Author Anthony Nefouse

Last week, we had two different rulings come out of the courts. The U.S. Court of Appeals for the D.C. Circuit ruled that it was not legal to give tax credits/subsidies to residents of states that did not develop a state-based exchange. In Richmond, we had another court rule that is was legal for the IRS to give tax credits to the residents of these states.

The Affordable Care Act is no stranger to conflict. Since the inception of this law, everyone has debated this issue. From the kitchen table to the courtroom, this topic is debated daily.

There is no doubt that the ACA has created many problems, but at the same time, it has given us affordable access to healthcare. Here in Indy, we have had over 130,000 residents take advantage of the health insurance marketplace. Most Hoosiers were found eligible for tax credits, and have received a 79% decrease in their premium. At the same time, the ACA is eroding employer-sponsored health insurance for small businesses, along with significant increases in premiums for higher-income residents. The employer mandate is going to have a crushing impact on industries in the area that can’t afford to offer group health insurance.

Dual Rulings on the ACA: How does this affect Hoosier small businesses?
It’s important to know that the subsidies aren’t going anywhere.
I don’t think you can’t take away the subsidized premiums. If this were to occur, then the entire individual market would crash. Under the ACA, we have had huge rate increases to the individual premiums here in Indianapolis. Rates have doubled in some situations. Therefore, the subsidies are absolutely mandatory for a majority of Hoosiers.

There will, undoubtedly, continue to be a flurry of rulings associated with the ACA and any aspect of it. Some rulings will fall the law’s way, and some will invalidate part of it. It’s a safe bet that your subsidies are safe for the time being, though, at least until the Supreme Court takes up the ACA — again.

If you have any more questions about how your small business is affected by this ruling, if at all, and how you can secure more affordable health insurance for your employees, contact Nefouse & Associates, or call us at (800) 846-8615.

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As the Affordable Care Act provides more and more clarification on the law, we are starting to see some serious mandates outside of what was known.

If you are receiving health insurance coverage through an ACA-compliant plan, you may be eligible for additional drug coverage that is not currently covered by your plan. The law stats that this drug coverage exception must be made by the carrier. This opens up a path to getting a drug covered that was not previously covered. Before this, if the plan did not cover a drug, it was difficult to get that drug covered at all.

We at Nefouse & Associates were able to get exceptions made in the past by going through the carrier and showing medical necessity. Now it appears that you will still have to show medical necessity, but now there is a path under the ACA.

Drug Exceptions Under the Affordable Care Act
It’s difficult to know whether you can get an exemption for a formulary drug under the ACA.

Exception Criteria

  1. Request for coverage of a drug that is not on the formulary list:For this exception, your medical provider would have to prove that all of the drugs on the formulary list are ineffective at treating your condition. There would have to be both clinical and scientific evidence that the condition could not be treated by the other covered medications, or that the other medications had adverse side effects.
  2. Dose limit/quantity limit:It would have to be proved that the maximum allowed dose or frequency has been ineffective in treating the condition. There is going to be a lot of checks and balances with toxicity risks and lab measurements.
  3. Step therapy for formulary drug:In this situation the plan would ask that you take a different drug first before approving the formulary drug. Your doctor would have to prove that the step therapy drug would cause an adverse reaction. Most common step therapy drugs are going to be antacids. I think the exception is more geared to cardiovascular drugs.
  4. Brand exclusion/generic requirements:In today’s fully-insured health insurance market, we are seeing more and more generic requirements, even if the brand drug is of medical necessity. This aspect of the law may steer the carriers away from forcing members to take only generic drugs or pay the difference.

This is only a snapshot of the exception rules. It would be a very long drawn out process to get some drugs approved. Your doctor has to be willing to work on your behalf by submitting all information that will make you eligible for the exception. In some cases, they are not only going to have to submit medical records showing medical necessity, but make a strong argument on your behalf. There is a lot more information on applying for an exception.

The approval process can take up to 1 year to get approved. You still want to have Nefouse & Associates in your foxhole if you need to go to war with a carrier. Contact Nefouse & Associates, or call us at (800) 846-8615.

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Here is some news you  may not see in the local media outlets: Parkview Hospital group had a blatant HIPAA violation.

HIPAA is the federal Health Insurance Portability and Accountability Act. One aspect of this law is to protect the confidentiality of health care information. You may have noticed in the last few years that there’s often HIPAA paperwork when you visit a hospital, which is designed to protect you. You may also notice that it’s now more difficult to call a hospital and learn the status of a patient, for the same reason.

Parkview Hospital Settles HIPAA Violation

This chart shows a breakdown of HIPAA violations nationwide, divided by the type of violation.
From this article, it looks like Parkview paid $800,000 to the Department of Health and Human Services to settle this HIPAA violation. The article is stating that the violation occurred when 71 cardboard boxes of medical records were left on a retiring physicians driveway, where anyone could walk by and leaf through them. The boxes contained anywhere from 5000-8000 medical records.

It’s difficult to understand how one would make the decision to leave medical records on a former employees driveway.

The article does not state if the they were Indianapolis patients or Ohio patients, but if you or a family member received medical services from this provider, you may want to ask if your records were in one of those boxes.

There were 91,000 HIPAA violation complaints nationwide in the last ten years; of these, 22,000 led to settlements or fines and 521 led to criminal action. This may lead one to believe that your confidential info is not safe at hospitals, but in fact this number is very low compared to the number of times patient data is stored throughout our nation’s hospitals. Still, it’s important for hospitals to exercise due diligence both to avoid another large fine, and to learn from the mistakes of rules-violating hospitals such as Parkview.

You can trust that your confidential information is safe with Nefouse & Associates. Contact Nefouse & Associates, or call us at (800) 846-8615, and ask about how we can help your small business save money and provide better coverage.

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Hola y Bienvenidos!

Mi nombre es Laura Martinez y soy nuevo miembro en la empresa Nefouse & Associates. Somos una empresa independiente y local, nos especializamos en los beneficios del seguro de salud. Ayudamos a familias, individuales y negocios encontrar la mejor cobertura de atencion medica disenadas para sus necesidades. Tengo el privilegio de ayudar a mi comunidad hispana; de hecho he notado que la ayuda para la comunidad hispana aqui en el estado de Indianapolis no esta muy desarollada todavia. Estoy aqui para ofrecer mi servicios ya sea cobertura, consultas, o con preguntas que tengan. Sabemos que el seguro de salud puede ser estresante, y estamos aqui para elimiar el estres haciendo el proceso lo mas facil posible para usted. Nos enorgullecemos de la construccion de relaciones personales, mientras trabajamos con los mejores redes para nuestros clientes. Mi meta es ayudar a la mayor cantidad de personas en mi comunidad hispana para que puedan obtener la mejor cobertura posible. Nuestro objetivo en Nefouse & Associates es simple, le conseguiremos el mejor plan al mejor precio y siempre cumplimos lo que prometemos. Nuestros clientes son nuestra prioridad y cuando tengan preocupaciones o preguntas siempre estamos disponibles para ayudar con cualquier situacion. Estamos aqui para ofrecerles el mejor servicio!


Laura Martinez

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ZaneBenefits is the leader in helping to self-administer employer reimbursement for employee medical expenses. In fact, they are the one of the few companies that will do this. This is one of the most controversial concepts out there. Zane believes that this is a legal approach to reimburse medical expenses for the employees from a tax free standpoint.

This self-insured medical reimbursement plan is often associated with:

  • Section 105 medical reimbursement plans
  • Health care reimbursement plans
  • Integrated health reimbursement arrangements

If this approach violates Affordable Care Act requirements, then an employer could be subject to thousands of dollars in fines.

Zane has constantly argued that its self-insured medical reimbursement approach is legal with both the Internal Revenue Service and the ACA. The reason this concept is so controversial is because of politics. The current administration is worried that we could see an abandonment of employer-sponsored health insurance plans, which would shift coverage to the individual market. If an employer can give tax-free money to employees to purchase health insurance, the marketplace could see an erosion of the employer health plan.

How Zane’s approach works is this:

  • The employer sets an allowance for the employee for medical spending
  • The employee pays for their own individual health plan
  • Zane reimburses the employee up to this allowance

Is the self-insured medical reimbursement plan legal?
Is ZaneBenefits’ approach really what the ACA had in mind?
With the ACA, there are unintended consequences for small group health plans. If your current group health plan is non-ACA compliant, and it moves to an ACA compliant plan, you may see a 55% rate increase. These rate increases are a direct result of the removal of underwriting requirements. Most Indianapolis small groups may not be able to afford the rate increases that are coming under the ACA. We will see a drop of small group health coverage, and it has already occurred.

Using this type of approach to benefits can save huge amounts of money. There is still risk, since this concept is not widely accepted.

Questions about this or any other small group health plan approach? Contact Nefouse & Associates, or call us at (800) 846-8615.

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Supreme Court ruling on healthcare and morality

The Supreme Court ruled that “closely held” companies can, on religious grounds, opt out of a federal healthcare law requirement that companies provide contraception coverage for employees. A closely held company is one with 50% of its stock owned by five or fewer owners — a definition that applies to 90% of businesses in the U.S.

Hobby Lobby and other companies said their religions consider certain birth-control methods immoral, and therefore they weren’t obliged to help provide them under a 1993 statute, the Religious Freedom Restoration Act.

Note that this only applies to a few emergency contraceptives, such as Plan B and Ella, and not all contraceptives or birth-control methods. Still, this ruling prompted swift and angry pushback from both sides of the debate. Does a company have the right to exercise its religious freedom? Do employees have the right to equal healthcare coverage regardless of their beliefs? This is a debate that will rage on for years in the courts, despite the ruling.

How does this ruling impact Indianapolis base health insurance contracts?

If you work for a large company, that company can, on the basis of religious grounds, carve out certain contraceptives from your healthcare plan, similar to how a religious hospital can refuse to perform certain procedures it believes are immoral.

If you work for a small company that has a fully insured health contract, you may not be impacted. Indianapolis-based insurance companies would have to design future plans that give employers the option to remove certain contraceptives. This type of plan design would have to be approved not only on the state level, but also on the federal level. If a lot of small-business owners feel this option is important to them, then we could see insurance companies provide this option.

If you are on an Individual health plan that is ACA compliant, then you will not be impacted.

Bottom line: be sure and know what your employer believes and whether that will impact your healthcare coverage going forward. It pays to be informed.

Nefouse & Associates can answer any questions you may have about this or any other aspect of your healthcare. Contact Nefouse & Associates, or call us at (800) 846-8615.

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Self-Funded Plans

What is a self-funded plan? It’s where an employer provides health benefits to employees out of the company’s own pocket. We have seen the introduction of self-funded plans for small groups in Indianapolis. Small employers are looking for options to try to control rate increases caused by the Affordable Care Act. The self-funded option is worth entertaining, but a small-business owner should approach the concept with extreme caution.

A self-funded arrangement is a sophisticated approach to group health insurance. People will try to simplify the approach to get new clients, or to keep existing clients. Buyer beware!

Beware of the details in the contracting. A self-funded arrangement may have more than a hundred pages that you have to sign off on. It you are well-versed in insurance contract law, it should not be a problem. Most small-group employers are not well versed in self-funded arrangements. Most small-group brokers are also not well versed in this area.

So are you entering a contract that is adding additional liability? YES!

All about small group self-funded insurance plans for Indianapolis
It pays to study the self-funded insurance contract before you sign anything.

A Closer Look at the Self-Funded Plan Contract

Contract definitions you need to pay attention to:

  1. Aggregate stop loss: This is the total risk a employer will pay in one year in claims. It’s just like it sounds: stop the losses. It is extremely important that you understand the total risk you are taking on. If you are a small group, is it worth taking on the risk of $20,000 to save $2,000?
  2. Specific stop loss: This is the limit that you will pay for on one individual’s claims on your plan.
  3. Fixed costs: These are your administration costs for the third party to manage your self-funded plan. This will include your stop-loss insurance and broker compensation.
  4. Run-out claims: This refers to claims that were not filed prior to the plan year.
  5. Definition of a claim: Its extremely important that you know the definition of a claim in a self funded contract.

It Pays to be Informed

A self funded plan for a small company may be a good option. Take into consideration that it’s a complicated insurance vehicle. The broker may not be well-versed in the plan contract. The Sales rep for the insurance company may not be well versed in the plan structure. You, the owner, need to align yourself with a broker like Nefouse & Associates that understands self funding.

Contact Us

To talk to us anytime about self-funded plans, or any other aspect of healthcare plans locally, contact Nefouse & Associates, or call us at (800) 846-8615.

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One of the points of the Affordable Care Act was to increase choices for insurance, both for small groups and individuals. That’s been the case, to a certain extent, but it’s worked out better in some situations that others.

Under the ACA, the exchange is suppose to offer small-group health insurance choices. These plans would have tax credits for the small group employer. The tax credits are on a sliding scale depending on number of employees and average income. These choices are called the SHOP program, for Small Business Health Options.

The federal-facilitated exchange for Indianapolis will have the option of multiple-plan elections for small group employees — Indianapolis has no state-run exchange. Some other states that have state-based exchanges have been able to opt out of offering multiple plans for small groups.

There are many reason why a state exchange may opt out of that option.  The first one is the technology to offer multiple plans and what it would cost to  integrate that technology with the carriers. The carriers may have the same issue.

SHOP: Multiple Choice on The Exchange for Small Groups
SHOP is supposed to give small businesses more choice in the marketplace.
The other issue could be the carriers do not want to participate on the SHOP plans in the first place. The exchanges are charging the carriers a fee to sell the group plans, and this fee is a percentage of the overall premium.  Why would a carrier want to give a percentage of the premium,  invest in additional technology, then hope that the exchange’s technology works?

In Indianapolis we will have the multiple-choice option for small groups on the exchange, but here is the reality. If your employees wages are so low that your small business qualifies for the 50%-of-contribution tax credit, you may be better off dropping your group plan. Move the employees to the exchange and allow them to pick up personal tax credits. They would end up in a better situation, unless you are willing to pay the entire premium for the employee and his or her spouse and dependents.

One recent SHOP article on Politico points out that only a small fraction of small businesses have signed up for SHOP thus far. One hurdle right now is that online enrollment is not yet available, but should be by fall — no consolation for businesses that don’t want to apply on paper.

The bottom line is that SHOP needs to be revamped. There has to be more incentives for small groups to go that route.

In the meantime, your business can always contact Nefouse & Associates or call us at (800) 846-8615 about your small business insurance options in today’s post-ACA world.



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The Republican-majority House of Representatives voted in favor of blocking the federal government from interfering with states that allow medical marijuana. The vote was 219-189, with many moderate and libertarian-minded Republicans joining most Democrats in passing the measure. This is an unusual break from party lines and suggests a fundamental shift in how Congress, and the public at large, views medical marijuana. This provision, included in a Justice Department budget, now heads to the Democrat-majority Senate. It’s likely the provision will remain in the bill at that point, as Democrats are largely in favor of medical marijuana legislation.

Medical Evidence for Medical Marijuana Benefits

Even though the medical marijuana industry is only regulated on a state-by-state level, there is a now a lot of research on end-of-life benefits, especially for patients with terminal cancer. The National Institutes of Health and the Institute of Medicine Report, for example, have medical evidence for likely therapeutic benefit for nausea and vomiting:

Nearly one-quarter of patients who initially agreed to participate later declined citing bias against smoking, the harshness of smoke, and preference for dronabinol. Among the remaining 56 patients, 78% rated smoked marijuana very effective or moderately effective.

Given that we’re in the health insurance business, every year we see people getting diagnosed and treated for cancer. The nausea that people experience during chemotherapy is horrible. There is targeted medication that helps with the nausea, but some patients seem to have better results with medical marijuana. Kate Scannell, MD, co-director of the Kaiser-Permanente Northern California Ethics Department, said this to the San Francisco Chronicle:

In a society that has witnessed extensive positive experiences with medicinal marijuana, as long as it is safe and not proven to be ineffective, why shouldn’t seriously ill patients have access to it?

Indianapolis Needs to Address this Topic

If you’ve ever had the misfortune to have a loved one with terminal cancer, you want their quality of life to be the best it can be. If medical marijuana can help Hoosiers who are going through cancer treatment, then this topic should be addressed on a state level.

Sen. Karen Tallian has introduced Senate Bill 314 to legalize medical marijuana in Indianapolis, but this bill hasn’t gone anywhere this year. We are a conservative state, and local government can sometimes be the last to address hot-button topics like these — but if it’s your loved one, what would you do?

If you have any questions regarding medical marijuana, please contact me, Tony Nefouse, at (800) 846-8615 and we can discuss further.

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A topic that will likely be addressed at your next next health insurance renewal meeting is likely going to be: Who will pay the Affordable Care Act related fees?

Will it be the employees, employers… or both?

Let’s find out more about what each of these ACA fees are and how much they will cost you:


Insurer Fee or Health Insurance Industry Tax:

This tax is funding people who purchase health insurance on the marketplace and qualify for tax credits.

  1. This fee is permanent and is paid on an annual basis.
  2. This fee is about 2.5% of the total health premium.

If your group plan is running at $500,000 a year, then that is about $12,500 in additional costs. Some of the carriers will show this fee as a part of your premium statement, while others will embed it in the total cost.

The Risk Adjustment Fee:

This tax is on small group health plans and individual health plans to redistribute premiums from low-risk to high-risk policyholders.

  1. This is a permanent tax and is about $66 per subscriber.
  2. This tax is also either embedded or a line item on your premium statement. Anthem shows the line item while UnitedHealthcare (UHC) embeds it.

This tax is to be used to help carriers offset claims in high risk areas. For example, Lake County may have higher premiums than Hamilton County. These funds would then be distributed to carriers that continue to insure Lake County despite losses.

Transitional Reinsurance Fee:

The transitional reinsurance fee impacts both fully insured and self-funded group health plans.

  1. This fee is collected for the years of 2014-2016.
  2. Estimated at $5 a month per member.

This fee is to help Individual carriers offset claims both on and off the exchange.

Patient-Centered Outcomes Research Institute (PCORI) Fee:

This fee impacts both fully insured and self-funded groups.

  1. This fee runs about $1 -$2 per member.
  2. This fee started in 2012 and will go until 2019.

The fee funds research that evaluates and compares health outcomes, clinical effectiveness, and risks and benefits of medical treatments and services.

Note: Per member means total number of people on the plan.

Who Covers the New Costs?

So now the big question is: Who is going to pay these new costs? Should it be passed to the employee, absorbed by the owner, or split up into current contribution levels? When we look at UHC’s billing, all of the fees for the fully insured groups are being embedded. For them, it is most likely to go into the contribution split.

In Anthem’s case, it is showing as a line item. The cost could be passed onto the employee or be covered in full by the company.

On self-funded plans, the situation is very different. Some of the carriers and third-party administrators are not collecting the fees. Instead, they are passing that responsibility on to the client. They are stating that because the group knows the accurate information on employee count, they would be best at determining the correct amount.

In 2018, the excise tax, or Cadillac Tax on high-value health plans, will be in effect. If your health plans cost more than a certain threshold, then a tax of 40% is applied. We are still waiting to find out what that threshold will be. Originally, the government set it at $10,200 for single coverage and $27,500 for family. If I understand correctly, if you had a group policy where the family cost was $35,000, then the issuer could be taxed an additional $3,200. This tax will have a huge impact on what kind of plans are offered by employers.

If you have any questions regarding the new fees please contact me, Tony Nefouse, at (800) 846-8615 and we can discuss them further.


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