Category News

federal_exchanges_onpageThe new Indianapolis Health Insurance Exchange will go live in only one week!  Here at Nefouse & Associates, we are authorized to sell and service the exchange plans.

There will be four options of coverage: Bronze, Silver, Gold and Platinum. Under the Affordable Care Act, often referred as Obamacare, no one can be denied coverage due to pre-existing conditions.  The other huge benefit is the access to subsidies to lower your monthly premium. These subsidies will only be available through the Indianapolis Health Insurance Exchange.

We are predicting that you will enter an authorized quote engine (which we will provide) and that platform will guide you to the subsidy portal. Once at that portal, you will have the option to apply for subsidies. When your eligibility is determined, then you should be assigned some type of identification number and you would place this number on the health insurance policy. The federal government will then send money to the insurance company, bringing your monthly premium down.

So we are looking to major factors that are going to change the way we purchase health insurance. The first one is guaranteed issue, meaning that no one can ever be declined for coverage. The second factor is the access to subsidized premiums, making health insurance affordable to you and your family.

Currently in Indianapolis we have about 800,000 people without health insurance. It is being projected that about 300,000 take advantage of the new health care law.




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autismFor families that are faced with Autism, there is great concern about how the new health care laws will impact them.

All of the insurance companies that will be participating have filed their plans with the Indianapolis Department of Insurance. From what we can tell, it looks like all of the plans will cover the Autism Mandate. It doesn’t matter if the plan is on the exchange or off of the exchange, the mandate will be covered.

When we look a the Federal Exchange plans, these plans are all HMO plans (Health Maintenance Organization) and operating on narrow networks. These plans state they are covering Autism under the mandate. The question is this: how difficult will it be to go out of network for the treatment of Autism? Unfortunately, we cannot answer this until we have actual claims. On an HMO plan, your doctor is the gate keeper to all of your care, so every medical procedure would have to be approved by your attending physician. This would add one more layer to the process of getting a treatment covered.

Outside of the exchange, we should see the same level of coverage that we have today. If you purchase a policy on a PPO plan (Preferred Provider Organization), then you will have one less obstacle to getting care covered. PPO plans allow you to visit whatever in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician. One issue that we are waiting on is if stand-alone child policies will be available, which would help families a great deal if they only have to pay premium on the child.

From a carrier standpoint, our options are going to be limited.  We predict there will only be a handful of carriers selling PPO plans off the exchange. Right now, it looks like Humana and Anthem will be the main carriers.  UnitedHealthOne and Medical Mutual will not be offering individual health plans next year. Autism treatment facilities will want to build relationships with Humana and Anthem as they may be the only carriers left in the PPO market.

If the exchange plans work out, we could end up adding three more carriers to the equation, which would give us a total of five carrier options. The question then becomes this: do you want to be the first person to file claims for the treatment of Autism with a carrier that does not have experience in that field?

Read More the 7,200 policy holders who currently have a health insurance policy through Indianapolis Comprehensive Health, I have some good news.

Most of you have never had good news when it comes to health insurance. Under the new health insurance laws, your luck might change!

The first and most important point is that you can not be declined or rated up for any ongoing condition. If you are on the ICHIA plan, then you know what it’s like to get declined for coverage. Well those days are over and  you could possibly see a rate decrease! We are still going to have age-based premiums, but you could end up getting a rich plan design for less of a monthly premium.

Don’t think that you’re stuck with only one choice for health insurance; there will be health insurance policies offered both inside and outside the exchange.  Should you want to really reduce your premium, you will have the option of buying an exchange policy with a subsidized premium. These policies will look like HMOs and have very narrow networks.

If you decide that you are not comfortable with the narrow network, then you can purchase a policy outside the exchange. We should have the option of open access PPO plans. PPO plans allow you to visit whatever in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician. The premiums for these plans could, in fact, be cheaper than what you are paying right now.

It’s rare in the health insurance industry to be able to deliver good news, so we’re excited to be able to give you this! Stick with us for information about Health Care Reform, and once October 1 comes around, you can sign up for your insurance plan right from our website!



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rising-resize-380x300-resize-380x300By now, you might have heard that the Indianapolis Department Of Insurance projected a 72% increase in individual health insurance market for Indianapolis. The IDOI has also released the Individual Insurance Market Report, which goes on to explain this projected increase.

This is a legitimate explanation for the increase, and the only thing that is not included into the 72% is the eligibility for subsidized premiums in the exchange. In the report, it does show that about 500,000 Hoosiers will be eligible for subsidies.

First, you must understand the way the IDOI determined the rate increase. They compared current medically underwritten health plans (in which they use  medical or health information in the evaluation of an applicant for coverage), Indianapolis Comprehensive Health plans (ICHP) (guaranteed issue, a policy that is offered to any eligible applicant without regard to health status) with Silver Plans.

According to the report, if you take a healthy 25-year old male and compare health insurance now versus on a Silver Plan, the current rates are $108 compared to $266 on the Silver Plan, which is a 145% rate increase. Now let’s use the same example, but this time we add pre-existing conditions. On the ICHP, the cost is $304 verus $266 on the Silver plan.  This is a 12.5% decrease.

In this example of healthy versus non-healthy, the non-healthy individual would benefit from the law with a rate decrease. Then, we add in subsidies and there may be real premium joy. For the healthy person that does not qualify for subsidies, now they have premium shock.

The report also looks at a 55-year old couple with excellent health and then with poor health. They may be paying $673 a month currently versus $1,188 on the new silver plan. This is a 76% rate increase…premium shock! If the same couple is unhealthy, they may be paying $1,673 a month on ICHP versus $942 on the Silver plan, which is is a 43% decrease. Premium joy!

I have two categories for post-Health Care Reform: Premium Joy and Premium Shock.

To get to Premium Joy, you will have to qualify for subsidies. To be really happy with the premium, one will need to be under the 250% Federal Poverty Level. Premium Shock is going to hit  Hoosiers that have household incomes over the 400% FPL.  These people could see 100% increases or more in premiums

Under the new law, everyone will have the same access to health insurance, which will help many Hoosiers. For instance, take the 7,200 people on the ICHP. The policy holders went to this high risk pool because they were turned down by a private insurance company. Each of those policy holders could see 25%-35% reduction in premiums in 2014.

So while the report states there will be a 72% increase in health insurance, that statement is only accurate if you don’t include federal subsidies.


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CompareSelfFundedandFully-InsuredIt’s common knowledge that offering health insurance benefits helps attract and retain great employees, yet businesses are looking for ways to cut costs as benefits get more expensive. Have you ever considered a self-funded insurance plan?

In a self-funded plan, a business can provide health benefits directly to employees. Instead of the insurance companies, the employer collects the premiums, assumes the risk and pays employee claims. Feel like that might be too much work? Insurance companies can still execute the administrative aspects for your company.

But what if the company underestimates its employees’ claims and can’t afford  to pay them? There are reinsurance contracts that have low stop-loss limits. Stop-loss insurance is just what it sounds like: stop the losses. This is a limit on the amount that a policyholder must make in coinsurance and out-of-pocket payments per year on an insurance policy. Generally, the stop-loss limit is stated as a flat dollar amount. Once the stop-loss limit has been reached, the health insurance company picks up all remaining expenses for the year. With a low stop-loss contract, a self-funded plan may be more of an option than what it has been in the past.

Below is a check list of what PPACA provisions will directly impact self-funded plans.If you are a group that has a self-funded plan or is entertaining a self-funded plan, these are the some of the provisions that must be covered. Once we see the full impact of the ACA on the fully-insured market, we may see that self-funded plans become an option for both small and mid-sized companies.


  • Prohibition on Lifetime Benefit Limit
  • Extension of Dependent Coverage to age 26
  • Restrictions on annual dollar limits for Essential Benefits
  • Medical FSA’s must limit reimbursements of over the counter products
  • Prohibition on cost-sharing for Preventive Services
  • Establishment of internal and external appeals process
  • Coverage for emergency services at an in-network cost-sharing level with no prior authorization required
  • Reporting on W-2’s of aggregate cost of employer sponsored coverage
  • Increase on HSA tax distribution for non-qualified medical expenses from 10% to 20%
  • Women’s Preventive Care expansion according to US Preventive Services Task Force
  • Quality of Care Reporting
  • Provide Summary of Benefits document
  • Medical Flexible Spending Plans limited election of $2,500
  • Notice of Exchanges
  • Eliminate tax deduction for employers taking the Medicare Part D subsidy for retirement prescription drug coverage
  • Comparative effectiveness research fees
  • Clinical trial coverage must be provided
  • Cost-sharing limitation for qualified high deductible health plans
  • Elimination of eligibility rules
  • Elimination of all pre-existing exclusion clauses
  • Reduce any eligibility waiting period to no more than 90 days
  • Employer mandate to offer coverage (delayed to 2015)
  • Reporting on minimum essential coverage to IRS
  • Reinsurance Contribution
  • Automatic Enrollment (delayed until regulations are published)







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health-care-reformblogIs Health Care Reform just what the doctor ordered?

The Affordable Care Act includes many provisions designed to help consumers obtain health insurance either through the exchange or free market. The law is meant to give access to health insurance while at the same time control costs. Here are the key provisions that will impact all residents.

1. Extensions of health insurance coverage to children up to age 26.

While this was a very useful provision of the law, in 2014 these young adults will be able to purchase a policy through the exchange or outside the exchange with no underwriting. So a parent may actually be better off taking the adult child off their employer plan and purchasing a individual policy.

2. Guaranteed Issue requires all insurers to no longer be able to decline coverage based on health status.

This is one of the biggest provisions of the health care law. In the past, all health plans have been subject to some type of underwriting. In 2014, you will not have to answer any medical questions to get a health policy. For Hoosiers with ongoing conditions, this will have a huge positive impact.

3. Insurance Companies will be prohibited from charging consumers more for gender.

In the past, women have always had higher insurance rates. This will no longer be the case.

4. Elimination of annual and lifetime coverage limits.

Very few Hoosiers will be impacted by this provision unless you are obtaining a lot of health care. There have been situations in the past where people have maxed out plans, but this will no longer happen.

5. Prohibition of Coverage limitation or exclusions based on Pre-Existing Conditions.

In the past, we have seen Insurance companies place riders on certain conditions or put a waiting period in before the condition would be covered. Now any on going condition will covered under the policy.

6. Approved clinical trials have to be covered by the insurance policy.

This is a huge provision! In the past, an insurance policy would never cover any clinical trials. Now they do. So if you have a terminal condition, you can participate in a clinical trial.

7. The Medical Loss Ratio.

80% of  your premium dollars must go towards medical claims. If a portion of the 80% does not go towards medical, then you could be eligible for a rebate.


These new provisions will have a huge impact on the entire state. Some people will be very happy because they will now have access to coverage. Others are going to be upset because they will see their premium go up.

In any case, there are going to be options for coverage. You will be able to look at a policy through the health insurance exchange and outside the exchange. Inside the exchange, you’ll have the option of applying for subsidies to help lower your costs. Outside of the exchange, you’ll have the option of the free market, where you can purchase a plan that has greater access to doctors.

Need help sorting it all out? Contact us and we can help find the best plan option for you!



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health-insurance-exchangesExchange, no exchange, where will you be getting your health insurance?

Right now, most of the national carriers have decided to have limited participation inside the health insurance exchange. In Indianapolis’s Health Insurance Exchange, we are only seeing four carriers that have submitted plans to participate inside the exchange. The only carrier that will be selling exchange plans through the entire state Anthem. So what does this mean?

This national carriers are hedging their risk to offer plans outside the exchange.

The carriers think that people who have household incomes around 400% of the federal poverty level will not want an exchange plan. Why? Well there are a lot of reasons why someone would choose to purchase a health plan outside the exchange, such as:

  1. The subsidy isn’t enough. A family may find a plan that is priced at the same level of premium after the subsidy is applied.
  2. Plan design. Many Hoosiers are accustomed to having the freedom to design a plan that best fits their needs.
  3. Network! This may be the biggest determining factor of why someone buys a policy from the exchange. All of the exchange plans look to be on an HMO network. HMOs are more restrictive than what most Hoosiers are used to and want. It will be very difficult for some parents to have to switch their pediatricians for their children; most people take the time to find doctors that they trust and won’t be willing to switch. The plans off the exchange should have the freedom of the PPO networks.
  4. Accessibility to doctors. There is some concern that the exchange plans could create a longer wait time to see a doctor. On a plan outside the exchange, you may have a much speedier response from your medical providers.


The plans offered outside of the exchange will have a guaranteed issue, which means no medical underwriting.  The application for these plans has been filed to the Department of Insurance and they look surprising simple to complete.  In the next few months, we should know the pricing for these plans offered outside of the exchange in Indianapolis.



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insurance-300x291The new health insurance plans for the Federal Facilitated Exchange have been submitted to the Indianapolis Department of Insurance. Once the IDOI approves them, they will need approval from the Federal Government. Indianapolis is fortunate that you can pull the plan designs from the IDOI website. So what are the plan designs looking like?

The plan designs are all coming in with narrow networks. I would even go a step further with the plans being filed as Health Maintenance Organizations (HMO). The plans are stating that if you do not choose a primary care physician (PCP), then one will be appointed to you. All of your health care must go through that doctor. If you see another doctor without the referral of your PCP, then the claim in not covered. The is no coverage for out-of-network services.

By law, if you have an emergency room visit, it has to be covered as a in-network charge. Some of the plans are stating that a claim must be received in 30 days to eligible for coverage.  This could be a huge problem for some Hoosiers that are not aware of the contracting.

So far, there have only been four carriers to submit plans for the Indianapolis exchange. Two of them are insurance companies and the other two are Medicaid-type providers.  So the plans are looking like Medicaid-type plans with cost-sharing to the insured. Depending on the kind of plan design you choose, deductibles are anywhere from $0-$6,350, co-pays are anywhere for $0-$50 along with co-insurance and Rx co-pays start at $10.

Rates have not been released yet on these plans. With the narrow networks and cost-sharing, it will be very interesting to see how much these plans cost.  It is starting to look like the only reason you would take one of these plans is because subsidies are being offered. If this is all sounding confusing, you can contact us to help you pick the right plan!



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00_HC_shutterstock_117506374_HealthCare_RisingInsuranceRates_3Recently, there have been publications saying that health insurance rates are going up 72% under Obamacare. For example, here is a story in the Indy Star which explains the that under the mandate, everyone must be covered, including those with pre-existing conditions. If this turns out to be true, it will be quite a shock to the wallets of Hoosiers across the state.

The industry really does not know if these statements are accurate. For one thing, all of the health plans have yet to be approved by the state, so we won’t know anything for certain until a later date. Forbes published a piece contradicting the information about the 72% rate increase and we think there might be some truth to it.

The individual health insurance market is going to go up, but the question is how much? As consumers, you will still have options between the four tiers of health insurance plans. When taking a look at the projections for how much insurance rates will increase, the projections you read about are averaged between all four tiers. Those tiers have significant differences, so it is unfair to group someone with a bronze plan in with someone with a gold plan.

Also, subsidies will be offered through the Federal Exchange to  many Hoosiers.  This will have a huge impact on monthly premiums, lowering the cost for many of our residents. As for group health insurance rates, we are hearing about rate increases of just 8%. If that turns out to be true, then that could be a good thing in the fully-insured market.

Until October comes, no one can say with 100% accuracy what will happen. But once the official rates are released, all of this uncertainty will disappear and we’ll know exactly what to expect for 2014.



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