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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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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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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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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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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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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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