link-exchange-placeWe’re less than 100 days away from the Indianapolis Federal Facilitated Exchange opening.

There are two very big things that need to happen before October for the exchanges to be fully operational.  The first one is from a technical standpoint; the government still needs to complete the infrastructure of the exchange. This will enable government agencies to transmit information between one another to see if one is eligible for subsidies. This is an enormous task because  Health and Human Services, Treasury, Homeland Security and other agencies will have to communicate with one another, and this has never happened before.

The next technical aspect is to finish the online portal for the Federal Exchange which will be operating in Indiana and many other states.

Let’s say that all of these technology issues are solved and tested. The next big issue is going to be outreach. Most have no idea how the exchanges are going to work.  Currently there are very few brokers that are touting the benefits of the exchange for Hoosiers. Luckily, we are!

It’s our belief that  many Hoosier families will benefit from the subsidies offered in the federal exchange. Contact us today to be prepared for Health Care Reform.


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the_exchange_FINAL.wideaAccording to this article from WSJ, health insurance exchanges are falling behind schedule, and there is a risk that they won’t be ready to open in time by October.

There are multiple news organizations that are commenting on the two reports from the Government Accountability Office.

“Whether [the government’s] contingency planning will assure the timely and smooth implementation of the exchanges by October 2013 cannot yet be determined,” said the GAO in twin reports released Wednesday.

The report states that the exchanges are about 44% behind meeting key milestones of establishing the exchanges. So what does that mean for Indianapolis?

It has been predicted that about 900,000 Hoosiers will benefit from getting their Insurance from the Federal Facilitated Exchange. The way the exchange would work is that people who do not have access to affordable group benefits could apply for advance tax credits or subsidies. These subsidies would pay a portion of the health insurance premium thus bringing down the cost of health Insurance in the Individual market.

If you make under 400% of Federal Poverty level then you could qualify for subsidies. A single person making less than $45,960, or a family of four making less than $94,200 will qualify.  Looking at those numbers, there are a lot of Hoosiers that can benefit from these subsidies.

It has already been announced that there will be a delay in the full establishment of the small group exchange plans, also known as SHOP.  What is going to be offered to small groups under 50 employees is the option of purchasing your group health insurance through the exchange. For groups under 25 employees that meet certain requirements, there will be tax credits available.  These tax credits could be very valuable in a company that is planning on keeping a group health plan.

If the exchanges are not up and running in October, it could result in many Hoosiers being delayed from enrolling online. Here is what Nefouse & Associates is willing to do if the online enrollments are delayed.

We will go back to paper applications. We will use the paper application that has been established to apply for subsidies. We will send that application by snail mail to the government and follow up with them to make sure it’s being processed. Once processed, then we have you apply for the individual health insurance policy from a carrier like Anthem that we know will be in the exchange. We will follow up with both the carrier and the government to make sure our clients are able to take full advantage of the new law.


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mzl.yzozlmve.320x480-75You’ve probably heard the saying “there’s an app for that,” and now there’s an Anthem app for your health care.

Anthem just released their new smart phone app for all subscribers. This cutting edge technology is a great tool for you and your family to have at your fingertips.

The app has multiple useful functions. First of all, you are able to save a copy of your insurance cards. By using the app, you can walk into the doctors office and simply email a copy of the card right on site.

The app also give you the function to find a doctor, urgent care, specialist or pharmacy in network with turn-by-turn directions. To be able to find an urgent care doctor in network is an extremely valuable tool in the Indianapolispolis metropolitan area. Urgent care centers have always caused network problems for these residents, so this technology can save you and your family money by giving you the correct in network provider.

To be able to easily and quickly locate all of this information anytime, anywhere makes life simpler and more convenient

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HealthInsurancePlansWe’re finally starting to get a glimpse into the future of health insurance under the Affordable Care Act.

Post 2014, there will be no underwriting in the small group or individual health insurance markets. Underwriting has always been the key tool for insurance companies to control risk. Underwriting is the use of medical or health information in the evaluation of an applicant for coverage; an individual’s health information may be used in deciding whether to offer or deny coverage and what premium rate to set for the policy. Once 2014 hits, that tool can no longer be used by law. If the industry cannot underwrite, then they will control cost by managing care.

Many people may have experience with an HMO (health maintenance organization plan) and now we are seeing the concept redeveloped on PPO (preferred provider organization) plan. Traditionally, an HMO contracts with health care professionals and facilities to create a “provider network,”  featuring lower premiums and co-pays than other plans. A traditional PPO also creates a “provider network,” but unlike HMOs, PPO health insurance will cover some – but not all – of the cost of care administered by out-of-network providers.

In 2014, you may be offered a plan that has a gate keeper. This gate keeper will be your primary care physician.  They will be in charge of managing and coordinating your health care. To see a specialist, you will have to get a referral from your gate keeper. To get diagnostic services, you will also need a referral from them. There will also be prior authorization for medical necessity, which should make specialty care more efficient. With this type of referral management we should see the cost of this health plan cost  a lot less.

Here are a few points about this type of plan:

  • This type of plan design may not have any coverage for non-network services except for emergency care.
  • This type of plan may not provide coverage for any treatment without a referral.
  • This approach to health care is going to put a strong emphasis on your relationship with your primary care physician. This may become a problem since we have a shortage of primary care doctors.
  • If you elect this type of plan, don’t be surprised if your primary care doctor is also listed on your insurance card.
  • This type of plan may be offered inside and outside the Federal Facilitated Exchange.
  • You may also see this in both the small and large group health markets.




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RateShock1Ohio reveals high exchange rates under the Patient Protection and Affordable Care Act, according to this article from BenefitsPro.

The state of Ohio just released their projected health insurance increases under the new health care reform.  As Hoosiers, we should look at those price increases closely as we may be in the same situation soon. The Ohio Department of Insurance stated that health insurance premiums will go from $223 a month to $420. which is an 88% increase in cost.

Most people thought that the Affordable Care Act would lower premiums. Under the law, health plans now have to have richer benefits and much less limitations.  These mandates all lead to higher premiums. The way the law plans to help people is by giving them subsidies through the exchange. You can find out more about subsidies at our sister site, Indianapolis Health Insurance Exchange.

If you make less than 400% of the federal poverty level and do not have access to group health insurance, then you may qualify for subsidies. If you get the subsidies then you will pay a percentage of your household income in premium. This ranges from 2.3%-9.5%.  The subsidies are how the law plans to reduce premium costs.

If you are above that 400% of FPL, then you should prepare yourself for what is now being called rate shock.



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Health Care Reform feesWe know you don’t want to pay anymore money than absolutely necessary for health insurance, but there are a few fees that are going to implemented in the new health care reform law. Under the Affordable Care Act (ACA), there will be new fees and taxes assessed on all Indianapolis commercial (group)  health insurance plans. These fees and taxes are to fund some of the changes mandated by the new health care reform law.

Fully Insured Health plans will see the following fees prorated into their premiums over 12 months:

1. Patient-Centered Outcome Research Institute (PCORI) Fee: The ACA imposed a new fee on group health plans and self funded health plans of $1 per member for the 1st year, $2 per member the second year and then indexed to medical inflation there after.

2.Insurer Fee: This fee is collected from health issuers based on the net premium of the group health plan. This is a permanent fee and is estimated to be about 2.5% of the fully insured premium. The Insurer fee will fund premium tax subsidies for people that buy insurance through the exchange.

3. Transitional Reinsurance Fee: Between 2014-2016, the ACA will impose a fee on fully insured  and self-funded group health plans. This fee is to help offset the initial claims that the health insurance industry is expected to take on at the beginning of 2014. The money will spread the financial risk that the health insurance industry takes on in the individual market. The fee is $5 per member per month on both fully-insured and self-funded group plans.

4. Risk Adjustment Fee: This fee is to spread the risk so that adverse selection does not occur.  The fee is $1 per member per year.

The total cost of the all the new fees is estimated at 3.8% of the fully insured premium. If your group plan is $100,000 a year you now have to pay about $3,800 a year to help fund health care reform. These fees are just one aspect that will impact rates.



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A company wellness program is set up in the workplace to offer employees a kind of comprehensive health service, to encourage employees to adopt healthier lifestyles and to take measures aimed at preventing the worsening or onset of illnesses.

In the last five years, wellness programs were supposed to bring the most amount of savings for group health insurance. These small group wellness programs have had obstacles to overcome:

  • The cost of implementing a true wellness program has been difficult to budget for most small companies.
  • Obtaining a positive return on investment have been very difficult to achieve. 10% of groups usually represent 80% of the claims on a group health insurance plan, so the health insurance premiums can continue to sky rocket even with strong participation in wellness.

In a small group, there are just not enough premium dollars to offset large claims.  It only takes one complicated condition to create a large loss ratio, which in turn creates a large rate increase at renewal.

But, there is something a wellness program creates that is not in the numbers: Company Morale!

When all of the employee are active in a wellness program, you create a healthy environment.  People are eating healthy lunches and taking the stairs for additional exercise. Employees are taking walks at lunch time or wearing pedometers. Your employees come together on a common goal and it creates a positive work environment.

With careful planning, your company can create a well-designed wellness program to contribute to your employees’ healthier lives, increased productivity, reduced absenteeism and reduced health care costs.


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With Health Care Reform there is a lot of uncertainty in the market place.

You do have options!

The 1st option is to go with a fully insured health plan. As you may know there are only a few companies that are competitive. We will deliver you the most competitive plan. Our relationships with the carriers create savings for our clients. We also provide a high level of service to both owner and employee.

The 2nd option is to look at the Self Funded or Partially Self Funded Market.  There are new options that are hitting the market place.  We are now seeing self funded plans for groups as small as 10 lives.  We would design a plan where you take on a certain amount of risk by paying a portion of the claims your employee have.  We would broker Stop Loss Insurance which would reduce your risk.  Stop Loss Insurance is exactly what it sounds like. Stop the Losses!   There are also Self Fund options that have a feel of a fully insured plan but can deliver premium back to the group.

The 3rd options you may only here about from Nefouse & Associates. Drop your group benefits and go Individual. With health care reform, the individual market now has guaranteed issue. Meaning no one can be denied. We also will be selling the health Insurance exchange.  Your employee may be eligible for subsidies that would pay a large portion of their premium.  We can also offer broker out a Health Reimbursement Arrangement that can still provide a benefit to the employees. If you are under 50 full time employees this may be a very attractive solution.

No matter what your philosophy is for group health insurance we can deliver you a solution.

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CMS is starting to issue more and more guidance on the Federal Facilitated Exchange that will operate.

The enrollment process could look like this:

1. Consumer Submits application to the exchange:




In Person

2. The Exchange/Marketplace verifies and determines the eligibility:

The step will determine the eligibility for:

Enrollment in a qualified health plan (QHP)

Tax credits and cost Sharing reductions

Medicaid or CHIP

3. Eligible Consumer now enrolls In a QHP or Medicaid/CHIP

There will be online comparison tools to view different health plan designs.

Premium tax credits and cost-Sharing reductions are sent to the Health Insurance Carrier

Enrollment into the QHP or Medicaid/CHIP


CMS is making the enrollment process sound easy. There will be a lot of Hoosier that are going to be eligible for the tax credits which will reduce their monthly premiums. Some Hoosiers will even qualify for cost sharing reductions if income is under 250% of Federal Poverty Level. This means that medical expenses could be reduced by subsidies.  Though the exchange you could have a very reduced premium along with a very low out of pocket.

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We are starting to see projections of the rate increase fully insured group health plan can expect.

30%-50% increases in fully insured premiums under the health care reform laws. These are huge increase that very few small group or large group plan will be able to afford.

These increase are due to different aspect of the law.

1. The Essential Health Benefits (EHB) provision of the Affordable Care Act of 2010 (ACA)
created 10 general categories of benefits:
} Ambulatory patient services
} Emergency services
} Hospitalization
} Laboratory services
} Maternity and newborn care
} Mental health and substance abuse services, including behavioral health treatment
} Prescription drugs
} Rehabilitative and habilitative services and devices
} Preventive and wellness services and chronic disease management
} Pediatric services, including oral and vision care

2.  Deductible caps cannot exceed $2,000 for individual and $4,000 for a family.

The deductible caps will have a huge increase on premiums. Most fully insured plans have a 3x single deductible and now they will have to be moved to 2x single.

3. Reinsurance Fee

The reinsurance fee is a per member per month assessment of approximately $5, which will vary by state. Now this is per member, so a family could be assessed an additional $20 a month in premium.

4. Insurance Fee

Industry sources have estimated that the amount to be collected under this provision will represent 2.3 percent of total premium. The 2.3% will be added in with the health insurance premium.

5. Adjusted Community Rating

Adjusted community rating, guaranteed availability (issue), guaranteed renewability, single risk pool, catastrophic plans and rate review provisions. The insurance industry can no longer underwrite against risk.

These are some of the aspect of the law that are impacting fully insured health insurance premium. The impact is insane!

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