Aetna Health Insurance Requirements

We want to clarify the Aetna health insurance underwriting requirements when a doctor’s visit is needed in order to approve applications. The doctor’s visit must be performed by a Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner/Certified Registered Nurse Practitioner (NP/CRNP) or Physician Assistant (PA).

Age/timeline requirements

Newborn through age 17:  The application must include a doctor’s visit within the past 3 years. If there is no doctor’s visit, a current medical exam (within the last 6 months) and physical is required. The only exception to this policy would be a newborn, under 31 days old, or a newly adopted child who is being added to a policy without underwriting.

Age 18 through age 30: The application must include a doctor’s visit within the past 5 years.  If there is no doctor’s visit, a current medical exam (within the last 6 months) and physical is required.  A physical must include height, weight, and a blood pressure reading.

Age 31 through age 49:  The application must include a doctor’s visit within the past 5 years.  If there is no doctor’s visit, a current medical exam (within the last 6 months) and physical is required. A physical must include height, weight, a blood pressure reading and lab results for blood sugar and cholesterol.

Age 50 and older: The application must include a doctor’s visit within the past 2 years. If there is no doctor’s visit, a current medical exam (within the last 6 months) and physical is required.   A physical must include height, weight, a blood pressure reading, and lab results for blood sugar and cholesterol.

If the Aetna health insurance underwriter determines (either through outreach to an applicant in a phone interview or by review of medical records) that the applicant has not had a doctor’s visit within the required timeframes, the underwriter will close the application.

The Aetna health insurance underwriter will document the information that is required to be considered for enrollment and a written letter will be sent to the applicant to advise that their application has been closed.

Example: A 50 year old applicant applies for Aetna health insurance coverage with no medical history.  A telephone interview is conducted and at that time, the applicant confirms that he/she has not seen a physician in over 5 years.

At that time, the clinician performing the telephone interview will advise the applicant during the conversation that “To proceed with underwriting your application, the results of a current physical exam is required.  This includes but is not limited to: height; weight; blood pressure; lab results for cholesterol and fasting blood sugar; and past medical history.

Your application can be continued if you submit this documentation to the underwriting department within the next 30 days.  You may fax this information to (866) 223-2041.”  The applicant should identify on the fax that this is a “Request to reopen their application” and they should include their closed letter.

Leave a Reply

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.