Tag American Recovery and Reinvestment Act

This is possibly the most interesting time in small group health history locally, not to mention the rest of the country.

Anthem releases 4th quarter renewals

Small group health insurance renewals have been released for the 4th quarter from Anthem. “WOW” is all I can say!

The renewals that are being released are all “grandmothered.” This means that the group can keep the current plan, even though it does not meet ACA compliance. In Indianapolis this block of business is renewing at low rate increases. In fact, we are seeing single digit rate increase on most groups. This is because these groups are running very well from a claims standpoint. Some groups are getting hit with double-digit rate increases and this has a lot to do with claims.

As I understand it, you may be able to keep that group plan through 2016. This can be a great option for the next two years because your premium will much lower than a ACA-compliant group plan. It’s important for any owner to also request numbers on a ACA plan just in case. This can be provided to you very easily, though this is where the premiums get very ugly. If your broker has been working for you, then they should have reduced your rate increase over the years with Anthem. Those years of constant negotiations with underwriting has saved small group thousands. This is a service Nefouse & Associates has always provided to even our smallest groups. Under the ACA plan, be prepared to see very large rate increases.

Anthem Small Group Renewals
Anthem groups can keep their current plans through 2016.

Small groups affected most

Small groups that are going to be hit the hardest are small-group plans that have run single digit rate increases and have composite rates in place.

An example would be a group of 22 employees electing coverage. There is one premium rate for each tier. So if you’re 62 or 22 years old, the employee-only premium is the same. Now under the ACA, there will be no more composite rating for small groups — it will be all age based. The 62-year-old employee that was running $435 a month, might see a new premium of $1,400 a month. On groups like this, we are seeing 85% rate increases on a ACA compliant plan.

Groups that have age-based rates in place right now are not seeing as large rate increases. If you have 15 employees on the plan and have had low rate increases you may a see a 37% rate increase with an ACA plan.

Among the grandmothering block in Indianapolis, the lowest ACA increase I have seen is 23%. This was on a case of 40 employees that had age-based rates in place.

You need to know what the impact of healthcare reform is going to have on your group benefits. We are being told groups will be able to keep the plans through 2016, but anything can happen. If the Indianapolis Department of Insurance decides not to allow non-compliant plans to stay in place next year, then you may be faced with these kinds of rate increases.

What to Do:

First, find out what kind of ACA rate increase you are looking at, then contact Nefouse & Associates, or call us at (800) 846-8615.

We may be seeing the beginning of the end of traditional small group plans. So let’s think outside the box!

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As the Affordable Care Act provides more and more clarification on the law, we are starting to see some serious mandates outside of what was known.

If you are receiving health insurance coverage through an ACA-compliant plan, you may be eligible for additional drug coverage that is not currently covered by your plan. The law stats that this drug coverage exception must be made by the carrier. This opens up a path to getting a drug covered that was not previously covered. Before this, if the plan did not cover a drug, it was difficult to get that drug covered at all.

We at Nefouse & Associates were able to get exceptions made in the past by going through the carrier and showing medical necessity. Now it appears that you will still have to show medical necessity, but now there is a path under the ACA.

Drug Exceptions Under the Affordable Care Act
It’s difficult to know whether you can get an exemption for a formulary drug under the ACA.

Exception Criteria

  1. Request for coverage of a drug that is not on the formulary list:For this exception, your medical provider would have to prove that all of the drugs on the formulary list are ineffective at treating your condition. There would have to be both clinical and scientific evidence that the condition could not be treated by the other covered medications, or that the other medications had adverse side effects.
  2. Dose limit/quantity limit:It would have to be proved that the maximum allowed dose or frequency has been ineffective in treating the condition. There is going to be a lot of checks and balances with toxicity risks and lab measurements.
  3. Step therapy for formulary drug:In this situation the plan would ask that you take a different drug first before approving the formulary drug. Your doctor would have to prove that the step therapy drug would cause an adverse reaction. Most common step therapy drugs are going to be antacids. I think the exception is more geared to cardiovascular drugs.
  4. Brand exclusion/generic requirements:In today’s fully-insured health insurance market, we are seeing more and more generic requirements, even if the brand drug is of medical necessity. This aspect of the law may steer the carriers away from forcing members to take only generic drugs or pay the difference.

This is only a snapshot of the exception rules. It would be a very long drawn out process to get some drugs approved. Your doctor has to be willing to work on your behalf by submitting all information that will make you eligible for the exception. In some cases, they are not only going to have to submit medical records showing medical necessity, but make a strong argument on your behalf. There is a lot more information on applying for an exception.

The approval process can take up to 1 year to get approved. You still want to have Nefouse & Associates in your foxhole if you need to go to war with a carrier. Contact Nefouse & Associates, or call us at (800) 846-8615.

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Is it legal to move an employee from my group health plan to the a guaranteed issue individual plan?

This is a big question with a lot of money on the line for employers and insurers.

During open enrollment (October 1, 2013–March 31, 2014), anyone could have purchased a health plan either on or off of the exchange. Keep in mind that if an employee has access to a group health plan, it might disqualify them from receiving tax credits on the exchange, but not on the actual health plan.

A University of Minnesota’s law professor had a paper published back in 2010 that predicted this exact situation. If you read the paper, you will see it was predicted that employers would redesign their health plans to intentionally try to move high-utilization employees off of the group plan. I, on the other hand, would disagree that a plan would be designed with that being the primary intention.

This issue opens up a very interesting discussion for large self-funded groups. This issue would not impact small companies that have fully-insured premiums. On large self-funded plans, the employers pay the initial claims up to a certain point. That certain point is called “stop loss” insurance. It is exactly what it sounds like, stop the losses.

Under these arrangements, the reinsurance contract to initiate a term is called lasers. Lasers (excluding individuals or setting a unique, higher pooling level for individuals who are expected to have large claims, increase customer liability) are optional, depending on risk tolerance .

An example would be a group that has a stop loss limit of $125,000 per person on the plan. This means the company is going to pay the 1st $125,000. There is a high claimant that is projected to have $700,000 in claims. The reinsurance contract has the ability to laser and moves the $125,000 stop loss to $400,000. Now, the employer is responsible for that $400,000.

At this point, options may be entertained on controlling cost. With the new Affordable Care Act, an option that might be discussed is moving the high claimant to an Individual health policy during open enrollment.

To learn more about how we can help your business, give us a call at (800) 846-8615 and we will be glad to sit down with you and answer any questions you may have.


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Did you or a loved one lose health insurance coverage in the last few weeks? You might still be able to get insured under special enrollment if you have a qualifying life event.

Every health insurance provider has different requirements to get insured, but they all follow the same set of guidelines put in place by the Federal Government under the Affordable Care Act.


Here are the most common reasons for loss of coverage and the documents and/or requirements needed:

  • Termination of employer contributions

Requirement: Letter from employer to verify termination

  • Exhaustion of COBRA coverage

Requirement: Certificate of Creditable Coverage and/or COBRA term letter (proof of prior health care coverage)

  • Loss of employer sponsored health insurance as a result of termination of employment

Requirement: Termination of coverage letter

  • Termination of short term medical plan

Requirement: Termination of coverage letter

  • Divorce or legal separation (loss of coverage under spouse’s health insurance)

Requirement: Certificate of Creditable Coverage (proof of prior health care coverage)

  • No longer eligible as a dependent due to age

Requirements: Letter from carrier indicating dependent is no longer an eligible dependent

  • Death of a spouse (loss of coverage under spouse’s health insurance)

Requirement: Termination of coverage letter

  • Spouses employment terminates (loss of coverage under spouse’s health insurance)

Requirement: Certificate of Creditable Coverage and/or Term Letter (proof of prior health care coverage)

  • Employer reduced working hours (no longer eligible for group coverage)

Requirement: Letter from employer to verify

  • Current plan change to eliminate coverage for certain groups (e.g. part time workers)

Requirement: Letter from employer to verify

  •  Group coverage terminates due to non-payment of premium – Employees can use this as a QLE  

Requirement: Letter from employer to verify

  • There is a health claim that will meet or exceed the plan’s lifetime limit on all benefits

Requirement: Explanation of benefit validating lifetime benefit met

  •  2014 Renewal

Requirement: Renewal letter from existing carrier

  • Non payment of premium, misrepresentation or fraud

Requirement: Reinstatement denial letter or rescission letter

  • Relocation/ Move

Requirement: One of the following is required to validate coverage is in force:

      • Other carrier information:
      • Name of carrier and phone number
      • Effective date
      • Termination date
      • Policy number
      • Type of coverage
      • EOB with Effective date and termination date of coverage

One of the following is also required:

      • Proof of new residence (e.g. mortgage document or rental agreement)
      • Driver’s license with current residence
      • Utility bill with current residence

Some of these requirements are easily obtainable whereas others are a little more difficult. The main problem at the moment is that the health insurance company or marketplace will request a copy of your Certificate of Prior Coverage (COC), but you won’t be issued this document until your previous plan has been terminated. It can take up to a month to get this document from your previous carrier.

Some insurance companies are putting a time limit of 15 days to provide this document. This is not a realistic time frame. If you are applying for a health insurance policy on the exchange, you can’t submit your application until you lose your current coverage. Then, your new plan will start the following month. This is not ideal because you could end up with a gap in coverage.

Here at Nefouse & Associates, we will look for other documentation that will satisfy the insurance companies. Tackling individual health plans off of open enrollment can be a difficult and stressful task. Let the experts at Nefouse & Associates take the stress off of you. Call us today at (800) 846-8615!

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Senator Rand Paul has been one of the biggest critics of the Affordable Care Act. You might remember when he took out a policy on the marketplace for his family, which placed his son in Kentucky on Medicaid. He told the public over and over his woes of trying to sign up, trying to pay and the general confusion about if he was actually signed up.

Now, Senator Rand Paul, is saying repeal is unlikely.

In Indianapolis, we have had about 100,000 people get health coverage because of the ACA law, and many Hoosiers have benefited from tax credits. We placed a large amount of people on the exchange which brought about huge tax credits. Older couples went from $1,400 per month to only $300 per month after the tax credit! 

Large families that were accustomed to paying $1,200 per month are now paying only $500 per month. Many Hoosiers were able to place dependents on Medicaid programs when they did not even know they were eligible for enrollment.

Then there was the “Holy Grail” benefit of the ACA: guaranteed issue! No matter how you felt about the new law, this was the one aspect that everyone could agree on. The ability to obtain a health policy without being denied is a positive impact of the law no matter how you look at it.

Despite all of the positives, there are still a few segments of Hoosiers that are not benefiting from the ACA, but instead being penalized.

First is our middle class, who do not qualify for tax credits. They have seen large rate increases in health premiums. Next are the group health plans being provided by small group employers. On average, these plans have seen 35-55% rate increases. This is going to be a huge problem for local small businesses. 

Recently, Indianapolis agreed to allow “grandmothering” which will extend non-ACA compliant health plans. The administration, both locally and federally, have realized how big of a negative impact the ACA is going to have on small groups.

Going forward, the opponents of the ACA will have plenty of arguments to make about the cost of the law. The proponents will have a difficult time defending the cost. The other issue is Hoosiers having to make decisions about new doctors and taking on more risk in out-of-pocket.

It does not matter if you agree or disagree with the law, you have to make the best decision for you regarding your health policy. That’s where we come in! We can help you make an informed decision. Call us today to get started at (800) 846-8615. 

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We have been in the trenches with the healthcare reform roll out also known as Obamacare. We have seen and experienced all sides of the new Affordable Care Act (ACA) law and the impact it has had on Hoosiers.

The Affordable Care Act has had a huge impact in the area, along with the rest of the country.

There has been a lot of good things about the new law. Many Hoosiers and their families have had huge benefits.

The Good

1. Guaranteed Issue. No one can be turned away for health insurance because of ongoing health conditions. This is one of the biggest positive aspects of the law. Many Hoosiers were able to obtain new health insurance who were originally denied coverage. I can’t begin tell you how many people were able to benefit from this aspect of the law. We had cases where people had been diagnosed with major conditions that were able to get a policy that would cover that condition. This happen both on and off the exchange.

2. Tax Credits on the Exchange. This was one of the primary selling points of the ACA. If your household income fell under the 400% of federal poverty level you had premium joy. There were many early retirees that went from $1,400 a month down to $2oo a month in premium cost. This was huge for many Hoosiers. That kind of savings creates large amounts of disposable income and makes the health policy more than affordable. Large families were able to get significant tax credits. We had families of 5 that were used to paying $1,200 a month and now pay as low as $400 a month. We also saw a lot of individuals get a policy for under $100 a month.

3. Cost Sharing Reductions. This benefit is where the out of pocket max is reduced because household income is under 250% of the Federal Poverty Level. We had families that elected to go with $200 deductible plans with $600 out of pocket costs for very little monthly premium. With the cost sharing reduction we also saw how a Health Savings Account through Anthem had huge incentives. A good example is with a lot of business owners or contract worker. They were able to elect a $1,100 Health Saving Account with 100% co insurance. In this situation they insured would only have $1,100 out of pocket expense for the entire year. Then they are able to write off their medical claims. This option created a tax benefit. Then there were others who had high claims, where this plan was a great choice. Here is an example; if you are incurring $100k a year medical claims and now all you have to pay out is $1,100 this was a huge win especially for Hoosiers that were used to paying large out of pocket fees. This kind of option really can only be explained by a broker like myself that has experience in health insurance and claims.

The Bad

1. Enrollment Process through the Federal Facilitated Exchange. The launch of the website was an absolute disaster. The customer services at the healthcare.gov was very poor. The government brought people right off the street that really had no clue about health insurance or customer service. Then when you add in difficult questions, it was a mess. They would then pass you on to management that fell into the same category.

2. Preparation. The insurance community was not prepared for the volume of calls they received. They underestimated what kind of services were needed. This is partly the fault of the government. The insurance industry estimated that they would receive 300,000 calls a day at an average of 12 minutes per call. The actual volume was around 1,000,000 a day with the average time of 29 minutes. The insurance carrier that had resources then shifted everyone they had to assist with open enrollment. This created a lack of customer service representatives for the other areas in the insurance companies like groups.

3. Lack of Information. The market place and insurance companies were unable to provide a summary of benefits of the plans that were being offered. The insurance industry did not have SBC until the middle of February. Hoosiers were buying plans where they had no idea what the benefits where. To make matters worse, the navigators were really unprepared to answer any questions. Even from a broker standpoint we had to do a lot of research to find out what was in the plan designs. I have over 16 years of experience and it took me some time. So there is no way a navigator that has zero experience could help someone understand.

4. Narrow Network. Many Hoosiers were confused about network access. Anthem created a narrow network for Pathway X for exchange business. The online network search feature was down most of January and February. Even when it was working correctly it did not show all of the participating medical providers. Even the medical providers themselves did not know what networks they were accepting. Many Hoosiers had to make decisions about getting new doctors.

The Ugly

The ACA has had a very negative impact on the Middle Class that do not have access to group health insurance. The middle class is absolutely getting hammered with increased premiums. The ACA has initially increased premiums for anyone that in not eligible for a tax credit. This has devastated many families. You take a family of 4 that is use to paying $600 a month for their health saving account plan, now they are paying $1,100 a month. This may be an extreme case where the premium doubled but we witnessed this with about 30% of our clients that were unable to qualify for a tax credit. The average increase was around 60%. Many people were able to get an early renewal and thus delay the impacts of the ACA but that will come to an end in December of this year. I am telling families right now that they are going to have to start budgeting for higher premiums.

Small group health plans also fall into the ugly category. We are seeing anywhere from 35%-55% increases. This type of increase is unaffordable to the small groups and the employees. These rate increases are a direct result of the ACA. In the 4th quarter of 2014 we have over 80% of the small group health plans coming up for renewal. There is going to a mass exodus of small groups dropping these employer sponsored plans because of cost.

On large group health plans we have seen an increase in fees/taxes on premiums. These fully insured groups are getting hit with 4.9% tax increases. Some people may think that is not a huge percentage but if we are talking about $500,000 in annual premium, that is a $24,500 tax increase which goes to fund the ACA. Is that fair? Many owners and employees would say no.

As we move closer to the 4th quarter, the ugly aspect of the ACA will become more and more known.


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now-later320Affordable healthcare is at your fingertips, but time is running out! We are coming to the end of open enrollment on March 31.

March 31 signifies the end of open enrollment for health insurance under the Affordable Care Act. Whether you’re for or against the law, the deadline for getting covered is about two weeks away, so it’s time to sign up or get penalized. Under the Affordable Care Act, most people must be covered this year or face a penalty of $95 per person or 1% of your income, whichever is higher

After open enrollment ends, insurance carriers will be getting back to “business as usual” and resuming their normal operations. During the initial open enrollment period of the ACA, most carriers shifted all their resources over to assist with the on-exchange business. In turn, this created a lack of resources in the other areas of health insurance companies. The main area that was impacted was small group health plans. Here at Nefouse and Associates, we noticed premium notices and new cards not being sent out and hold times for group services sitting at unacceptable levels. Once April rolls around, we are hoping to see these levels go back to some type of normalcy.

If you have a small group health plan (under 50 employees) and need assistance, your best source is a broker. Your broker should have direct access to the insurance carriers and  be able to use this technology in your favor. Be cautious though, because the end of March will not be a good time to try and get things done. There will be a mad dash of people applying for health coverage through the marketplace which will put a strain on resources with the health carriers that are active in the federal or state marketplace.

After open enrollment ends, every small group should start considering their options. This should start no later than July of 2014 since we have already seen what kind of impact open enrollment has on the insurance industry. When it comes to small group health plans, we are seeing average rates increase at around 57%, so it’s time to start doing your research. Right now, employers with 50 or fewer full-time equivalent employees don’t face a penalty for not offering health coverage, but this will not always be the case. Stay tuned to our blog to find out more information on small group health insurance options, or contact us for assistance in finding a plan that’s right for you.

In the meantime, don’t procrastinate any longer, it’s time to sign up for health insurance! If you’re unsure of where to go or what to do, call us at (317) 803-4220!




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chi-blue-cross-blue-shield-health-plans-renew--001Welcome to the new world of health insurance plans under the Affordable Care Act.

Some people have experienced premium joy. This has come from the Federally Facilitated Health Insurance Marketplace in Indianapolis. Hoosiers have been eligible for subsidized premiums in the marketplace.  The average subsidy we are seeing is about $2,800 a year.  On the high end, we have help many Hoosier in their early 60’s pick up subsidies for over $11,000 a year. The biggest subsidy I have seen so far is $15,900.  This has created a lot of premium joy for Indianapolis residents. They have had to make some difficult decisions on doctors though; the networks on the exchange plans are 40% smaller than what they use to be. In some areas there is no access to primary care doctors. There has been a lot of frustration getting these policies but now the process is getting a lot better.

Guaranteed Issue in the individual market has helped a lot people. When we look at policies off of the exchange, there is no more underwriting. This has increased premiums!  If you don’t qualify for a subsidized plan you may have premium shock.  Many young families in the area have been content with a $700 per month premium. That is no longer the case; these young families now are looking at $1,200 a month for a similar policy. On the plus side, the new policies have more coverage and cover maternity.

One of the key benefits to these new off-the-exchange policies is the traditional PPO network. Not all of the off the exchange policies have it but a few still do. So if you do not want to have to decide between doctors at medical facilities and would rather have the ability to go to almost any doctor, you still have this option.  The interesting thing is these traditional PPO plans cost about the same as narrow network plans.

Remember: there is an open enrollment season right now that ends on March 31 for both on and off the exchange plans. Get signed up now!

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If you to took out an individual policy from Anthem with a 1-1-14 start date, I would recommend making your payment online if you have not.


On Anthem On the Exchange Payment Portal  If you mailed in you check you will be better off submitted an online payment. Anthem is having a hard time processing the Paper Checks because they may not have the Anthem Control number on it. Without that control number they don’t know who you are.


Anthem Off the Exchange Payment Portal  Same issue with off the exchange business.


If you elected a January 1st effective date you have until Jan. 31st to get your payment made.



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healthcare_reform_banner2_rdax_100We are starting to see the impact of Obamacare, both the positive and negative initial outcomes. It depends on every Hoosier’s individual situation to say if they feel joy or if they feel pain.

There is a lot of joy for Hoosiers that suffer from ongoing health conditions. This segment of our community is now able to get access to health insurance, which will lead them to receiving health care, sometimes for the first time in years. If you have ever been denied coverage then you know how frustrating this can be.  Those days are now over. Everyone is guaranteed issue and can not be carry the title of pre-existing condition.

If you have been priced out of the health insurance market, you may experience a lot of joy. With the Federal Facilitated Marketplace, you may be eligible for a subsidy which is going to reduce your monthly premium. We are seeing some estimates that the policy holder may not have a premium at all because the subsidy is more than the monthly premium. To go from not being able to afford a policy to getting a policy for free is extraordinary.

If you are healthy and do not qualify for a subsidy  you might be feeling pain right now. You have gotten a notice from the insurance company on how much your premium is going up in 2014, and these are very ugly increases. If you are a family of four, the new budget for health premiums is around a $1,000 a month.  This is creating a lot of pain for Hoosiers.

Small group health insurance premiums are going to feel a lot of pain also. There have been projections of 30%-60% increases. Most small companies can not absorb that kind of increase. Neither the employer or employee will be able to pay their portion of the premium. This could turn out to be a significant blow to small business. Small business owners are going to have to get really creative on keeping key employees. It’s difficult right now competing with large companies on employees. In 2014, it may be impossible.

One thing is for sure: we are a part of the biggest transformation in health care history. Everything is going to change.

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