Category News

Senate Passes Insurance Industry Aid Bill

NY Times reported a interesting view on health care reform.  They are reporting a glitch in the health care law.

Under the Affordable Care Act, if an employee has access to group health benefits, then their dependents are not eligible for subsidies through the exchange. This is basically the short version of the argument. This aspect of the law have been interpreted by both the IRS and Congressional Joint Committee on Taxation.

The so called “glitch” is that a employee may be able to afford their portion of the premium, on a employer sponsored health plan but not the dependent portion.  In Indianapolis, an employee only contribution, maybe below $1,000 a year. Now if we add the dependents to the plan the cost may very well jump to $7,000 year. A lot of Indianapolis small group and mid size companies, the employer has gone with the philosophy to pay the for the employee. The lower pay employees, then are unable to afford to put their families on the plan. This is 100% a legit issue.

These dependents will not qualify for subsidies under the health care reform. The reason the law was written this way is to keep some type of retention on employer sponsored plans.

In Indianapolis, we are going to see a lot of employers with under 50 employees consider dropping group health coverage in 2014.  There is going to be many health insurance and legal factors a decisions maker will consider. If the employee base are low wage earners, then the employer may be doing the employees a favor by dropping coverage. This will give the low paid employees full access to subsidies. So the argument could be made that if this is not fixed then it will lead to groups dropping coverage.

This is just one of many issues we are going to face in Indianapolis when it comes to health care reform

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Mike Pence recently sent his letter to Gov. Daniels regarding the development of  a state based exchange.

Governor Elect Mike Pence, has choose not to establish a state based exchange.  He stresses the lack of clarity coming out of the federal government. Indianapolis developed the health Indianapolis plan that has been very successful, form a cost stand point while keeping insureds satisfied. There are over 40,000 Indianapolis residents on this plan. The state of Indianapolis wanted to be able to offer this plan in a state based exchange. At this time, that plan is not an option with in the exchange.

The letter also points out the tax increase that will impact Indianapolis residents and businesses.  We are going to see tax increases for medical devices manufacturers, individual mandate, employer mandate, Medicare tax, & tax on investment properties.  Every Indianapolis resident is going to feel the impact of these tax increases.  There is a new 3.8% tax on investment property income. No one except Mike Pence is talking about this tax increase.

Mike Pence states in the letter that the health care law is going to lead to more dependence on federal subsidies for Hoosiers. This could happen as individual health insurance premiums almost double.  Under the health care law there will be subsidies available and a majority of people could qualify for this assistance.

The letter also state the uncertainty of how a state based or federal exchange is going to operate. There is a fear of the Federal Government is going to micro managing a state based exchange.  If  Indianapolis does not have the flexibility to add the Health Indianapolis Plan that is a huge red flag.

The cost of operating the exchange is a huge unknown. There have been estimates from $44-$88 million a year. The current state administration does not know where that funding is going to come from.

If Mike Pence becomes the next Governor of Indianapolis, you can expect to have a Federal Facilitated Exchange. At this time we do not know how the exchange will operate.  In the next few months more details should come out on how the Federal Exchange will operate.

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US Federal Exchange

It has been reported that Governor elect Mike Pence is not going to establish an Indianapolis State Based Health Insurance exchange.  If the state does not elect to set up our own exchange then a Federally-Facilitated Exchange will be set up without state partnership.

HHS will establish and operate the Federal Exchange.  Indianapolis will still have options to coordinate with CMCS on decisions and protocols for either eligibility assessment or eligibility determination model with in the federal exchange. HHS intends to work with in collaboration with them, where appropriate, to ensure the best, most effective experience for Hoosier residents.

If Indianapolis does not notify HHS by November 16, 2012, the HHS will operate the federal exchange.

1.  Indianapolis will not be able to administer a reinsurance program.

2.  The Individual and small group markets will be merged into one risk pool.

3.   Indianapolis’s definition of small group employer will be followed.

At this time HHS has released few details on how the federal exchange will operate.  We do not know if the Insurance carriers are going to participate. We also don’t know how the policies will be distributed.

The current administration has made reference to using local agents and brokers to distribute the Federal Exchange.  We should see a online application that not only will allow you to enroll into the exchange but determine if you are eligible for subsidies.

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Under the Health Care Reform there are new preventive care benefits that every Non Grandfathered policy will have to cover. Some of these benefits will be covered at no cost to the insured. It’s very important that you consult your current coverage to determine if these new benefits will be covered. There will be some plan that do not cover these benefits.

Some Indianapolis based insurance companies will not have grandfathered plans. Each health insurance carrier operating locally will determine if they can administer grandfathered and non grandfathered plans. Self Funded plans my also be exempt.

It’s very important to know your current benefits. When seek wellness visits it extremely important to know what is covered and what could end up not covered.  Some times our medical providers may not be well versed on coverage changes. Check with your health insurance carrier.


A pregnant woman
A pregnant woman (Photo credit: Wikipedia)


From, the federal government’s site providing basic information on health care reform, including PPACA:


Preventive Services for Adults – Including Senior Citizens

Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

Alcohol Misuse screening and counseling

Aspirin use for men and women of certain ages

Blood Pressure screening for all adults

Cholesterol screening for adults of certain ages or at higher risk

Colorectal Cancer screening for adults over 50

Depression screening for adults

Type 2 Diabetes screening for adults with high blood pressure

Diet counseling for adults at higher risk for chronic disease

HIV screening for all adults at higher risk

Immunization vaccines for adults- -doses, recommended ages, and recommended populations vary:

Hepatitis A

Hepatitis B

Herpes Zoster

Human Papillomavirus

Influenza (Flu Shot)

Measles, Mumps, Rubella



Tetanus, Diphtheria, Pertussis


Learn more about immunizations and see the latest vaccine schedules.

Obesity screening and counseling for all adults

Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk

Tobacco Use screening for all adults and cessation interventions for tobacco users

Syphilis screening for all adults at

Covered Preventive Services for Women, Including Pregnant Women

Note: Services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, 2012. See Affordable Care Act Rules on Expanding Access to Preventive Services for Women.

Anemia screening on a routine basis for pregnant women

Bacteriuria urinary tract or other infection screening for pregnant women

BRCA counseling about genetic testing for women at higher risk

Breast Cancer Mammography screenings every 1 to 2 years for women over 40

Breast Cancer Chemoprevention counseling for women at higher risk

Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*

Cervical Cancer screening for sexually active women

Chlamydia Infection screening for younger women and other women at higher risk

Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*

Domestic and interpersonal violence screening and counseling for all women*

Folic Acid supplements for women who may become pregnant

Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*

Gonorrhea screening for all women at higher risk

Hepatitis B screening for pregnant women at their first prenatal visit

Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women*

Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older*l Osteoporosis screening for women over age 60 depending on risk factors

 Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk

 Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users

 Sexually Transmitted Infections (STI) counseling for sexually active women*

 Syphilis screening for all pregnant women or other women at increased risk

 Well-woman visits to obtain recommended preventive services for women under 65*

 Behavioral assessments for children of all ages

Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

Blood Pressure screening for children

Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

Cervical Dysplasia screening for sexually active females

Congenital Hypothyroidism screening for newborns

Depression screening for adolescents

Developmental screening for children under age 3, and surveillance throughout childhood

Dyslipidemia screening for children at higher risk of lipid disorders

Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

Fluoride Chemoprevention supplements for children without fluoride in their water source

Gonorrhea preventive medication for the eyes of all newborns

Hearing screening for all newborns

Height, Weight and Body Mass Index measurements for children

Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

Hematocrit or Hemoglobin screening for children

Hemoglobinopathies or sickle cell screening for newborns

HIV screening for adolescents at higher risk

Immunizationvaccines for children from birth to age 18 -doses, recommended ages, and recommended populations vary:

Diphtheria, Tetanus, Pertussis

Haemophilus influenzae type b

Hepatitis A

Hepatitis B

Human Papillomavirus

Inactivated Poliovirus

Influenza (Flu Shot)

Measles, Mumps, Rubella






Learn more about immunizations and see the latest vaccine schedules.

Iron supplements for children ages 6 to 12 months at risk for anemia

Lead screening for children at risk of exposure

Medical History for all children throughout development

Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

Obesity screening and counseling

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Walgreen’s rejoins Anthems Network

Anthem just announced that Express scripts and Walgreen’s have reached an agreement.  Anthem members can use the Walgreen’s pharmacy as they will be considered a in network provider.

Walgreen’s is a great provider of pharmacy benefit in the area. It is important to remember to check local pharmacies for the most competitive prices on medications.  The large pharmacies can sometime have the most expensive prices. If you are on a Health Savings Account it makes sense to be a consumer shopper for RX.  Comparing prices of local pharmacies might bring large savings to you.

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2005 US cent, obverse side] has released the medical loss ratio for all health insurance companies operating in Indianapolis. It is interesting to see just how close the carrier are to the 80% or 85% loss ratio. With all of the tools the carriers use to keep cost down it is surprising that the loss ratios are not lower.  This is just another indicator how expensive medical care is.

  • Medical Loss Ratio: Insurers must, in general, spend 80% or 85% of the premium dollars they take in on health care costs and health care improvement activities. If they do not, they must provide refunds to policy owners.


Advantage Health Solutions, Inc.

Insurer’s MLR MLR Standard Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market: Not Applicable Not Applicable Not Applicable
Small Group Market: 95.8% 80.0% Not Applicable
Large Group Market: 93.5% 85.0% Not Applicable


Anthem Ins Companies Inc(Anthem BCBS)

Insurer’s MLR MLR Standard Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market: 81.8% 80.0% Not Applicable
Small Group Market: 79.2% 80.0% $61.00
Large Group Market: 92.4% 85.0% Not Applicable


Golden Rule Insurance Company

Insurer’s MLR MLR Standard Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market: 76.4% 80.0% $130.00
Small Group Market: Not Applicable Not Applicable Not Applicable
Large Group Market: Not Applicable Not Applicable Not Applicable


Medical Mutual of Ohio

Insurer’s MLR MLR Standard Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market: 82.1% 80.0% Not Applicable
Small Group Market: 81.5% 80.0% Not Applicable
Large Group Market: 115.5% 85.0% Not Applicable



Time Insurance Company

Insurer’s MLR MLR Standard Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market: 77.7% 80.0% $121.00
Small Group Market: Not Applicable Not Applicable Not Applicable
Large Group Market: Not Applicable Not Applicable Not Applicable


UnitedHealthcare Insurance Company

Insurer’s MLR MLR Standard Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market: Not Applicable Not Applicable Not Applicable
Small Group Market: 82.5% 80.0% Not Applicable
Large Group Market: 87.6% 85.0% Not Applicable
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Countdown to Health Care Reform

This is a great video explaining the negative consequences of the Health Care Reform law.

The Governor gives an excellent explanation on how negative the impact will be. He also explains our Healthy Indianapolis Plan and how successful it has been. This plan might not qualify under the new federally requirements for health insurance.

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Welborn Health Plans announced that they are exiting the health insurance market in Indiana.  They had more than 30,000 members. It comes to no surprise why small health insurance providers pull of Indianapolis. Most of these small companies rent PPO networks. This means they have additional cost in the form of access fees. The rented network also can not deliver as deep of discount vs. a national network.

The last few years we have seen carriers like UnitedHealthcare and Anthem really control the Indianapolis market. In the Southern part of the state Humana is very competitive.  One of the reason these companies have a huge advantage here is they own their own network. This gives them the ability to get the deepest network discount when it comes to claims.

Small companies like Welborn are going to have a difficult time competing now and in the future.  One could go as far to say they cannot compete against national companies.  

The problem with the small health carrier leaving the area is that it reduces the competition.  A lack of competition can only lead to higher pricing.

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The Star of Life, medical symbol used on some ...

What Doctors Think of the Affordable Care Act

This document looks at how the Implementation of the affordable Care act will affect doctors.

The introduction is a snap shot of the uncertainties with the new law. The law it’s self is 2,700 page and the Department of Health & Human Services has already issued over 12,000 pages elaborating on the original document. It is expected there will additional clarifications needed. 

Reimbursement rates are a major economic concern with doctors. There are concerns with both Medicare and Medicaid reimbursement rates as it is. This could create a barrier for Doctors to embrace the ACA. It is estimated that Medicaid reimbursement rates are just 56% of private payment.

The attitude of the medical professional toward the ACA will have a big impact on the public. This article addresses some of those perceptions. One of those perceptions is if doctors feel the ACA will harm their ability to interact and treat patients. Doctors have concerns that medical decisions could ultimately made by the government. An example of this would the Independent Payment Advisory Board.

How will Doctors React to the new law. “If doctors cannot practice as they wish, it raises the question of whether they will practice.”  

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This map gives an idea where each state stands on setting up a health insurance exchange. The majority of states have taken grants to establish a state based exchange. The states have positions themselves to set up the insurance market.  Some states have taken grants to research a stat based exchange. They are looking at what it would take to run a successful exchange.  Two states have declined setting up a state based exchange. These states could have made the decision based on the eventually cost of exchange is going to have on the state. Two states currently have a state based exchange in operation. Massachusetts & Utah are the only states to have an actual track record of operating a state based exchange. Massachusetts has some of the highest health insurance cost in the country. They have also encountered law suits from different hospitals over reimbursement rates. Utah’s exchange is more of a free market exchange and a blue print to what some state would base a state based exchange off of. Utah has had problems with the exchange being competitive and efficient. They have a much lower group participation rate in the exchange than expected. 

Most state have put on hold any further development of a state based exchange until the supreme court has a ruling on the health care law. Indiana is no different.

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