Category News

Here at Nefouse & Associates we have found a carrier that will insure Individuals that are suffering from Diabetes.

There are some very strict underwriting guidelines. The diabetes has to be treated with medication and not insulin. Also the applicant cannot be taking more than 3 medications.

This is a true health insurance plan.

Let us know if you have questions.

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I know most people find health care debate to be boring but the reality is this is going to effect you one way or the other.

Congress has formed two committees to investigate the entire law and the impacts that it will have on the economy.  I know some people feel this might be a waste of time but we really do not know what is in the 2000+ pages of the law.  The law effects 1/6Th of our economy and will effect all of us personally.  There should be plenty of bills being introduced to change certain aspect of the law.

So keep your ears open to the debate.

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The house is going to vote on repealing the health care reform.  Most news outlet are stating this is a symbolic gesture.  I think its a lot more than that. The healthcare reform bill is a huge gamble with 1/6th of the economy. The health care reform bill has done nothing to address the cost of care. The best way I can describe the reform is an attempt to increase benefits to reduce cost. The bill really fails to use math in calculating health coverages.

There are many states right now that are trying to figure out how they are going to pay for the reform. Most of this comes from an expansion of Medicaid. The carriers could pull out of certain markets because of restrictive laws regarding Medical Loss Ratio.  Some fear the law could keep companiesfrom hiring employees because they do not want to go over the 50 employee market. With50 employees that opens the doors to many penalties that come in the form of fines.  There is real concern with how the exchanges are going to be set up and if they can be set up on a state level.  There is so many issues that have not been clarified that it is many people are worried.

People that support the health care reform high light areas that sound good. No child under 19 can be declined a policy. This is a good thing but the carriers have pulled out of that market because the federal gov. would not put conditions so people don’t game the system.  Adults can stay on their parents group health plan until age 26 is being pressed as a very good thing.

There is huge discrepancies in what this bill is actually going to cost.

The health care reform is a huge gamble with our economy. The law need to be looked at openly. There is also another 1000 pages of the law that could be viewed as nothing more than an expansion of government into private lives.

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As health insurance prices continue to surge we are seeing a higher demand for Surgical and Hospitalization health plans.

This type of approach for health insurance is being entertained in both individualand small group health markets.  These plans show a change in how we view health insurance. People are willing to take out a plan that covers the most expensive aspect of health care and that is surgeries.

A typical hospitalization and surgical plan has a lot of craves out that in the past have been automatic with health coverages. A big carve out is coverage for diagnostic services. So if a customer is on one of these plans and needs a MRI on their knee then they half to pay for it out of pocket but could still get the network discount. We are seeing plan designs that carve out all prescription drugs.

Someone might look at this plan and think this is too much risk to take on. Not really! If you look for a plan that covers all the carve outs on an inpatient basis then the coverage can be satisfactory.

As we move along with health care reform there is no premium relief in site. These type of plans are going to continue to get serious looks from consumers because they usually are 50%-60% less in premium than a traditional.

Do not confuse these plans with limited liability policies! Hospitalization and Surgery plans are true forms of insurance.

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As we enter in 2011 more aspects of  health care reform will have a direct impact on you.

All wellness and preventive care is now covered at 100% with not cost to the customer.   So there is no reason not to get your yearly check up. Technically speaking if you have diagnostic services done for wellness you would not pay anything.

 Guaranteed issue for children under 19 year of age:

This means a carrier can not deny a child coverage. Now we have a huge problem with aspect of reform because all of the carriers have pulled out of the stand alone child policy market. The other issue is the rate up that the carrier can charg for the child. We are seeing about 400% increase in premium for the child.

Medical Loss Ratio.

This states that at least 80% of your premium has to go to claims or you get a refund. This sounds like a great thing but in the long run it could prevent carriers from entering certain markets. The market where we could see carriers pull out of is Individual.

Individual Maternity Plans are no longer available

Health carriers have pulled out of these markets because of the negative impact of health care reform. It still is not 100% clear but I think if the carriers were to stay in the market the plan could not have a waiting period for the maternity benefit to kick in. In the past a policy had either a 1 year or 9 month waiting period.

Health insurance premium increases

The health care reform does nothing to reduce the premium increases. The premium increases are a direct response to the cost of care. The Reform does put in place a process of review if a carriers want to increase premiums more than 10%.  It is important to have these checks and balances in place so everyone sees the process.

Health Savings Accounts

For 2011 the contribution levels will stay the same for a H.S.A custodial account.  (Single $3,050, Family $6,150)  For members over 55 years of age there is an additional catch contribution of $1,000.  Over the Counter medicines are no longer qualified to use HSA accounts to pay for.

Waivers for Health Care Reform

There are a lot of waivers for health care reform because the reform would result in people losing coverage. There should be many states that ask for waivers in 2011.

These are just some aspects of health care reform that will impact you.

There are going to be positive things but we fear the negative could destroy certain markets.

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In 2003 the Medicare Prescription Drug, Improvement, and Modernization Act went into place and created the Health Savings Account.

The health saving account is a high deductible health insurance plan.  All medical claims go towards the deductible for the exception of wellness. All preventive and wellness procedures are covered at 100% with no cost to the insured.  The best way to look at these plans is they are major medical policies that will cover you for the major claims and you are responsible for the small things. 

The health savings account makes it easier for families and individual to budget for health care expenses.  Once your deductible is satisfied then all eligible claims are covered at 100% depending on the plan design. With this plan there are also tax advantages.

I think everyone should look at this approach to health insurance. The health savings account engages people to look at their health care expense and I think that is very important. If you take advantage of online tools then you will discover that diagnostic test you  need has a huge cost difference. The hospital might charge $2,000 and an outpatient facility charges $400.  If the first $2,000 in claims comes out of your pocket I think you might want want to use the facility that charges less.

Now is the right time to entertain this approach to health insurance.

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Here at Nefouse & Associates we have been insuring children that suffer from Autism for almost 5 years. I feel we are the most experienced Brokers in the state when it comes to insuring  autism.

The past few years children suffering from Autism have been very fortunate with the Indianapolis Autism mandate. Under the mandate Autism has to be covered as any other illness with few limitations on treatment.

Anthem has been the leader in the health insurance industry for treating Autism. They have set up their own claim division that has processed claims. The majority of these claims have come from out of network providers.  Anthem has treated these claims as if they were in network providers because they have not established a network for Autism.  The Autism providers have been able to treat patients and be paid without joining any kind of network.  This is about to change!

Currently Anthem is building a Autism network. This is going to change the way people are treated for Autism. In the near future Doctors, Facilities, and Specialists will have to be a part of the Anthem network or the claims will go toward out of network deductibles for policy holders. This could create a disruption in treatment and payment for both patients and providers.

On the provider side of it if they do not join network they might have problems getting paid by the carriers. If its a out of network claim then the insurance company could send the payment directly to the insured.

On the patient side if the claim is considered out of network then carrier could usual and customary charge for the claim. This means the provider charges $500 for a procedure but the insurance company states the average price for this is $200. The insured its stuck with the difference.

Anthem is building this new network and its not expected to go live until April. If Anthem is building one then the other national carriers are not far behind.

If you have a loved one suffering from Autism then start asking questions of your provider about them joining a network.

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There is been a much higher demand for the short term health policies here in Indianapolis than in the past. I think the reason for this is the lower cost of the short term policy.

In the past short term policy were manily used by students and singles that were in transition from one health plan to the other.  Now it has changed a great deal. We are seeing families looking into short term policies.  A family that would cost $400 a month on an H.S.A can pick up a short term for $100 a month.  With so many dual income families losing one of those incomes these short term policies are becoming serious options.

We have seen a variety of short term plans hit the market in the last 3 years. In the past there were only emergency room type policies to choose from. Now we are seeing co pay type plans being introduced. These co pay plan might even have a rx benefit. So now a client can choose what level of short term policy they would like.

If you are serious about taking out a short term policy then you should be looking at a company that owns their own network. The reason for this is you have to use it you want the deepest discounts available. The deepest discounts are going to come from companies like UnitedHealthcare and Anthem.  Smaller carriers can be competitive in this market but I would advise a client to take a short term policy form a national carrier.

If you do take out a short term policy remember that policy is not re newable.  This is a major different when comparing short term policy with a long term. So if you get diagnoised with something major you might have trouble finding a policy to cover you.  This is a very serious issue when comparing.

In the near future I expect to see short term policies that have 11 month terms. That mean you will be able to take a policy out for almost a year. I see this a quick fix not only for the very young but the family market too.

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Under the health care reform children under 19 can not be denied or pre x on health insurance. This law is now in place and the carriers have developed strategies on the law.

The first thing the carriers have done is completely with drawn from the stand alone children’s policy. So now in this country you are unable to buy a stand alone health insurance policy for your child. The carriers were very concerned that parents would game the insurance market. This means that a parent might wait to take out a health insurance policy on the child until they need it. Since the Government would not address this issue the carriers just  pulled out of that market.

So the only way to insure a child in the private market is for a parent to be on the plan also. This has created some unique situations. The carriers will except the entire family but they now are rating the children up 200% for any on going health conditions. This strategy is making the health insurance unaffordable for most family that have children with medical conditions.  A family of 4 that should run around $400 a month now is over $800 if they have children with major medical conditions.

From the insurance carrier stand point even with the rate increase they will still lose money. Any child needing major health care is going to incur much more than the annual premium in claims.  If a family is paying $9,000 a year in premium plus the deductible but they incur $25,000 in claims the insurance company is going to lose. So then how long will the carriers be able to sustain writing those policies.

This is a very complicated situation that the health care reform has caused.

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The new Medical Loss Ratio will have a huge impact on health insurance companies. There is major concern in the industry that we could see some carriers pull of certain markets. The market that creates the most concern is the Individual market. This segment of insured represent a small portion of the overall block of business. Some companies will look at this block of business and ask themselves is it worth the risk.  In the individual market a company might make money on one policy but then lose 300%  on the next policy. In the past they have been able to pool the policies together to offset risk. This pooling is no longer an option for the carriers with the health care reform.
The Patient Protection and Affordable Care Act (or health care reform law) added a new provision to the Public Health Service Act that sets requirements for the minimum medical loss ratio. The medical loss ratio is the percentage of premiums that insurers spend on medical care (including claims and activities that improve health care quality), as opposed to the percentage spent on administrative expenses.Health insurance issuers offering insured group or individual coverage must meet the following minimums:

85% in the large group market

80% in the small group and individual market

Issuers who do not meet these minimums will be required to issue rebates.

The National Association of Insurance Commissioners (NAIC) was responsible for recommending to the U.S. Department of Health and Human Services which activities count as medical and quality improvement expenses, as well as how plans should calculate the medical loss ratio. The interim final regulations issued by Health and Human Services on November 22, 2010, adopted the NAIC’s model regulation in full but modified some of NAIC’s recommendations and added other provisions to the NAIC model.

Some key points from the interim final rules:

Medical loss ratio calculation would include premium used to pay medical claims and premium used for quality improvement activities. It would exclude federal and state taxes, and licensing and regulatory fees.

Issuers will need to report calendar-year premium, claims and other expenses for all insured group and individual health insurance coverage as an aggregate by legal entity state by state and by health insurance market (small group, large group, individual).

Reports must be submitted to Health and Human Services by June 1 of each year. Rebates must be paid by August 1 of each year.

The medical loss ratio provision does not apply to self-insured or ASO plans; it applies only to the issuer of insurance plans in the large and small group and individual markets.

Rebates will be provided to the enrollee (defined in the interim final rules as anyone covered by a group plan, as well as anyone covered by an individual policy, despite the fact that this term is not ordinarily used in the individual market).


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