Medical Group Benefits Underwriting Guidelines
Quality Group Insurance Benefits with Exceptional, Customized Service
nipponlifebenefits.com Nippon Life Insurance Company of America®. Global plans are available to foreign-owned companies operating in the U.S., with over 101 employees worldwide, and where substantially all of the enrolled employees are expatriates. Nippon Life Insurance Company of America (Nippon Life Benefits), NAIC number 81264, is a member company (subsidiary) of Nippon Life Insurance Company of Japan (“Nissay”). Nippon Life Benefits is responsible for its own financial condition and contractual obligations.
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NLB 30747 09/2026
Protection for What Matters Most Since 1991, Nippon Life Benefits has delivered customized employee benefits with a commitment to quality, compassion, and respect. Our flexible offerings include Medical, Dental, Life, Disability, and Vision coverage, supported by multilingual service in Japanese, Korean, and Spanish. Nippon Life Insurance Company of America holds an A- (Excellent) rating from AM Best. As the U.S. subsidiary of Nippon Life, one of the world's largest mutual life insurers with over $656 billion in assets and an A+ (Superior) AM Best rating, we bring global strength and stability to our clients.
Medical Plan Options
• Evolution PPO Plans: Flexible deductible, copay, coinsurance, and out-of-pocket options. • Evolution PPO Value Plans: PPO coverage with incentives for in-network care.
• Evolution HDHP Plans: Cost-effective, high-quality coverage that can be paired with an HSA. • Evolution HDHP Value Plans: Lower-premium HDHP options that encourage in-network use.
National PPO Networks
• Aetna Signature Administrators (ASA): More than 1 million providers and 6,400 hospitals nationwide. • PHCS: More than 1 million providers and 4,700 hospitals with nationwide access.
International Benefits Plan Powered by Aetna International
• Coverage for healthcare needs while traveling abroad.
• Same coinsurance, deductibles, and out-of-pocket costs as U.S. in-network benefits (benefits don’t crossaccumulate). • 24/7 member support in 240 languages.
Prescription Drugs •
Prescription coverage through CVS Caremark, with access to 60,000+ pharmacies nationwide.
Lab Testing Benefits • • •
Outpatient lab services through Quest Diagnostics®. QuestSelect™ offers covered lab testing at no cost, with no deductible, copay, or coinsurance. HDHP members receive discounted lab testing through QuestSelect™.
Teladoc® •
24/7 access to U.S. board-certified doctors and mental health
Care Management • • •
Utilization and Case Management support employees who may need additional care. Evidence-based guidance helps ensure the right care at the right time. Integrated technology and targeted outreach support employees with complex health needs.
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Prenatal Care Program • •
Special Delivery provides no-cost support for expectant mothers. Includes a voluntary health screening, pregnancy guide, and 24/7 access to pregnancy resources.
Organ Transplant
• Access to leading transplant care through OptumHealth (Members in PHCS) and Aetna Institutes of Excellence™ networks.
Wellness Services (Powered by ActiveHealth)
• Included with every medical plan at no additional cost. • Wellness portal with health assessments, records, and educational resources. • CareEngine identifies care gaps and improvement opportunities to support better health outcomes.
Active&Fit Direct®
• Access 12,000+ online workouts and 12,500+ fitness centers, plus personalized wellness coaching with no long-term contract.
Employee Assistance Program (EAP)
• 24/7 support for emotional, legal, financial, childcare, and eldercare needs. • Available by phone, web, app, chat, and in-person counseling. (Groups with 2+ lives.)
Additional Employer Offerings* Healthcare Accounts
• Tax-advantaged FSA, HRA, and HSA options to help manage qualified healthcare expenses.
Employee Assistance Program (EAP)
• 24/7 support for emotional, legal, financial, childcare, and eldercare needs via phone, web, app, chat, and counseling.
IdentityForce® ID Theft Protection
• Monitors identity and credit activity with expert restoration support if identity theft occurs.
Ancillary Benefits • Dental Provider Networks: Access to Aetna Dental, Careington, Connection Dental, and DenteMax networks with 500,000+ provider locations nationwide. • Vision (Powered by EyeMed): Coverage for exams, lenses, frames, and contacts through a network of 154,000 providers. • Life Insurance: Affordable Basic, Dependent, and Supplemental Life coverage. • AD&D Insurance: Additional protection for accidental loss of life, limb, or eyesight. • Disability Insurance: Short- and long-term disability protection during illness or injury. • Online Benefits Management: Easy benefits management through our website and mobile app. *Additional Employer Offerings pricing available upon request.
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General Guidelines Eligible Groups
Eligible groups generally include corporations, partnerships, and sole proprietorships where a bona fide employeremployee relationship exists. Groups must satisfy all applicable federal and state requirements for employersponsored group health coverage.
Ineligible Groups
Multiple Employer Trusts (METs), Multiple Employer Welfare Arrangements (MEWAs) , Multiple Employer Associations, Associations, Taft-Hartley Welfare Funds, Employee Leasing Firms, Professional Sports Teams, Franchise Groups, and Professional Employer Organizations (PEOs) are not eligible for coverage unless specifically permitted and approved by Underwriting and applicable law.
Required Enrollment
A minimum of one eligible employee must be enrolled. Groups must have more than 100 full-time employees nationwide. For groups with fewer than 51 eligible employees in New York or California, coverage is not available. For groups situated in New York or California, a minimum of 101 full-time employees is required.
Eligible Employees
All full-time employees who satisfy the applicable eligibility requirements are eligible to participate in the medical plan. Eligibility must be determined in accordance with applicable federal and state law and the employerestablished eligibility criteria. Owners, sole proprietors, partners, officers, trustees, and directors are eligible only when they meet the applicable definition of an eligible full-time employee.
Ineligible Employees
Seasonal employees, temporary employees, and independent contractors/1099 workers are generally ineligible. Coverage of individuals classified as 1099 workers requires prior Underwriting approval and must comply with applicable federal and state requirements.
Eligible Dependents
Eligible dependents generally include a lawful spouse and dependent children through age 26, in accordance with applicable federal and state requirements.
Carve Out Groups
Proposals involving employee class carve-outs or eligibility exclusions require prior Underwriting approval. Any allowable class distinction must be based on bona fide employment classifications, such as management/nonmanagement, salaried/hourly, union/non-union, geographic location, or rotational/non-rotational status, and must comply with applicable law.
Retirees
Plans providing coverage to retirees require prior Underwriting approval. For retirees age 65 and older, Medicare is primary and the Nippon Life Benefits plan will generally pay secondary to Medicare, subject to applicable Medicare Secondary Payer requirements. Retiree enrollment should generally not exceed 10% of total group enrollment unless otherwise approved by Underwriting. For Illinois governmental groups, retiree enrollment may be permitted up to 20%, subject to applicable requirements and Underwriting approval.
COBRA/State Continuance
COBRA and applicable state continuation participants are subject to Underwriting guidelines. COBRA/state continuation enrollment should generally not exceed 10% of total group enrollment. Groups exceeding this threshold require prior Underwriting approval.
Policy Situs Availability
Medical coverage is currently available in California, Delaware, Georgia, Illinois, Indiana, Kentucky, Michigan, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Texas, subject to applicable state requirements and regulatory approval.
Minimum Hours
Eligibility for full-time employment must comply with applicable federal and state requirements. Unless otherwise required by applicable law, the standard minimum eligibility threshold is generally 30 hours per week.
Effective Date
Group coverage may generally become effective on the 1st or 15th of the month. Groups with a 15th-of-the-month effective date will generally have an initial policy period of approximately 12½ months. Exceptions require prior Underwriting approval.
Waiting Period Requirement
Employer-sponsored medical plans may not impose a waiting period exceeding 90 days, consistent with applicable federal requirements. Any eligibility/waiting period provision must comply with applicable federal and state law.
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General Guidelines (Continued) Participation
There is no minimum participation requirement imposed by these guidelines, unless otherwise required by applicable law, regulatory requirements, or the terms of the applicable product. Underwriting may review participation levels as part of the overall risk assessment.
Employer Contribution
No minimum employer contribution requirement is imposed by these guidelines, unless otherwise required by applicable law, regulatory requirements, or the terms of the applicable product. Employer contribution levels may be considered as part of the overall underwriting assessment.
Pre-Existing Condition
In accordance with applicable federal and state requirements, group health plans do not exclude eligible individuals from coverage based on pre-existing conditions.
Rate Guarantee
Medical rates are generally guaranteed for 12 months, subject to the terms and conditions of the applicable policy and any requirements under applicable law.
Dual Medical Options
Groups with 10 or more enrolled medical members may generally offer two medical plan options. At least one actively enrolled employee must be enrolled in each plan option. If a group currently offers only one medical plan and requests the addition of a second option, additional pricing may apply based on the applicable underwriting guidelines.
Annual Open Enrollment
Annual open enrollment is available as a standard feature of the medical plans, subject to the applicable plan provisions and administrative requirements.
PPO Networks
Available PPO networks include ASA and PHCS, subject to product availability and applicable network requirements.
ASA PPO Network Requirements
Groups utilizing the ASA PPO Network must meet applicable network requirements. At least 80% of the enrolled population must select the ASA PPO Network. A minimum 20% coinsurance differential between in-network and out-of-network benefits is generally required, except where otherwise permitted under applicable plan/network guidelines. ASA is not available to certain existing Aetna medical clients pursuant to applicable network contractual requirements.
Years in Business
There is no minimum number of years in business required under the standard underwriting guidelines. Start-up organizations may be considered subject to Underwriting review and applicable eligibility requirements.
Application/Forms
All required application materials and forms must be completed and signed by an authorized officer or representative of the employer. Documentation must generally be submitted no more than 60 days prior to the requested effective date, unless otherwise approved by Underwriting.
Claims Experience Requirement
Claims and enrollment experience is required for groups meeting the applicable enrollment thresholds. For most states, experience is generally required for groups with 150 or more enrolled employees. California requirements may differ based on enrollment size. Level-funded or self-funded groups may also require submission of available claims experience for Underwriting review. Exceptions require prior Underwriting approval.
Required Experience Documentation
When experience is required and available, Underwriting will generally request: (1) detailed enrollment/census information; (2) current benefit plan information; (3) current premium/rates; (4) renewal rates or renewal package, if available; (5) monthly claims and enrollment information for the most recent two-year period, when available; and (6) large claim information/reporting.
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Target Market Scorecard (TMS) Target Market Scorecard (TMS)
The Target Market Scorecard (TMS) is an underwriting and pricing discount program used to evaluate characteristics of prospective groups and determine whether an applicable pricing adjustment may be warranted. The TMS score, together with the applicable renewal rate increase and other underwriting considerations, may be used to determine eligibility for an additional pricing adjustment in accordance with established underwriting guidelines.
TMS Information Requirements
To evaluate a group for an applicable TMS pricing adjustment, Underwriting may request the following information: (1) current rates and the complete renewal package, when available; (2) benefit summaries or SBCs for all medical plans; (3) number of years with the current carrier; (4) employer contribution toward employee medical costs for each plan; and (5) nature of the employer’s business.
TMS Approval
Any pricing adjustment generated through the TMS is subject to applicable underwriting authority, pricing guidelines, and approval requirements. The TMS does not replace Underwriting’s overall assessment of the group.
Census Quoting Requirement
The following information is required on the census to rate: • First and Last Name of Employees and Dependents
• Relationship (Employee, Spouse. Domestic Partner, Child) • Zip Code
• Date of Birth (DOB) • Gender
• Medical Plan Name
• Medical Tier Structure
• Reason for Waiving Coverage
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Ineligible Industries Fishing, Hunting, and Trapping
Industries
SIC Code 0912-0972
Metal Mining
1011-1099
Coal Mining
1221-1241
Oil and Gas Extraction
1311-1389
Non-Metallic Minerals
1411-1499
Logging and Sawmills
2411-2429
Explosives
2892
Asbestos Manufacturing
3292
Primary Metal Industries
3312-3399
Local/Interurban Passenger Transit
4111-4173
Water Transportation
4412-4499
Drinking Places
5813
Liquor Stores
5921
Other Personal Services
7221-7299
Social Services
83XX
Amusement & Recreation
7911-7999
Membership Organizations
8611-8699
Educational Services
8211-8299
Public Administration (Executives, Legislative, and general Government)
9111-9199
Justice, Public Order & Safety
9211-9229
Policy Series NP 5500, et al, and Booklet-Certificate Series NBM 5100, et al is underwritten by Nippon Life Insurance Company of America® - marketing name Nippon Life Benefits®, NAIC number 81264, licensed & authorized in all states plus DC, except ME, NH or WY, domiciled in Iowa, with a principal place of business at 666 Third Avenue, Suite 2201, NY, NY 10017. Nippon Life Benefits is a member company (subsidiary) of Japan-based Nippon Life Insurance Company. Nippon Life Benefits is responsible for its own financial condition and contractual obligations. Benefits may vary by state. For costs and any further details of coverage, including exclusions, any reductions or limitations, and the terms under which the policy may be continued in force, see your Nippon Life Benefits representative.
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