What is needed to bind coverage?


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Coverage is bound once the disclosure statement, deposit premium and any other qualified information is received and approved by Symetra. Typically this is 30 days prior to the effective date and no more than 15 days after the effective date.
What changes in the census can cause a change in rates or liability limits?




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We reserve the right to establish new premium rates and new monthly Aggregate attachment factors at any time during the policy period if one or more of the following occur: a.) the number of enrolled covered units changes by more than 25 percent, b.) Symetra discovers an individual who was not disclosed, who should have been, and whom Symetra determines to be an unacceptable risk, c.) an amendment is made to the employee benefit plan; or d.) a change in the terms of the stop loss coverage occurs.
Does Symetra's second year policy automatically renew as a paid policy?


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The renewal policy terms are usually determined in coordination with the in-force policy basis in order to avoid gaps in coverage. Incurred, paid and run-in policies will normally renew on a paid basis. If the previous policy is a 12/15 or other run-out policy, a paid renewal is not quoted unless specifically requested by the client.
Does Symetra increase the Specific stop loss pooling point from one year to the next?
Not unless specifically requested, or as the result of a plan amendment/change that could include significant growth (e.g., adding a subsidiary) during the plan year.

To what extent is Symetra amending their stop loss policies due to the ACA, including the external review process and IROs?








 

Symetra's policies are designed to follow the eligibility and eligible expense criteria of the employer's benefit plan. This design helps eliminate gaps between what plans will pay for and what we will reimburse.

No changes have been made to our stop loss policies as a result of the ACA, the external review process, or IROs. However, the following statement will be included on the Schedule Page of each policy:

"Claims determined to be eligible under the Employee Benefit Plan in final and binding external review by independent review organizations (IROs) will also be deemed Covered Expenses under the Policy. Claim exception requests pending and under IRO review at the end of the Policy Period will continue to be considered for coverage."

​What is Symetra's position with respect to determinations made by IROs? ​Claims determined to be eligible under the plan in final and binding external review by IROs will also be deemed eligible under our stop loss policy.

If a claim goes to external review, and an IRO decides that the claim is valid, will Symetra honor that determination?

Yes.

 

Does Symetra have to approve the IROs that plan sponsors elect to utilize?

 

 

 

 

No.

 

 

 

 

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