Category News

WASHINGTON - OCTOBER 08:  U.S. Supreme Court A...

Today starts the first day of the debate on health care reform. It will be very interesting to see how the supreme court rules in the next 3 days.


Fox News reported on what a fine line the administration’s argument is on. Not having health insurance cause to get a penalty or a tax? The administration’s attorney had a difficult time distinguishing either or.


Supreme Court Health Care Law Here is the transcript of day 1.




In day 2 there was emphasis from the justices on three significant constitutional areas to determine if the ACA is lawful. The Commerce Clause, the Necessary and Proper Clause and the federal government’s taxing power.


The government made the case that the law was “classic economic regulation of economic conduct” That all people at some point must purchase or use health care. The government also pointed out economic problems of sustaining the current system.


The plaintiffs were more focused on the individual level and if Congress can regulate activity or in this case inactivity. They argued the Federal government does not have the constitutional authority to force people into a marketplace by making them buy a product. This line of argument about unchecked authority gives concern that the Government could mandate the purchase of any product they want.

The 3rd day of arguments was what to do if the individual mandate was deemed unconstitutional.  Since the individual mandate is the key component of the ACA without it could bankrupt every health insurance company.  The justices ask many questions and the Government stated that without the individual mandate guaranteed issue would have to be removed from the law. The plaintiffs said that entire law should be struck down.  The supreme court could not go through the entire law and decide was stays and what goes. This would be a form of judicial activism and the court really does not want to go through 2,000+ pages of the law. They even called it cruel and unusual punishment if they had to do that.

It is being predicted that in June of 2012 the supreme court will decide the fate of the health care reform passed by the Obama administration.

Official 2007 portrait of U.S. Supreme Court A...


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$1.76 Trillion for Obamacare

The CBO released the cost of the Health Care Reform for the next 10 years. The congressional Budget office originally projected the cost of the reform at $940 Billion for 10 years. Now the CBO is projecting $1.76 Trillion for the next 10 years. Then in 2022 with another $265 billion for coverage expansions it is estimated the cost could be $ Trillion.

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English: Kathleen Sebelius speaking after her ...

Senator Johnson Questions Secretary Sebelius Regarding Obamacare Cost

Here is a questing  from Senator Johnson to Secretary Sebelius on the cost of the health care reform.

The Senator has some of his facts mixed up and the Secretary seems to be unprepared for the questioning.

The Senator was using cost estimate and predictions that had different time frames. Some numbers were for 10 years and others were for 20 years.

The Secretary seem unprepared to answers or address any of these facts/estimates.

This is a snap shot on how complicated the health care reform law is.

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English: U.S. Health Insurance Status (Under 65)

The department of Health and Human Services has release a 644 page document on the rules for a state based exchange.  This document is going to have a huge impact on health insurance and health care.  At this point no one really has an idea of how a state based exchange is going to look and operate.

If a state can not meet these rules then the federal government’s exchange will operate in the state. There has been very little information on how a federal exchange will look. We do know that the current administration has asked for $800 million a year to administer the federal exchange.


The Exchange final rule includes standards for:

The  establishment and operation of an Exchange

Health insurance plans that participate in an Exchange

Determinations of an individual’s eligibility to enroll in Exchange health plans and in insurance affordability programs

Enrollment in health plans through Exchanges

Employer eligibility for and participation in the Small Business Health Options Program (SHOP)

HHS Exchange Rules

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IBJ reported that Franciscan St. Francis Health plan to build an Emergency room and physician office building is on hold in Greenwood.

“This is a result of concerns about the changing environment related to  National healthcare reform” The CEO of the hospital was reported saying.

The hospital official stated that they have a real concern over reimbursement rates with Medicare and private health insurers like Wellpoint.

We are now seeing the beginning affects of healthcare reform with uncertainty. What makes this even more concerning is that Franciscan was the only local hospital to participate in the Accountable Care Organization initiative.  The ACO model is under the health care reform law where hospitals are paid on performance.  It would be interesting to know what conclusions St. Francis have about the ACO model.

A hospital delaying construction is just the tip of the iceberg when it comes to Health Care Reform.  Think about all the research of health care that has been put on hold because of the new law.

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Smartphone Configuration for Social Media Mark...Health4Me App


Unitedhealthcare is one of the leading health insurance carriers when it comes to technology. They are not always user friendly but this Smart Phone App is really cool.


As you know the words cool usually are not in the same sentence as health insurance.


This app is to help families track their health care. With health plans shifting more up front cost onto the insured these kind of tools can be very effective in tacking and budgeting for health expenses.


Right now there are few smart phone apps associated with health insurance. These type of apps are not for everyone but if you want to take control of your health care dollars this is good starting point.

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English: English: Barack Obama signing the Pat...
Image via Wikipedia

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
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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The Marketplace must ensure you’re eligible for a health insurance plan through the government program. To do so, several pieces of your personal information are pulled from federal agencies, as approved by the Department of Health and Human Services (HHS). The following sources, and perhaps several more, may be used to verify your identity:

  • Social Security Administration (SSA) for your social security number and citizenship status
  • Internal Revenue Service (IRS) for household size and income
  • Department of Homeland Security (DHS) for citizenship information and immigration status
  • Consumer reporting agencies for income levels

Inconsistencies between your application for a Marketplace plan and information acquired through these agencies could lead to delays in approval. If notified of any problems, you’ll be given time to solve the issues, as well as sources you can use to do so.

To learn more about how the Marketplace verifies your identity and ways we can help you complete the process smoothly, contact us today.

© 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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generic drugs
Image by :: Wendy :: via Flickr

Lipitor, one of the most frequently prescribed medications for lowering cholesterol and preventing heart disease, is now available in generic form. Access to atorvastatin – the generic name for the drug – is going to save residents thousands of dollars. Here’s how:

According to the American Heart Association, heart disease is the leading cause of death in Indiana. Particularly alarming are the obesity rates (more than 65 percent) and the number of active smokers (more than 23 percent), both higher than the national averages. The state has the 14th highest death rate from the disease in the country.

In the past, residents on high deductible health plans who were prescribed this medication had to spend about $80 a month for the drug.  Now that the generic version is available, the cost will decrease to just a few dollars for a 30-day prescription. Even residents on a co-pay plan will realize the savings; atorvastatin is expected to fall in the $10-or-less co-pay category.

On an individual level alone, this is great news. But it’s also going to benefit those enrolled in a group health plan. Employees in group plans will not only personally save money, but they’ll save their company money by reducing the overall claims. A large company that may have been spending more than $100,000 each year on Lipitor may now be able to reduce those claims by as much as 90 percent. As a result, the group health plans will have more buying power.

Some  residents may be hesitant to make the switch. Although most generic medications are usually the same, the formulations can have minor differences. Keep in mind that if you do choose to continue taking Lipitor over the generic version, you will pay a higher cost – most health plans will categorize Lipitor as a Tier 3 drug, which means the co-pay would be substantially higher. Some carriers may choose not to cover it because the generic alternative is available. In that case, a person would likely be required to provide a letter from their doctor explaining why they have to take the brand name in order to get it covered.

For local residents agreeable to the switch, the availability of the generic version of Lipitor should provide a substantial savings.

Are you or a loved one currently taking this medication? How does Lipitor going off-patent affect you?

Source: “Indianapolis Fact Sheet” American Heart Association ( Accessed December 10, 2011

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Trustmark Bank

Indianapolis has seen the introduction of several new group health products designed for companies with between 10 and 250 employees. What makes these plans intriguing is that they are self-funded health insurance vehicles.

In a traditional self-funded plan, the employer pays for its own medical claims directly. Meanwhile, a third-party administrator administers the health plan by processing claims and performing other tasks.  Self-funded plans usually include stop-loss insurance, which limits an employer’s annual claims responsibility.

A self-funded health plan has several advantages, including the following:

  • ·         The employer pays only for claims incurred after the network discount
  • ·         The employer can track the types of claims being incurred
  • ·         The employer can offer the same plan throughout Indianapolis because self-funded plans are not subject to state mandates
  • ·         Self-funded plans can be tailored
  • ·         The employer receives fewer billing surprises, because claim data is accessible all year

The newest Indianapolis health plans are a hybrid of self-funded and fully insured, also called level funding plans, which enable Indianapolis companies the opportunity for future savings. Companies can realize these savings if group claims are down. When claim levels are reduced, the employer may receive a portion of the aggregate claims liability account – also known as a claim pre-fund or claims funding. Some plans are designed to return up to 50 percent of the account, which could be equivalent to about 25 percent of the overall premium.

The stop-loss protection is what enables the plan to work like a fully insured contract. Even if your medical claims are higher than your claims funding, you won’t pay a higher premium, thus removing much of the risk from the traditional self-funded plan. You can predict your monthly payments.

The value of a level-funded plan is that you have access to claims activity. When it’s time to renew your policy, you have the knowledge to target and modify specific areas of the health plan.

Self-funded, group health insurance isn’t new in Indianapolis. Level-funded vehicles have been around for some time, too. So why are companies launching these new plan designs?

Companies are offering new products in anticipation of the healthcare reform community ratings set to take effect in 2014. With community ratings, the rates for sick and healthy groups are essentially the same. Underwritten groups will no longer exist and everyone will pay similar rates.

Level-funded plans have been successful in community rated states. Health groups or low utilization groups are scoring huge savings from these types of plans. Because the plans are consider self-funded, providers have more room to operate under the health care reform law.  As a result, companies have greater control of the health benefits.

Indianapolis health insurance plans begin with as few as ten people enrolled.  Are you responsible for selecting the insurance options for your company? If so, please contact me today. I’d be happy to provide you with a quote.

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