Category FAQS

indiana group health insuranceMany companies will turn to the internet to search for insurance benefits. Since 1998, we have been helping these businesses obtain group benefits. In the beginning of the internet, very few people would go to the world wide web for insurance information. Today that has all changed, business owners want information at their fingertips.

We have seen all type of companies/people come to our site and ask questions. Over the last 20 years there has been a trend on the situations the company is in that leads them to us.

Here are common situations:

Small business that is less than 5 years old, looking to attract or retain employees. Start up companies that are funded will seek benefit information from the web. These companies usually need costs quickly because employee benefits are last on this list. Businesses under new ownership, a small business was recently purchased there may be an existing benefit package in place, new owners want to revamp benefits or shop out the market for a better deal. Then their company’s that are looking for new broker representation. The insurance community is understaffed, which is becoming a serious issue for companies when it comes to service.

Requirements for Group benefits:

For business to be eligible for group insurance benefits. Every week we field questions on how do we qualify for group benefits?

Group Health Insurance: There needs to be two enrolling members and one of the members needs to be on the wage n tax form (W2). With the passing of the affordable care act (ACA) no longer will husband & wife companies be eligible for a group plan, there must be a W2 employee.

indiana group health insuranceParticipation Requirements:

Most insurance companies require group to have a certain amount of participations to be eligible. Small group health plans carriers have different requirements. The standard use to be 50% of the full-time employees to be on the plan. A full-time employee in the insurance world is 30 hours a week. Other companies you must have 75% of “net eligible”. Net eligible is employees that do not have other coverage, so an Insurance company like Anthem, would accept a group that had 40 full time employees but only 7 electing coverage, if all the waivers had qualified coverage.

Group with 50+ participation requirement can be a bit more flexible. UnitedHealthcare has no participation requirements, a company of 99 employees could have only 10 taking coverage and the company would qualify as a group.

Additional lines of coverage like Life, Dental, Vision, & Disability have more standard participation requirements. Most companies require 25% participation.

Participation requirements do change more frequently than you would expect. The health insurance carriers could change every year.

One benefit of the affordable care act is the not having to meet participation for group health. If you submit your group health installation between November 15th and December 15th, you do not have to meet participation guidelines. Essentially every small company in Indiana can obtain health insurance, should they choose to do so.

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It would be wishful to say that group health insurance under the ACA has stabilized. Comparing it to the Individual market under the ACA, the group is calm.

For companies with less than 50 full time employees, or the equivalent under 50, fully insured products are guaranteed issue. This mean there is no underwriting. When employees complete applications, they are not asked any questions about current/past health conditions. The cost of the plan is based on county, age of the employees & plan designs. This can be an advantage for companies that have younger employees. The younger employees can reduce the rates through composite rates. This can have a huge impact, if a company and the employees can afford the health plan. We have been able to get the employee rate down as low as $239.

The county where the company is located act will impact rates. Under the ACA, this is perfectly acceptable to increase or decrease rates based on the county. If a county has had a history of higher risks/claims, then the group health plan can and will cost more.

Plan design has the largest impact on group premiums. The two main carriers in Indiana are UnitedHealthCare (UHC) and Anthem. They are really the only carriers that are in the small group fully insured market.

Anthem small group plans designs, really have not changed much under the ACA. The plans are somewhat straight forward. The deductibles & office visit copays have stayed the same. Anthem has slowly started to change their prescription drug co pays. The one aspect that has changed is the out of pocket max. These have increased under the ACA. As it stands Anthem is not competitively priced in the small group product. This is by choice.

UHC surprisingly, has been very creative on developing new products that reduce premiums. They have changed plan designs, networks and even added gate keeper plans, with the goal of controlling cost. They have established that a split co pay is now acceptable to most insure. This is where you have a lower co pay for general doctors, then a much higher co pay for specialists. This is to create consumerism. A specialist may cost $330 for a visit and general doctor may cost $90. So UHC would rather pay for the general office visit. The next change they have made is co-insurance. They have created some plans with 50% co-insurance after the deductible has been met. The insured will hit the out of pocket max much faster. Another surprising move from UHC was the establishment of the EPO network. This type of network is a hybrid of a PPO & HMO. It has national provider access but no coverage out of network. Gate Keeper policies, where the insured must choose a doctor for all of their care. That doctor must be involved with all care provided or it will not be covered. UHC also has changed their RX co pays significantly. It appears that they are running a three tier co pay system, the reality is they are running a six. They have increased cost to the insured, on drugs that cost more. All of these cost cutting measures add up for both UHC and small groups. These have led to lower premiums under the ACA but they have shifted more cost onto the insured.

The small group plans have stabilized with UHC. Anthem has not pulled the trigger on the new plans under the ACA. Anthem could come out with a new product line up that is very different than what they are offering small group now.

There is one segment of Indiana small group that is very unstable and that is grandmothered policies. These are policies that were sold prior to the ACA going active. The Federal government and the State of Indiana have agreed to allow these plans to be in place until Dec.31st of 2017. The health insurance companies and many so called experts, do not know what will happen when these plans are no longer terminated. Will these small Indiana companies accept a 44% rate increase under a ACA plan? The answer is NO, they will not. These business owners will look for alternative solutions. They will contact a broker like myself, Nefouse & Associates, INC, and we will provide that solutions to lessen the blow of the ACA.

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Late February 2016, CMS sent out a bulletin for extended transitional policies. The bulletin outlined to extend small group health insurance policies to Dec. 31st 2017.  The former rule was that these policies would be terminated on October 1st, 2017.

How does this impact Indiana small group health plans?

If you purchased a health plan that is considered “grandmothered” that plan will continue until Dec.31st 2017. This will allow you to keep that coverage for the entire 2017. These plans can be anywhere from 30% cheaper than ACA compliant plans. This is because of the rules of the ACA with small group.

CMS in their infinite wisdom, realized the huge problem that was going to occur if the plan ended in October.  Now Indiana companies will be able to start a new group plan on the calendar year.

Beginning Jan. 1st 2018, all small group health plans will have to move to ACA complaint plans with the exception of grandfathered plans.

There is fear that we could see the additional decline in employer sponsored health plan in 2018.  Very few business owners are going to accept a 30% rate increase.  In Indiana, we have seen new solutions for the small group health coverage. There are association plans and even partially self-funded options.

January 1st is one of the most hectic times in the insurance world, it’s better to start reviewing options sooner than later. July 2017, you should contact us and we will deliver every options that is available for you to review.

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Preferred Provider Organization  (PPO)

A PPO plan is a network of medical providers, who join a network and reduce their fees, in exchange for patients. The insurance Industries used these PPO to give their members access to medical care. Then the Insurance carriers started to develop their own PPO networks.

The PPO has been very common to Indiana for the last 25 years. If you had an Individual Health Insurance plan, it was very common you had a PPO network.

The death of the PPO network for Individual plans is just around the corning for Indiana. Maybe in 2 years or even in 2017.

The Affordable Care Act (ACA) has forever changed the individual market in Indiana. With guaranteed issue, no person can be denied health insurance. This has created a huge amount of claims for the insurance industry, especially here in Indiana. The insurance companies have very few options in controlling cost. Limiting network access is really the only option they have left.

This year Assurant Health is closing their Individual division in Indiana and the rest of the country. In 2014, they offered a PPO network through Aetna, this network apealled to a great deal of people.  Those people were high utilization members with large claims, which leads to large losses.

This year 2015, Humana has pulled their PPO plan from Indiana and 14 other states. No one knows the exact reason but one can assume they also had very large losses.

This leads us with one last Individual PPO option for Indiana. United healthcare AKA United Life Insurance. How long will they be able to offer a PPO plan?  I don’t think it will be very long and it could be gone by 2017.

With in 3 years of the ACA going into full effect, Indiana has only one PPO option. This use to be the type of Individual network.

What is in the near future for Indiana insurance networks?

Narrow networks!

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The first tax season is behind us and no one knew what was going to happen with tax credits. The Federal Marketplace compared what was reported on the tax credit application and what the individual filed on their tax returns.

It was estimated that 45% of the people that purchased health insurance with tax credits, would have to pay a portion of the credit back. The average repayment is around $800 for the country.

A lot of people that had to repay a portion of the tax credit fell into a couple of different situations. Commission Sales people seem to be in a situation where they had to repay. Unemployed Hoosiers, that found employment, forgot to notify the exchange about a change in circumstance. There has also been a lot of confusion over Social Security benefits.

03B90497

The problem with the new tax credit system, is there is nowhere to get answers for complicated situations. The IRS, will refer you to different sections of the IRS code. The health insurance market place employees, have very little to no training on tax issues. If you have a complicated situation there is very little help.

For 2015 enrollments, we were able to recognize some of these situations in advance. We advised our clients not to take the entire tax credit up front. This is a very difficult decision for some people to make. Premiums are extremely high, so without taking that full tax credit, it can be affordable. For some Hoosiers, that knew they were going to have income changes, they did go with this option. Some even choose not to take any tax credit until they file their 2015 taxes.

 

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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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The Affordable Care Act (ACA) requires that all health insurance plans sold on state exchanges beginning Jan. 1, 2014 cover ten essential benefits:

 

Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
However, the specifics of what will be included in each of the categories have been left to individual states. Each state will choose an existing health plan to use as a model:

One of the three largest small-group plans in the state
One of the three largest state employee health plans
One of the three largest federal employee health plan options
The largest HMO plan offered in the state’s commercial market
In addition to addressing what will be covered, the ACA also broadly outlined the level of benefits – how health care costs will be split between health plans and consumers.

General percentage by level paid by consumer
(through deductibles, copays and coinsurance)

Bronze Level – 40%
Silver Level – 30%
Gold Level – 20%
Platinum Level – 10%

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English: Accrington Pals Medical Health Care C...

One significant downside to a high-deductible health plan (HDHP) is that you’re responsible for paying everything out-of-pocket until you reach your deductible (which typically ranges from $1,000 to $5,000 on these plans).

You’ll pay 100 percent of the cost of prescriptions, doctor visits and emergency room visits. You’ll also pay for the cost of surgeries and out-patient procedures.

If you’re considering a pregnancy, make sure there’s maternity coverage on your policy. There usually isn’t.

While a high-deductible plan can lower your overall health insurance costs while protecting you from unexpected and large medical bills, make sure you have your own plan to pay those initial out-of-pocket expenses. You’ll need a tax-deductible health savings account or your own savings plan to satisfy the deductible.

Research shows that people with high-deductible plans do cut their overall health care expenses. But they also tend to cut back on preventive health care such as childhood immunizations, cancer screenings and routine tests. This “penny wise and pound foolish” approach to medical care can be dangerous.

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A high-deductible health insurance plan can provide affordable coverage for unexpected major health and medical expenses.

Essentially a form of catastrophic insurance, these plans charge a high annual deductible – from $1,000 to $5,000 and higher – in exchange for lower monthly premiums.

You’ll have to pay out-of-pocket costs for routine doctor’s office visits or trips to the emergency room until you hit your deductible. The insurance covers everything after that.

To help pay these out of pocket costs, it’s both wise and typical to pair your high-deductible plan with an IRS-qualified health savings account. You can make tax-free deposits into this account (even if you take the standard deductions and don’t itemize), up to $3,050 annually for individuals or $6,150 for family coverage. If you’re 55 or older, you can contribute an extra $1,000 a year.

This money is yours to withdraw, tax free, at any time, to pay for medical expenses that aren’t covered by your high-deductible policy.

High-deductible insurance is considered a consumer-driven health plan, giving the patients control over how to spend and invest their money.

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