Author Anthony Nefouse

When you have a health insurance policy in place and you end that coverage, you would usually receive a certificate of prior coverage. With that certificate, the new insurance company that you signed up with would then ask for that document to confirm you had prior coverage. In 2014 specifically, the insurance industry used the certificate to confirm your qualifying event.

This year Anthem stated that they would no longer mail out these certificates and we expect other carriers to follow suite. If a carrier can cut out additional administration cost, they will. Under the Affordable Care Act, carriers have to operate in the medical loss ratio. This means they can only use 20% of the premium for administration and profits.

Not having your certificate could create issues with qualifying events in 2015. However, you might be able to get a copy of the certificate if you have an online portal. Another option for obtaining your certificate is contacting customer service on your insurance card and asking for one.

Here at Nefouse & Associates, we will not let something like this prevent you from obtaining new coverage. We will adapt and find new ways to overcome these type of obstacles.

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Benefit

Benefit Details

Monthly Cost Monthly Cost Includes:

  • Total Monthly Premium
  • Subsidized Premium
  • Non-subsidized
  • ACA Insurer Fee
  • Exchange Fee
  • Reinsurance Fee
Deductible(s) $3,500 (Does not apply to Tier 1 and Tier 2
Primary Care Visit to Treat an Injury or Illness You pay $45.00 – not subject to deductible
Out of Pocket Max $4,500 (includes deductible)
Specialist Visit You pay 0% after deductible
Most Generic Drugs (Tier 1) 30 day Retail: You pay $15.00 – not subject to deductible 90 day
Mail Order: You Pay $30.00 – not subject to deductible
Most Preferred Brand Drugs (Tier 2) 30 day Retail: You Pay $40.00 – not subject to deductible 90 day
Mail Order: You pay $100.00 – not subject to deductible
Most Non-Preferred Brand Drugs (Tier 3) 30 day Retail: You pay 0% after deductible 90 day
Mail Order: You pay 20% after deductible
Most Specialty Drugs (Tier 4) 30 day Retail or Mail
Order: You Pay 0% after deductible
Inpatient Hospital Services (e.g., Hospital Stay) You pay $500.00 after deductible
Outpatient Surgery Physician/Surgical Services You pay 0%
Emergency Room Services You pay $200.00
HSA Compatible No
Mental/Behavioral Health Outpatient Services You pay 0% after deductible
Urgent Care Centers or Facilities You pay $50.00 after deductible
X-rays and Diagnostic Imaging You pay 0% after deductible
Chiropractic Care You pay 0% after deductible limited to 12 Visit(s) Per Calendar Year
Preventive Care/Screening/Immunization You pay 0% – not subject to deductible
Prenatal and Postnatal Care You pay 20% after deductible
Imaging (CT/PET Scans, MRIs) You pay 0% after deductible
Laboratory Outpatient and Professional Services You pay 0% after deductible
Mental/Behavioral Health Inpatient Services You pay $500.00 after deductible
Delivery and All Inpatient Services for Maternity Care You pay $500.00 after deductible
Inpatient Physician and Surgical Services You pay 0% after deductible
Emergency Transportation/Ambulance You pay 0% after deductible
Allergy Testing You pay 0% after deductible
Durable Medical Equipment You pay 0% after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) You pay 20% after deductible
Diabetes Care Management You pay 0% after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant) You pay $45.00 – not subject to deductible
Outpatient Rehabilitation Services Occupational Therapy: You pay 0% after deductible limited to 20 Visit(s) Per Year
Physical Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year
Speech Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year
© 2015 Nefouse & Associates
This website is operated by Nefouse & Associates Inc. We are certified to offer the federal exchange so we do comply with Personal Identifiable Information. This means any information you submit to this website will not be sold or misused. We will only use that information to assist you with obtaining a health insurance policy. At any time you may request us to destroy/deleted all information you have submitted. These are the rules under 45 CFR 155.220(c) and (d) and standards established under 45 CFR 155.260 that protect your privacy.
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Benefit

Benefit Details

Monthly Cost Monthly Cost Includes:

  • Total Monthly Premium
  • Subsidized Premium
  • Non-subsidized
  • ACA Insurer Fee
  • Exchange Fee
  • Reinsurance Fee
Deductible(s) $5,750 (Does not apply to Tier 1 and Tier 2
Primary Care Visit to Treat an Injury or Illness You pay $40.00 – not subject to deductible, for the first 2 visits. For additional visits you pay 20% after deductible
Out of Pocket Max $6,600 (includes deductible)
Specialist Visit You pay 20% after deductible
Most Generic Drugs (Tier 1) 30 day Retail: You pay $25.00 – not subject to deductible 90 day Mail Order: You Pay $50.00 – not subject to deductible
Most Preferred Brand Drugs(Tier 2) 30 day Retail: You Pay $55.00 – not subject to deductible 90 day Mail Order: You pay $137.50 – not subject to deductible
Most Non-Preferred Brand Drugs (Tier 3) 30 day Retail: You pay 20% after deductible 90 day Mail Order: You pay 20% after deductible
Most Specialty Drugs (Tier 4) 30 day Retail or Mail Order: You Pay 20% after deductible
Inpatient Hospital Services(e.g., Hospital Stay) You pay $500.00 and 20% after deductible
Outpatient Surgery Physician/Surgical Services You pay 20% after deductible
Emergency Room Services You pay $200.00 and 20% after deductible
HSA Compatible No
Mental/Behavioral Health Outpatient Services You pay 20% after deductible
Urgent Care Centers or Facilities You pay $50.00 and 20% after deductible
X-rays and Diagnostic Imaging You pay 20% after deductible
Chiropractic Care You pay 20% after deductible limited to 12 Visit(s) Per Calendar Year
Preventive Care/Screening/Immunization You pay 0% – not subject to deductible
Prenatal and Postnatal Care You pay 20% after deductible
Imaging (CT/PET Scans, MRIs) You pay 20% after deductible
Laboratory Outpatient and Professional Services You pay 20% after deductible
Mental/Behavioral Health Inpatient Services You pay $500.00 and 20% after deductible
Delivery and All Inpatient Services for Maternity Care You pay $500.00 and 20% after deductible
Inpatient Physician and Surgical Services You pay 20% after deductible
Emergency Transportation/Ambulance You pay 20% after deductible
Allergy Testing You pay 20% after deductible
Durable Medical Equipment You pay 20% after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) You pay 20% after deductible
Diabetes Care Management You pay 20% after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant) You pay $40.00 – not subject to deductible, for the first 2 visits. For additional visits you pay 20% after deductible
Outpatient Rehabilitation Services Occupational Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year Physical Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year Speech Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year

© 2015 Nefouse & Associates
This website is operated by Nefouse & Associates Inc. We are certified to offer the federal exchange so we do comply with Personal Identifiable Information. This means any information you submit to this website will not be sold or misused. We will only use that information to assist you with obtaining a health insurance policy. At any time you may request us to destroy/deleted all information you have submitted. These are the rules under 45 CFR 155.220(c) and (d) and standards established under 45 CFR 155.260 that protect your privacy.

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workerThe Employer Mandate is a part of the Affordable Care Act (ACA) that penalizes employers who do not offer health insurance coverage to their employees and dependents. The health plan has to meet certain criteria of the ACA and meet the definition of affordable to the employee. It does not address affordability to the dependents. The mandate applies to large employers with 50 or more full time employees or the equivalent of 50 full time employees. Employers with 100 or more full time employees and 50-99, will need to comply in 2015.

When would the Penalty apply?

In general (because no one knows for sure) if an employee applied for coverage on the Federal Marketplace and was found eligible for a tax credit, because they were not offered an employer health plan or the group health plan did not meet the requirements of the ACA.

In 2015, the Employer Mandate will apply to companies with 100 or more full time employees or the equivalent.

The penalty may apply to 3 different situations for a large company listed below:

Situation #1

  • The large employer does not provide group health insurance coverage and an employee qualifies for a tax credit or cost sharing reduction on the Marketplace and enrolls in that individual plan.
  • The penalty is $2,000 per full time employee. When calculating the penalty, the first 80 full time employee are subtracted from the penalty.
  • The penalty is assessed per full time employee for each month an employer does not off coverage that meets the ACA.

Situation #2

  • A large company offers coverage that is deemed unaffordable to a full time employee, and the employee then qualifies for a tax credit on the marketplace and enrolls in that plan.
  • The annual penalty is $3,000 per full time employee that qualifies for a tax credit.
  • The penalty is assessed per full time employee for each month the employee qualifies for premium assistance.

Situation #3

  • The large employer provides a plan that does not meet the coverage requirements of the ACA. This then leads to the full time employee qualifying for tax credits on the exchange.
  • The penalty is then assessed per full time employee, per month, who receives the tax credit

The Employer Mandate has created a lot of confusion here in Indiana and the rest of the country. Certain industries are scrambling on what to do. If you look at certain industries that have hourly wage employees, there is no good solution. Most of these companies are adopting a 29 hour work week. This decision comes with consequences because many employees then will go pick up 20 hours of work with the employers competition. These companies cannot afford to insure the employees either on a fully insured basis or self-funded.

Some of these industries have put in place group health plans that meet the requirements of the ACA. The employer is paying the majority of the premium for the employee only. The employer contribute anything towards the dependents premium and that cost is way more than that hourly wage the employee can afford. Having access to the group plan then disqualifies the dependents from getting tax credits on the exchange. Now there is a high level of frustration with the employees because they can’t afford to insure their dependents.

If your company is severely impacted by the Employer Mandate, there is no good solution only bad ones.

I can deliver you the best of the bad options!

Tony Nefouse

 

 

 

 

 

 

 

 

 

 

 

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The Save American Workers Act is a Bill Authored by Rep. Todd Young that would change the definition of a full-time employee under the Affordable Care Act (ACA). The current definition states that any employee working more than 30 hours a week qualifies for employer sponsored group health benefits. Also under the ACA is the employer mandate that penalizes employers for not providing coverage. This too is based on the 30 hours a week.

02J64093The Save American Workers Act would increase the hours that are considered full time from 30-40 hours.

This bill has already passed the house of representative 252 to 172. If the bill does go through, it will have huge impact on Indiana and the rest of the country.

Here in Indiana, a lot of employees have lost work hours. The companies that they work for are trying to budget the employer mandate or reduced health insurance costs. It’s easy for people to put blame on the employers for not insuring their employees. This is very difficult for certain industries that are unable to cover the health care cost of their employees. Then, add in the $2,000 penalty per employee under the Employer Mandate,, and it leads to less hours for the employee.

What is the positive side to the bill the passing?

The employees that are not found eligible for group benefits will be able to get coverage on the health insurance exchanges. They will also be eligible for reduced premiums through tax credits. The employers will be able to give the employees more hours of work without taking on additional costs.

What is the Negatives?

This may add $53 Billion to the federal deficit in the next 10 years. There will be employees that do not qualify for assistance on the exchanges and who do not qualify for employer sponsored health plans that will not be able to afford the individual premium.

My view as a broker:

If the Save American Workers Act gets passed, certain industries will be able to survive with their current business models. Any industry that has hourly wage employees is going to benefit from this act. Most of those hourly wage employees are going to benefit from tax credits on the exchange. This is a further step to the erosion of the employer sponsored health plan.

If you need help navigating the exchange or are interested in getting rates, get in touch with Nefouse and Associates. We’d love to get you the coverage you deserve at a price you can afford.

Tony Nefouse

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anthemlogoUnder the Affordable Care Act (ACT) Also known as “Obamacare”, the law has tried to make plan options easier for people to understand. We now have 4 categories that are described as metallic.

Bronze, Silver, Gold, and Platinum.

These categories are for individual and group health plans both on and off the exchange.

These descriptions are based on how you and the plan are expected to share in the cost of medical claims. Each plan category, has percentages of what the insurance will pay.

60% Bronze, 70% Silver, 80% Gold and 90% for Platinum.

For all the 4 categories, the plans will offer the same set of essential health benefits. The bench mark for the essential benefits has already been set by the federal government for Indiana. The differences in the % are determined by how much you want to share in medical cost with the insurance company.

When you start thinking about sharing the medical expense, you may want the Platinum plan. On this plan you would only pay 10% of the cost, no exceeding your out of pocket maximum. This plan will have the highest premium because you pay the least out of pocket. Some carriers are not even offering Platinum plans, because they know that high utilization people will elect them.

Example: You need a knee surgery. That surgery is going to exceed any out of pocket on any of the plan.

The platinum option has a $750 out of pocket max and then 100% coverage. Your premium is for that plan is $600. The total cost of the year is $7,200 in premium plus another $750 in out of pocket, for a grand total of $7,950.

Same situation on the Silver plan.

Your premium is $400 a month, and the out of pocket is $6,600. You have $4,800 in premium plus another $6,660 in medical claims, and your total is $11,400.

Question: If you knew you were going to have a large procedure, which would be the best plan?

Answer: The Platinum is going to cost you $3,450 less than the Silver.

This is the best way to determine which metallic plan is going to be the best for you and your family. When you work Nefouse & Associates THIS is the kind of value we bring to the table!

 

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computerPlans went live for Indiana on healthcare.gov over the weekend.

Until the November 15th this is only for review. We have 7 companies offering a total of 75 plans with designs. Of the 75 planned designs, 6 are PPO, 1 POS, 7 EPO and 61 HMO. These are networks arrangements.

PPO = Preferred Provider Organization:

Most people in the state have experience with the PPO. On these plans you would have PPO Network, where most, if not all, the medical providers were participating. Then with most of these plans, you also had out-of-network benefits. If you want to get out-of-network, you could. For the health plans on the exchange for 2015, we have 7 PPO plans, offered by Assurant Health. This PPO plan is using the Aetna Signature Network. This is the most expensive plan on the exchange. If you qualify for tax credits and think you are going to utilize out of state providers this may be the best option.

POS = Point of Service:

This is a plan where you may have a narrow network but you still have an out-of-network benefit. Right now the only POS on the exchange is through Anthem. So for someone that wants a plan that has some out-of-network benefit but does not want to pay the highest premium. Then the Anthem POS is going to be the best option.

EPO = Exclusive Provider Organization:

This network looks similar to a PPO plan. This is because they can have a large network participation. The one thing about EPO is they do not have coverage out-of-network. UnitedHealthcare is the only company that is offering an EPO on the exchange. The network is very strong throughout the entire state. This plan is going to be your middle of the road plan from a cost standpoint, but if you want access to multiple hospital organizations, this is a good solution.

HMO = Health Maintenance Organization:

This type of network will only provide coverage inside the network. With this type of plan, you will have to have a primary care doctor, involved in every aspect of your care. This type of plan can also be referred to as a “gatekeeper”. We have 61 HMO’s for Indiana on the exchange. They are not all the same type of HMO. Some have very narrow networks, with only a couple of hospitals.

Buyer beware!

Do not go with the cheapest option.

Why?

  • The cheapest option only has 2 hospitals. So, if you need a surgery, it is possible you will have to drive 60 miles for it.
  • There are some HMOs where the doctors in their network are not accepting new patients.

If this seems overwhelming, please know that at Nefouse and Associates, we are able to help you with narrowing down the plan selection. We know there is no way anyone wants to analyze 75 plan options. We can narrow it down to 17 plans!

Then, with basic information, we are able to suggest the best 2 plans for your individual needs.

We can do this in less than 5 minutes. Here at Nefouse & Associates we have been preparing for this open enrollment since last year’s open enrollment. If you are still reading this, then our FREE professional advice will save you time and headaches.

We will help you make the very best decision.
Tony Nefouse

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groupUnder the Affordable Care Act (ACA) or” Obamacare” health insurance companies are required to offer coverage to all people and businesses. This is called guaranteed issue and has helped a lot of Hoosiers.

With Guaranteed issue, the ACA requires health insurance companies to use community ratings for Individual and small businesses. This is where the insurance companies charge premiums that are not based on the health history of the Insured. This used to be called underwriting. Now health Insurance companies must base rates off of a group or people. This is called a risk pool. By pooling a group of people together, healthy people should help to offset the cost of unhealthy people. Then the risk and costs are shared by the entire group.

Community Ratings

The ACA introduced rules for community ratings. The insurance companies now base rates on age, tobacco use and geographical location. The ACA limits how much the coverage can cost. The highest rate can’t be more than 3 times the lowest rate. Indiana is able to keep Individual and small business risk pools separate. The rates are based on the entire risk of the pool. The ACA is does not allow the insurance companies to create separate risk pools

The Impact on Indiana Health Plans

With the removal of underwriting, we are seeing large rate increase in both the individual and small group markets. There are many reasons why we are seeing the rate increase. One of the biggest impacts is there is no underwriting. In the past, health people had better rates because they had less risk. Now the healthy people are in the same risk pools as unhealthy. Then we add in that highest premium can’t be more than 3 times the lowest. Young healthy people are seeing a very large rate increase under the ACA plans.

What are the options to reduce costs?

On Individual plans, it is worth looking at the exchange to see if you qualify for tax credits. If you do qualify for tax credits, then this will be your best option for coverage. If don’t qualify for tax credits, then you may want to explore a health saving account.

On Small group plans, If your group has more than 10 employees, you may want to explore an underwritten plan. These plans may be a self funded option, Associations, or even a PEO. If you have a healthy group plan, these may be your only options to control health premium.

At Nefouse and Associates, we are a company that will help you navigate the Exchange site and find the best insurance plan for you!

If you have any questions, get in touch with us! We’ll be glad to help.

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A common situation here in the United States is an older parent living with a first generation American. This older parent is often not a US citizen, meaning they don’t qualify for Medicare.

Here at Nefouse & Associates we have found a solution to this problem under the Affordable Care Act. We’re able to provide health insurance for the entire family, which is great for multi-generational families living under one roof.

How This Works

As an example, let’s say we have a grandmother, mother, and then children. The grandmother is not eligble for Medicare, but is eligible for health coverage through the Health Insurance Marketplace. So, what we do is take the entire household and apply tax credits at the Federal Exchange where, because the grandmother in this situation, is eligible because she is not on Medicare. The entire family may qualify for a tax credit, which is then applied to lower the monthly premium cost on all the members of the family, including the grandmother.

This is a great benefit for older immigrants that don’t qualify for Medicare because of their age. But now, we can insure the immigrant parents living with their children through the Health Insurance Market Place.

To learn how Nefouse & Associates can help provide health insurance for your entire family, contact us today!

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This is possibly the most interesting time in small group health history locally, not to mention the rest of the country.

Anthem releases 4th quarter renewals

Small group health insurance renewals have been released for the 4th quarter from Anthem. “WOW” is all I can say!

The renewals that are being released are all “grandmothered.” This means that the group can keep the current plan, even though it does not meet ACA compliance. In Indianapolis this block of business is renewing at low rate increases. In fact, we are seeing single digit rate increase on most groups. This is because these groups are running very well from a claims standpoint. Some groups are getting hit with double-digit rate increases and this has a lot to do with claims.

As I understand it, you may be able to keep that group plan through 2016. This can be a great option for the next two years because your premium will much lower than a ACA-compliant group plan. It’s important for any owner to also request numbers on a ACA plan just in case. This can be provided to you very easily, though this is where the premiums get very ugly. If your broker has been working for you, then they should have reduced your rate increase over the years with Anthem. Those years of constant negotiations with underwriting has saved small group thousands. This is a service Nefouse & Associates has always provided to even our smallest groups. Under the ACA plan, be prepared to see very large rate increases.

Anthem Small Group Renewals
Anthem groups can keep their current plans through 2016.

Small groups affected most

Small groups that are going to be hit the hardest are small-group plans that have run single digit rate increases and have composite rates in place.

An example would be a group of 22 employees electing coverage. There is one premium rate for each tier. So if you’re 62 or 22 years old, the employee-only premium is the same. Now under the ACA, there will be no more composite rating for small groups — it will be all age based. The 62-year-old employee that was running $435 a month, might see a new premium of $1,400 a month. On groups like this, we are seeing 85% rate increases on a ACA compliant plan.

Groups that have age-based rates in place right now are not seeing as large rate increases. If you have 15 employees on the plan and have had low rate increases you may a see a 37% rate increase with an ACA plan.

Among the grandmothering block in Indianapolis, the lowest ACA increase I have seen is 23%. This was on a case of 40 employees that had age-based rates in place.

You need to know what the impact of healthcare reform is going to have on your group benefits. We are being told groups will be able to keep the plans through 2016, but anything can happen. If the Indianapolis Department of Insurance decides not to allow non-compliant plans to stay in place next year, then you may be faced with these kinds of rate increases.

What to Do:

First, find out what kind of ACA rate increase you are looking at, then contact Nefouse & Associates, or call us at (800) 846-8615.

We may be seeing the beginning of the end of traditional small group plans. So let’s think outside the box!

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