Tag Healthcare Reform

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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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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federal_exchanges_onpageThe new Indianapolis Health Insurance Exchange will go live in only one week!  Here at Nefouse & Associates, we are authorized to sell and service the exchange plans.

There will be four options of coverage: Bronze, Silver, Gold and Platinum. Under the Affordable Care Act, often referred as Obamacare, no one can be denied coverage due to pre-existing conditions.  The other huge benefit is the access to subsidies to lower your monthly premium. These subsidies will only be available through the Indianapolis Health Insurance Exchange.

We are predicting that you will enter an authorized quote engine (which we will provide) and that platform will guide you to the subsidy portal. Once at that portal, you will have the option to apply for subsidies. When your eligibility is determined, then you should be assigned some type of identification number and you would place this number on the health insurance policy. The federal government will then send money to the insurance company, bringing your monthly premium down.

So we are looking to major factors that are going to change the way we purchase health insurance. The first one is guaranteed issue, meaning that no one can ever be declined for coverage. The second factor is the access to subsidized premiums, making health insurance affordable to you and your family.

Currently in Indianapolis we have about 800,000 people without health insurance. It is being projected that about 300,000 take advantage of the new health care law.




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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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There has been a lot of news about the government trying to replace Health Insurance Agents with non-licensed, non-insured and in-experienced “navigators” whom will be paid by the government and have less than 20 hours of training. The government has now realized they cannot successfully implement this extremely complicated law without agents. The government is now going to allow insurance agent to enroll people both inside and outside the health insurance exchanges. This will impact millions of Hoosiers. Insurance agent’s advice is free and we will continue to offer out advice for free.

Health insurance premiums are the same if you use an agent or go direct with the carrier. This will continue to be the case if you buy a policy through the Indianapolis health insurance exchange which is going to be run by the federal government.

We have spent our entire career getting clients the best deal in the insurance market. We have also provided the highest level of customer service when it comes to claims and administration.  We will continue to offer this level of service in 2014 and beyond.

We believe that we will still offer the best solutions for your company or your family.

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Employer Mandate Calculator

Many people have heard of the employer mandate. Under Health Care reform, employers with more than 50 full time employees to offer health insurance to their employees.
IF they don’t they will have to pay a penalty that is not tax deductible.
They may also have to pay a penalty if any of their employee get subsidies through the health insurance exchange.
This calculator will help you determine if you fall under the employer mandate.

1. Count the employees who worked at least 30 hours per week each month (including seasonal employees) in the prior calendar year.
2. Count the employees considered full-time by adding the number of hours worked by all part-time employees (as well as seasonal) and dividing by 120.
3. Add the monthly totals of steps 1 and 2 and divide by 12.

What are the penalties?

There are different kinds of penalties, based on what part of the rule the employer didn’t follow.

Employers have to pay a penalty for:

1. Not offering health coverage to full-time employees and their dependent children to age 26, and if any full-time employee gets government aid to lower the cost of coverage. The  annual penalty is $2,000 x the number of full-time employees, minus the first 30 employees.
2. Offering health coverage for only part of the year. The penalty is based on the number of full-time employees and the number of months coverage was not offered.
3. Offering health coverage to 95% of full-time employees but one or more full-time employees gets government aid to lower the cost of their coverage because the coverage is not considered affordable. The annual penalty is $3,000 per employee getting government aid.


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The Hill has posted an interesting article about Senator Max Baucus.

It looks like the Senator is worried about the communication of the health insurance laws. The Senator has had public conversations with HHS about getting actual information and not just concepts.  Since the Senator was one of the main authors of the bill he has a lot of concerns.

If the Senator is have problems getting information, how do you think the public feels?

Anyone in the industry has predicted this would happen.

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The Society of Actuaries released a study on the projected increases for health insurance premiums under the new health care laws.

It does not look good. Our health insurance premiums are projected to go up 67% under the new health care laws.  This is a huge jump because of health care reform.

We are one of the states getting the highest increase. The SOA believes these increased premiums will be on new policies purchased in 2014.

They state that self funded group plans should not be affected in this manner.


This study should be getting more attention.


With these kinds of rate increases projected, Hoosiers are going to be more dependent of Federal Subsidies through the health insurance exchange.


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Community rating is most often found as part o...
Community rating is most often found as part of health insurance systems in various countries

In 2014, we are going to see a major transformation of the small group health insurance market.

One of the biggest changes is the community ratings. No longer will a small group premium be based on medical conditions. This means most will groups will have similar pricing. Right now small groups in the area are medical underwritten.  Healthy groups have lower cost than high utilization groups. The high utilization groups could have a decrease in premium.  The healthy groups could have an increase in premium.  This will create a unique situation for small business that has not been seen.

At this time, we do not know what the community rating will look like. Some of the carriers do! The national carriers that have been operating in states that have community ratings have large amounts of data on this subject.  This could create a problem for the smaller companies that do not have experience in these markets. This could lead to less competition in the small group market.

If a small business decided to keep a group plan they will want to be with a company that has the experience of community rating.

United Healthcare is really the main carrier in the Indianapolis market, that has that kind of experience for small group.

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Health Savings Accounts look to be qualified health plans under the health care reform act. This is huge news!

Initially when the health care laws were passed, Health Saving Account we not considered qualified. This meant that if you had an H.S.A plan you would be subject to the tax penalty.

From this report, the Actuarial Value calculator gave a pass to the H.S.A plans under the Bronze category.  This means that local residents will be able to purchase an H.S.A plan inside and outside the exchange. Inside the exchange, a policy holder could qualify for subsidies which would pay a portion of the premium.

When the private carriers join the federal exchange the H.S.A plan may be their primary offering. This plan designs encourages people to become a consumer in their health care spending.

Some Hoosiers really dislike the H.S.A approach because there is no first dollar benefit. A first dollar benefit is co pays for office and RX. Other Hoosiers love the plan design. The plan design is very easy to budget for and the premium is less. If you are not using first dollar benefits why pay the higher premium?

This is very good news that these plans will still be a viable option in the area and for and the rest of the country.



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