January 1st, 2021, all hospitals are required to display at least 300 “shoppable medical Services “that a health care consumer can access prior to having a procedure. The goal is to give greater transparency to people who wish to be better consumers of health care.

The medical providers are supposed to display these services in a “consumer friendly’ format. They have to list:

  • Discounted Case Price The cost of the procedure for someone that pays cash.
  • Payer-Specific Negotiated Charge This is the charge the hospital has pre-negotiated with third-party payers like an insurance network.

De-Identified Maximum Negotiated Charge: The highest charge the hospital has negotiated with a third party.

Let’s look into the transparency rules and how they actually work in central Indiana. We thought we would look at Community, St Vincent’s (Ascension) & IU Health.

First, finding the transparency page is not easy as it does not show up on the website’s first page. We would expect the medical providers to have the link at the bottom of the page. On a couple of the medical providers, we had to search for the transparency page through a search engine as we could not find it. Once you find the transparency link be prepared to enter your health insurance information. This allows for the “Payer Specific Negotiated Charge- to be shown.

Next, you will need to brush up on your medical billing coding, which is necessary to get to the “user-friendly” transparency information. We thought we would use CPT code 73718- MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL

St Vincent’s Carmel– List the procedure at $1,185 after insurance. The cash discount price is $570.

IU Health is taking our insurance information and running an electron feed where you can see where you are year to date on your deductible and how much of the procedure would apply to your out-of-pocket max. IU is not allowing a quick CPT code search but a more in-depth definition of the procedure.  IU estimates the cost $3,732.88 with a network discount of $2,227.13 = $1,505.75 & professional charge of $159.07 services. We run the costs with no insurance, “Discounted Cash Price” $893.72 and professional service $219. At IU Health, the procedure would cost the insured less to go with the cash discounted price.

At the Community Health Network, we can use the CPT code with the insurance policy, and it takes us directly to the cost of the procedure. The total list fees $2,536- Then Insurance covers $1,836, which is the insurance network discount, and you pay $700. If we remove the insurance and look at the cost, $2,536 is still the charge with a $1,014 discount leaving the patient with $1,522.

We looked at a few of the surrounding hospital’s transparency:

Parkview Noble– Unreadable chart.
Franciscan Health– $3,147 with a network discount of $1,979, leaving a balance of $1,168

Quick Recap of the “consumer-friendly” transparency report:

  • IU Health- $1,505 after insurance
  • IU Health- $893.72 with no insurance/Cash discount.
  • St. Vincent’s- $1,185 after the network discount.
  • St. Vincent’s- $570 with the cash discount.
  • Community Health- $700 after insurance
  • Community Health- $1,522 Cash discount.
  • Franciscan- $1,168 after Insurance.

To shop out one CPT code with multiple hospitals took a couple of hours. It isn’t easy to find the transparency tabs on the hospital’s web page. After finding the search tab through additional search engines, you have to click through multiple pages to get results. Each site has different requirements to search. One needs basic medical knowledge on the procedure they are researching along with the CPT code.

There is now a path to research the cost of medical procedures. The medical provider is not making it easy, but they are doing their best to provide information. Until the process becomes streamlined, which is a will, many consumers will not know how or have the resources to research the cost, but there is the option of calling the hospital.

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Under the Affordable Care Act, an employee can qualify for premiums assistance if the current employer costs more than 9.83% of the employee’s income.  The “family glitch” is where the dependent’s costs are more than 9.83% of household income. Still, they do not qualify for premiums assistance because the affordability is based on the employee costs.

The “family glitch” may become a topic of debate as President Biden did indicate this is an issue his administration may take up.   The President noted that they would change the premium assistance eligibility for dependents, which would open the door for dependents on purchasing policies on the exchange with premium assistance.

Why does the “Family Glitch” matter?Affordable Care Act

The Kaiser Family Foundation reported that individuals impacted by the family glitch are in good health, which could be as high as 5.1 million.  For Indiana, KFF estimates 121K dependents would fall into the “Family Glitch.” Indiana’s 2021 open enrollment had 136K people enrolled in the federal marketplace. 

Indiana’s peak enrollment was in 2015, with 218K people enrolled and eight carriers offering coverage.  If all sudden that enrollment number doubled with healthy young people, that could lead to lower individual rates and possibly more carrier participation.  

The majority of Hoosier that falls into the family glitch is reported as low income, which could produce lower monthly costs but lower out of pockets through cost-sharing reduction on the exchange.  

From an employer standpoint, a company may change their contribution strategy if they know their employees’ dependents could get lower costs going through the exchange.  

The “Family Glitch” could be an issue that gains bipartisan support, leading to additional changes in the health insurance markets.

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President Biden officially signed into law H.R 1319 aka American Rescue Plan Act of 2021 on March 11, 2021.   One of the goals of the law is to expand Health Insurance by making it more affordable.

Marketplace Tax Credits Expansion on Health Insurance

Under the new law, people that purchase individual and family Health Insurance through the federal marketplace could see their monthly premiums drop.

Currently to be eligible for the tax credit aka premiums assistance household income has to be under 400% of the federal poverty level.   Under the new law, the 400% requirement is being lifted. It’s not clear what the income cap is going to be or if there is going to be an income cap.  

Currently, those that qualify for premium assistance pay no more than 9.83% of their household income towards premiums.   Now qualify subsidies recipients will not pay more than 8.5% towards Health Insurance premiums.   Those making less than 400% of the FPL could pay as low as 2% of their income for the Individual health insurance policy. 

Health Insurance Premium

If there is indeed no cap in household income for premium assistance, we could see a huge migration to the individual market.   Small groups with less than 20 employees could see participation drop off.


Under H.R. 1319 the government will fully subsidize 100% of COBRA premiums for those employees that were laid off, furloughed, or had a reduction in hours.   This should allow any employee that qualifies to continue the group health to keep that coverage in place with no cost to them.  In fact, the subsidized cobra premium may be lower than what they were contributing as a full-time employee.   Employees that leave employee voluntarily are not eligible for the premium assistance.  This benefit will expire in September of 2021.  

The American Rescue Plan is going to have a huge impact on the individual Health Insurance markets.  We will see a large portion of individuals that have purchased a short-term, med share, & indemnity policies return to the exchanges because now they will qualify for premium assistance. 

Small employers with less than 10 employees that are offering group health plans may be forced to drop coverage because of participation issues.

As always, Nefouse & Associates is in a position to provide our client with the best Health Insurance options.

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The Covid-19 pandemic has changed everything in our society, and now we could see job classes change for all size companies.  Through the pandemic, it has been proven employees can be productive working remotely and, in some cases, more productive. We are seeing different employee class terminology being thrown around by tech companies:

Flex employee- This class of employees comes onsite maybe a couple of times a week.
Fully Remote- Just like it sounds, this class does not visit corporate headquarters.
Office-Based- Traditional workforce that comes into the office every day. It predicted this would be the smallest class of employees in the future.

What impact will the new work classes have on Insurance Benefits?

Large Corporations:

Most large company’s HR departments are already well versed in recruiting remote employees. They are in tune with their current insurance offerings, especially if their health benefits have a national provider network. The national provider network is critical when determining if that remote employee will have access to their local medical providers.  

They also have the resources in place to understand different state laws that impact them hiring remotely.  

Medium-Sized Companies:

Companies with under 500 employees may find obstacles when most of their employees become remote. These companies will have to evaluate their current group health insurance to see if they offer national networks with adequate network access for remote employees.  They will also have to analyze their network access fees and determine if they are paying too much to use that network.   There will be multiple areas that HR and CFO’s may have to look at that in the past were nonissues.  The state compliance piece could create additional administration responsibilities; otherwise, they have not had to address.

Small Companies

Companies under 200 lives with limited resources for HR will find themselves leaning heavily on their advisors for guidance.  HMO networks’ re-emergence with attractive cost savings and integrated care models may not work for remote employees.  Small groups may be forced to consider outside of the box options for remote employees.  The new Health Reimbursement Accounts could play a role in providing a tax-free benefit to out of state employees.   Small companies are going to have to adopt a digital onboarding system. The day’s of sending paper PDF’s of Insurance Benefits is not going to give an out of state/remote employee the best second impression of their new employer.  Small groups should consider a customized benefit admin system that a new hire can log into from a mobile device whenever they want and view plans and cost before making plan selections.  If you are going to recruit remote employees, having a benefits admin platform is essential. We see groups give the prospective employee access to the benefits offering prior to them deciding to accept the position.

Insurance Industry:

The insurance industry is going to have to adjust to the future employee classes. One of the first things is they will have to change requirements in their insurance contracts of x % of employees being domiciled in the home state, which is common with fully insured contracts—developing plans that address multiple out of state pharmacies being in the network.  We could see what was once considered a radical approach of all mail order being the norm. 

The Increase network provider will continue to be an important aspect of every insurance contract, especially if we see a shift to remote employees living in rural communities.  The Insurance companies will also have to change the tax documents that use to prove an employee and employer relationship (Wage N Tax).  Every state has different filing requirements.

How is Nefouse & Associates Inc Adjusting?

We have been handling clients that have been engaged in hiring remote employees for over two decades. In the last five years, the remote employee has become more than just a trend.  We have had to address these issues and additional for our clients as they have had to engage in remote hiring.

With the prediction that most employees could be remote, this could create a huge obstacle for small companies who now must quickly change and adapt to this new environment.  These issues are not new, but they may become new for many small Indiana employers who must change their company culture.  Some companies may not be ready to address these challenges on their own.

Recently a wise and successful entrepreneur said, In the past, we have had to reinvent ourselves every seven years, now it’s every three years. This new employee class may be an area where employers must reinvent themselves.

We can help you with your Insurance Benefits!


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President Biden has issued an Executive Order creating a Special Enrollment Period (SEP) in response to the COVID-19 national emergency.  According to the Centers for Medicare & Medicaid Services, all states that operate a federally-facilitated exchange will have a SEP for all uninsured or underinsured people.  The SEP will begin on Feb. 15th, 2021, and continue through May 15th, 2021.

A Special Enrollment Period allows for an election of new coverage or changing existing coverage. Also known as a qualifying life event. 

Indiana is one of the 36 states that use to distribute Individual marketplace health insurance.

Starting Feb. 15th, any Hoosier that does not have health insurance can apply for coverage without providing any documentation to prove they have a qualifying life event.  Most of the population is well aware of the strict open enrollment periods associated with the individual health insurance through the exchange. A segment of the population is not familiar with open enrollment periods, and this SEP could benefit them in obtaining health coverage. 2020 we have seen many people lose employer-sponsored coverage with little to no experience in the individual health insurance markets. The COVID-19 SEP may benefit these people with a second chance to evaluate their current health insurance options.

During the COVID SEP, the marketplace will not require any documentation to certify a qualifying life event has occurred.  

CMS is going to spend $50 million on promoting this Special Enrollment Period which should create awareness to those that may benefit. 

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As President Biden becomes the next President of the United States, we are starting to get a glimpse of the agenda when it comes to health insurance.

President Biden has strong support for the Affordable Care Act, and every indication is that support will continue under his presidency. The recent proposal called the American Rescue Plan provides an outline to increasing access to health insurance and medical services.

The impacts of the COVID pandemic many Americans have lost access to employer-sponsored health insurance. President Biden is calling on Congress to subside COBRA premiums until the end of September 2021. The federal government would cover 100% of the cost for employees that lost employment but wish to continue their employer group health insurance.

This is not a new concept and was first used during the 2008 financial crisis. At that time, employers paid the Cobra premium and then deduct that cost from their federal tax liability.   Fast forward to 2021, and this prevents people from moving to the marketplace even if they qualified for assistance because the COBRA would have no monthly cost.

The American Rescue Plan also looks to expand and increase the premium tax credit on the health insurance marketplace.  Those who qualify for assistance would not pay more than 8.5% of their household income towards health insurance premiums.  Under the ACA, household income has to be below 400% of the federal poverty level to qualify for premium assistance. It’s not clear in the American Rescue Plan outline if that 400% FPL threshold would change.   If there are changes in the requirements to qualify for premium assistance, this could have a considerable impact on the health insurance markets.

When the Affordable Care Act was first launched, small companies had an enormous shift and how they offered insurance benefits.  Most companies with less than 20 employees dropped their group health plans and moved their employees to the individual marketplace.  When the individual marketplace collapsed from a network access standpoint and large increase, the small employer moved back to the group health plans. If more employees can qualify for premium assistance, we could see another shift away from employer-sponsored health plans.

We will not know the true impacts on health insurance until the details are released on the American Rescue Plan, but it is fair to say that we see more government support of the Affordable Care Act.



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The surprise Medical Billing fix has been included in the Covid-19 relief deal, which would protect patients from receiving large medical bills from out of network providers.

The bill calls for patients to be held harmless in emergencies where they have no control over where they receive medical services, especially when it comes to ambulance services. The patient will still be required to pay for out of network services, but those charges must be reasonable.

Health Insurers and providers will have to negotiate the out of network medical charges or bring the issue to a mediator. The law would forbid insurers from using Medicare reimbursement rates as the benchmark and bars providers from using their billed charges as the benchmark. The new system will take place in 2022.

For Hoosiers, surprise medical billing has been a real issue. Very few ambulance services participate in any insurance network, which has resulted in surprise medical bills. We have also seen on multiple occasions where the anesthesiologist is not in the insurance company’s network. The patient has little to no say on who performs the anesthesiology during a procedure.

Then there is the latest trend of emergency physicians not participating in a carrier network even though they appear to be employees of the hospital group. All the situations have led to Hoosiers receiving surprise medical bills outside of the health plan.

It is important to remember that even with the new Medical Bill fix, a patient may have satisfied their in-network deductible but the out of network claims go to a separate deductible. The patient could still have a financial burden, but now at least it’s one that is manageable.

In 2022 it will be interesting to see how the arbitration pans out. This could lead to more health care cost transparency in Indiana and the rest of the country.

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The 2021 Individual Health Insurance open enrollment is in full swing.  Originally started on November 1st and will end on December 15th, 2021. Don’t wait until the last minute to finalize your enrollment. History has shown that the marketplace will have problems in the last couple of days of open enrollment due to high volume.

With us being at the halfway point of the open enrollment, most of the glitches have been worked out on the marketplace and the insurance companies.  Some of the problems have been with the networks not showing correct participating providers. It’s always a good idea to call your physician’s off to confirm if they are participating in one of the Indiana individual networks.

The Individual health insurance options for Indiana.

On the exchange aka marketplace aka Federal Facilitated Exchange aka

We have CareSource and Ambetter offering coverage in all Indiana counties and Anthem is offer coverage in a few counties.

CareSource has the lowest costing plans. Ambetter has a larger network.

If your household income is under 400% of the federal poverty level, you could qualify for premium assistance.   If you are eligible, then the health insurance policy may only cost you about 9% of your income. If you are under 200% of the poverty level, then you may qualify for HIP 2.0 through the state.

Off-Exchange AKA outside of Obamacare

Anthem is offering an individual policy that is about 30% less than the marketplace. This policy does require medical underwriting to get approved but does cover preexisting conditions.

Ambetter- Is offering an off-exchange policy for the entire state of Indiana.  Little bit different plan designs, and the premium is less than on exchange offerings.

Short term policies- these are 60% less than marketplace plans but are medically underwritten. These plans do not cover preexisting conditions but can be the right solution for healthy Hoosiers.

Indiana is slowly starting to get more Individual Health Insurance options. If you qualify for premium assistance, then on the exchange is going to be the best option.

If you are healthy and do not qualify for premium assistance, then off-exchange may work from a cost standpoint. Once we can determine if on or off the exchange will work for you, then we narrow down the plan options. 

Contact us, and we will help you.

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Every year the insurance companies participating in the Indiana Individual Health Insurance market must submit their rates and plan designs to the Indiana Department of Insurance for approval.

Any Hoosier who has had to purchase health insurance in the Indiana Individual Health Insurance market know that we have only a few carriers offering coverage in the last few years. This has bee a point of frustration from network access and cost on premiums and out of pockets. With the impact of COVID, we have seen many Hoosiers lose their employer-sponsored insurance benefits, leading them to the individual market.

For 2021, we have just three health insurance companies participating in the Indiana Indiana Individual Health Insurance market:

  • CareSource Indiana Inc.
  • Celtic Insurance company (MHS/Ambetter)
  • Anthem Insurance Companies, Inc.

CareSource offered health insurance in all 92 Indiana counties in 2020 and will continue in 2021. They have requested an average rate increase of 4.30% for their 2021 plans. They will offer 3 Bronze, 6 Silver, & 2 Gold plans.   

Celtic/ Ambetter- Will offer coverage in all 92 Indiana counties, and the average requested rate increase is 14.30%. They will offer 4 Bronze, 16 Silver, & 4 Gold plans on the exchange.   

Ambetter is also going to offer off-exchange plans in 2021. This is worth noting as these plans may cost less than plans on the exchange. Off-exchange, they will offer 12 silver plans and 4 gold plans in all 92 Indiana counties.

Anthem is going to offer Indiana Individual Health Insurance plans in 8 counties, which is an expanded form 2020. Off-exchange, Anthem will offer a 1 catastrophic plan in Benton, Jasper, Newton, Warren, and White Counties.  

On-exchange Anthem will offer 2 bronze, 1 silver, and 1 gold plan in Lake, LaPorte, and Porter counties. With estimated 700k residents of these three counties, this is Anthem return to the individual exchange market. The cost of Anthem plans higher than CareSource and Ambetter, but depending on which anthem offers, this could be a solution. It would a surprise if Anthems offers their PPO network, but instead, their HMO network called Health Sync.

We hope to have all plans approved and released by the middle of October.

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If you work or own a small business, you may be familiar with using HRA’s to help reimburse employees for individual health insurance. This strategy has been around for over a decade and has always been controversial under the tax code.

Small businesses that have struggled with group health insurance costs and participation requirements have utilized the HRA approach to offer employee benefits. Many of these small businesses are in industries or locations with lower compensated employees who qualify for Medicaid or under the Affordable Care Act qualify for subsidized health insurance (premium tax credits).  This has created a tax advantage for both the employer and individual regarding individual health insurance.

The Government has now changed the regulations for HRA’s in conjunction with Individual health insurance reimbursements. If an employee participates in a company-sponsored HRA, they can no longer receive premium tax credits.  This will negatively impact a lot of Hoosier that are not aware of these new regulations resulting in the paying back of all the premium tax credit one receives.

Here is an example of what is going to happen.  An employee of Company X works for a company that provides $400 a month in an HRA benefit. The employee has a family of 5 with a household income of $80,000, which qualifies them for a tax credit/premiums assistance of $1,053 a month.  The plan they choose on the marketplace costs $1,549 a month. Subtract the $1,053 tax credit, $400 HRA benefit- Now, the employee’s health plan for their entire family costs $96 a month.  Great deal!

Now when that employee goes to filer their taxes, they will be required to pay the tax credit back. $12,636 This will create severe hardships for families that will not be aware of the new rules.  Most employers offering the HRA do not have time to stay compliant on new rules and regulations, so they will not know, which leads to a massive surprise to the employees and employers.

For 2021, employers may want to reconsider offering an HRA if they suspect their employees will qualify for subsidized premiums on the exchanges.

Here is a link to that provides more details.


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