Category News

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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If you have a United Health One policy you may have experienced a rate increase this year. This has become a major problem, not just from a cost standpoint, but also from a Qualifying Life Event (QLE) standpoint.

United Health One made a decision to move the renewal date of their Indianapolis members to December 31. At that time, this decision made sense with the information they had available. These members were able to keep their health plans and delay the impacts of the Affordable Care Act. The impact they were avoiding was a premium rate increase.

Now, United Health One is issuing rate increases to their individual plans in Indianapolis outside of the renewal period. These rate increases went through the Indianapolis Department of Insurance for approval. The IDOI approved these rate increases without fully understanding the QLE under the Affordable Care Act. In all fairness, the QLEs were not clarified until late March by the Health and Human Services and Centers for Medicare and Medicaid Services.

What is the Problem?

The rate increase of an individual plan is not considered a QLE. This means that you are unable to shop for new coverage. You have to wait for the policy renewal period. In United Health One’s case, that is in December for Indianapolis. Think you might have a QLE? Check out my blog to find out if you’re eligible for special enrollment.

I Have a Solution for You

If you received a rate increase and there is a better option out there for you, you have to wait until the renewal period. In my research, I have found one strategy that is available that may work for you. Contact me, Tony Nefouse, and we can discuss possible solutions and help you save money.

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Small group health insurance renewal from July 1 to the end of the year just got really interesting.

If you have been following my blog posts, then you may have read an article titled “What Is “Grand Mothering” And How It Will Impact You?”

Grand Mothering is the ability to keep your current group health plan, even if it isn’t compliant with the Affordable Care Act in Indianapolis.

Why would you want to keep your current group health plan?

Well…because of the cost!

The current non-ACA small group health plans cost much less than the new ACA-compliant plans. We are talking 35-55% cheaper, which is a huge percentage.

Under the ACA, the non-compliant plans will not have any pre-existing coverage provisions. These plans are going to have the definition of “Legacy Plans.”

Have you experienced a rate increase?

It might be valuable for you to take a look at the new ACA-compliant plans if you have received a large rate increase in the past or if your employee base is, on average, older. In high utilization groups, we have seen some rates actually go down. This has happened! It is very easy to pull the numbers and plan designs for the new ACA-compliant plans.

If you decide to move to a new ACA plan then you will not have the option of moving back. If you stay with your “Legacy Plan” you cannot make any plan changes.

Small business could gain huge savings.

This is the time a small group should consider new options. Under the ACA, there are some advantages that have not been revealed to most small groups in the area. These advantages could create huge savings for your company and your employees. If you are interested in learning about a new approach to health insurance, contact me, Tony Nefouse, at (800) 846-8615.


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Is it legal to move an employee from my group health plan to the a guaranteed issue individual plan?

This is a big question with a lot of money on the line for employers and insurers.

During open enrollment (October 1, 2013–March 31, 2014), anyone could have purchased a health plan either on or off of the exchange. Keep in mind that if an employee has access to a group health plan, it might disqualify them from receiving tax credits on the exchange, but not on the actual health plan.

A University of Minnesota’s law professor had a paper published back in 2010 that predicted this exact situation. If you read the paper, you will see it was predicted that employers would redesign their health plans to intentionally try to move high-utilization employees off of the group plan. I, on the other hand, would disagree that a plan would be designed with that being the primary intention.

This issue opens up a very interesting discussion for large self-funded groups. This issue would not impact small companies that have fully-insured premiums. On large self-funded plans, the employers pay the initial claims up to a certain point. That certain point is called “stop loss” insurance. It is exactly what it sounds like, stop the losses.

Under these arrangements, the reinsurance contract to initiate a term is called lasers. Lasers (excluding individuals or setting a unique, higher pooling level for individuals who are expected to have large claims, increase customer liability) are optional, depending on risk tolerance .

An example would be a group that has a stop loss limit of $125,000 per person on the plan. This means the company is going to pay the 1st $125,000. There is a high claimant that is projected to have $700,000 in claims. The reinsurance contract has the ability to laser and moves the $125,000 stop loss to $400,000. Now, the employer is responsible for that $400,000.

At this point, options may be entertained on controlling cost. With the new Affordable Care Act, an option that might be discussed is moving the high claimant to an Individual health policy during open enrollment.

To learn more about how we can help your business, give us a call at (800) 846-8615 and we will be glad to sit down with you and answer any questions you may have.


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Did you or a loved one lose health insurance coverage in the last few weeks? You might still be able to get insured under special enrollment if you have a qualifying life event.

Every health insurance provider has different requirements to get insured, but they all follow the same set of guidelines put in place by the Federal Government under the Affordable Care Act.


Here are the most common reasons for loss of coverage and the documents and/or requirements needed:

  • Termination of employer contributions

Requirement: Letter from employer to verify termination

  • Exhaustion of COBRA coverage

Requirement: Certificate of Creditable Coverage and/or COBRA term letter (proof of prior health care coverage)

  • Loss of employer sponsored health insurance as a result of termination of employment

Requirement: Termination of coverage letter

  • Termination of short term medical plan

Requirement: Termination of coverage letter

  • Divorce or legal separation (loss of coverage under spouse’s health insurance)

Requirement: Certificate of Creditable Coverage (proof of prior health care coverage)

  • No longer eligible as a dependent due to age

Requirements: Letter from carrier indicating dependent is no longer an eligible dependent

  • Death of a spouse (loss of coverage under spouse’s health insurance)

Requirement: Termination of coverage letter

  • Spouses employment terminates (loss of coverage under spouse’s health insurance)

Requirement: Certificate of Creditable Coverage and/or Term Letter (proof of prior health care coverage)

  • Employer reduced working hours (no longer eligible for group coverage)

Requirement: Letter from employer to verify

  • Current plan change to eliminate coverage for certain groups (e.g. part time workers)

Requirement: Letter from employer to verify

  •  Group coverage terminates due to non-payment of premium – Employees can use this as a QLE  

Requirement: Letter from employer to verify

  • There is a health claim that will meet or exceed the plan’s lifetime limit on all benefits

Requirement: Explanation of benefit validating lifetime benefit met

  •  2014 Renewal

Requirement: Renewal letter from existing carrier

  • Non payment of premium, misrepresentation or fraud

Requirement: Reinstatement denial letter or rescission letter

  • Relocation/ Move

Requirement: One of the following is required to validate coverage is in force:

      • Other carrier information:
      • Name of carrier and phone number
      • Effective date
      • Termination date
      • Policy number
      • Type of coverage
      • EOB with Effective date and termination date of coverage

One of the following is also required:

      • Proof of new residence (e.g. mortgage document or rental agreement)
      • Driver’s license with current residence
      • Utility bill with current residence

Some of these requirements are easily obtainable whereas others are a little more difficult. The main problem at the moment is that the health insurance company or marketplace will request a copy of your Certificate of Prior Coverage (COC), but you won’t be issued this document until your previous plan has been terminated. It can take up to a month to get this document from your previous carrier.

Some insurance companies are putting a time limit of 15 days to provide this document. This is not a realistic time frame. If you are applying for a health insurance policy on the exchange, you can’t submit your application until you lose your current coverage. Then, your new plan will start the following month. This is not ideal because you could end up with a gap in coverage.

Here at Nefouse & Associates, we will look for other documentation that will satisfy the insurance companies. Tackling individual health plans off of open enrollment can be a difficult and stressful task. Let the experts at Nefouse & Associates take the stress off of you. Call us today at (800) 846-8615!

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Senator Rand Paul has been one of the biggest critics of the Affordable Care Act. You might remember when he took out a policy on the marketplace for his family, which placed his son in Kentucky on Medicaid. He told the public over and over his woes of trying to sign up, trying to pay and the general confusion about if he was actually signed up.

Now, Senator Rand Paul, is saying repeal is unlikely.

In Indianapolis, we have had about 100,000 people get health coverage because of the ACA law, and many Hoosiers have benefited from tax credits. We placed a large amount of people on the exchange which brought about huge tax credits. Older couples went from $1,400 per month to only $300 per month after the tax credit! 

Large families that were accustomed to paying $1,200 per month are now paying only $500 per month. Many Hoosiers were able to place dependents on Medicaid programs when they did not even know they were eligible for enrollment.

Then there was the “Holy Grail” benefit of the ACA: guaranteed issue! No matter how you felt about the new law, this was the one aspect that everyone could agree on. The ability to obtain a health policy without being denied is a positive impact of the law no matter how you look at it.

Despite all of the positives, there are still a few segments of Hoosiers that are not benefiting from the ACA, but instead being penalized.

First is our middle class, who do not qualify for tax credits. They have seen large rate increases in health premiums. Next are the group health plans being provided by small group employers. On average, these plans have seen 35-55% rate increases. This is going to be a huge problem for local small businesses. 

Recently, Indianapolis agreed to allow “grandmothering” which will extend non-ACA compliant health plans. The administration, both locally and federally, have realized how big of a negative impact the ACA is going to have on small groups.

Going forward, the opponents of the ACA will have plenty of arguments to make about the cost of the law. The proponents will have a difficult time defending the cost. The other issue is Hoosiers having to make decisions about new doctors and taking on more risk in out-of-pocket.

It does not matter if you agree or disagree with the law, you have to make the best decision for you regarding your health policy. That’s where we come in! We can help you make an informed decision. Call us today to get started at (800) 846-8615. 

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