FFM I.D. Tnefouse. NPN : 3311409

Indiana Health Insurance Exchange The Unofficial Health Exchange Resource Site


Children’s Health Insurance Eligibility

Oct 21 2014

Last year’s open enrollment we had a great deal of children in Indiana qualify for Hoosier Healthwise and Healthy Indiana Plan. This was a surprise to many families that were applying for tax credits. Last year there was so little information released about the process of eligibility and, at Nefouse and Associates, we had a great deal of confusion.

For Hoosier Healthwise and Hip there are multiple eligibility factors.

  • Age
  • Income/family


These are the main determining factors:

For Hoosier Healthwise Package A:                                             Package B

Family Size

1 Monthly Income Limit $1,537                                                                      $2,432

2 Monthly Income limit $2,072                                                                       $3,278

3 monthly Income limit of $2,606                                                                   $4,123

4 monthly income limit of $3,141                                                                    $4,969

5. Monthly Income limit of $3,675                                                                  $5,815


child-careIf you were completing a tax credit application and then downloaded your results, you may have seen that your child was eligible for Hoosier Healthwise.  This has to do with the child being under age 19 and the annual household income. This created a lot of frustrations for some families.  Hoosiers are proud people and many families did not want their children on a Medicaid type program.  To add to the frustration was the turnaround time to determine eligibility at Hoosier Healthwise. Average time was around 45 days. The other problem we had last year was the marketplace was suppose to send the child’s information over to the program for approval. They did not do that last year, and it was up to the parents to initiate that application.

The Healthy Indiana Plan (HIP)  encountered the same type of issues.  Requirements for this programs are based on age, income and family size.  This plan is for adults 19-64.

Family Size and Income

  1. $973 a month
  2. $1,311 a month
  3. $1,649
  4. $2,326 a month


With this year’s open enrollment, there is a good chance that we will see high levels of eligible children in the Hoosier Healthwise plans.  HIP 2.0 may not be able to take any new members.  So when one completes their tax credit application and we see a qualification for HIP, we will know right away you are not eligible for that plan. Last year, the marketplace truly went on the honor system. If you stated that you were turned down for a Medicaid type program, they took your word. This year you may have to provide documentation of that denial.

Here at Nefouse & Associates, we know how to work with families interested in Hoosier Healthwise and the insurance exchange to best facilitate for their needs.  The experience we bring to the table with enrolling 100’s of Hoosiers is going to help our clients and new clients find the health coverage they deserve!


The Affordable Care Act Helps Treats Autism for Non-US Citizen

Sep 19 2014


The Affordable Care Act’s Influence on Hoosiers

With the passing of the Affordable Care Act, people who are non-US Citizens but here legally can now qualify for true health insurance coverage.

Here in Indiana, we have had this situation come up quite a bit and, in the past, we would not have been able to provide true health insurance coverage to Indiana residence in need. With the help of the Affordable Care Act, however, this has all changed.

Recently at Nefouse & Associates we were able to place our first health insurance policy on a child that was on visa to be in this great country of ours.  The family brought the child to Indiana to receive medical treatment for Autism. They had decided to spend everything they had to provide treatment for their child. They took out a 2nd mortgage on their home, pulled all of their savings, & all of their retirement. They were looking at treatment costing around $80,000 a year.

Non-US Citizens Can Obtain Indiana Health Insurance

With the knowledge I had about the new rules for health insurance, I decided it was worth our time to look at applying for health insurance coverage off of the exchange.

We designed a plan that best fit the needs for the treatment of Autism. We submitted the application, using the Visa number in place of the Social Security Number.  It was accepted and approved. With it’s acceptance the family will pay $2,328 a year in health insurance premium, with another $4,000 in out of pocket. The total cost with premium and claims $6,328.  We just saved this family $73,000 a year.

With the help of the Affordable Care Act and the team at Nefouse & Associates, this family will not have to break the bank to treat their child for Autism.

Having health care coverage is imperative for everyone! At Nefouse & Associates will continue to treat all people the way we would want to be treated and get them the health care coverage that they deserve.


Health Insurance Providers and Premiums

Sep 17 2014

Here are the insurance companies that will be participating in the individual health insurance market for Indiana. These are the average premiums for the health insurance policy. These rates do not include tax credits if a Hoosier is found eligible.

All Savers is a United Health Care company using the United Health Care network.  This is very interesting because this carrier looks to have a true PPO Network, which makes this policy very attractive.

The lowest costing policy is CareSource, a large Medicaid provider in Ohio. There is not much information on their plans designs, but what I do know is this may be a true HMO with a very limited network.

Anthem is coming in right around the middle of the pack of carriers from a price point. Anthem has proven to be a good option both for on and off the exchange. Their network continues to grow and the customer support should be solid. They have hired an additional 900 people to help the Individual market.

We recommend the best plans for our clients, even if we don’t represent the carrier. As a broker, our main focus is finding the best plan to meet the healthcare needs of each client.


Submitted on 5/11/14 2015
All Savers Insurance Company $422.58 New* Submitted
to HHS
New* New*
Anthem Insurance Companies, Inc. $494.55 2.53% Submitted
to HHS
-9.9% 11.9%
CareSource Indiana Inc $415.06 New* Submitted
to HHS
New* New*
Coordinated Care Corporation $430.88 -7.8% Submitted
to HHS
-15.2% 0.6%
IU Health Plans $578.92 New* Submitted
to HHS
New* New*
MDwise $606.74 8.8% Submitted
to HHS
2.59% 9.57%
MDwise Marketplace, Inc. $606.74 New* Submitted
to HHS
New* New*
Physicians Health Plan of Northern Indiana, Inc. $448.04 12.9% Submitted
to HHS
3% 27.3%
Southeastern Indiana Health Organization, Inc. $558.48 New* Submitted
to HHS
New* New*
Time Insurance Company $469.87 24% Submitted
to HHS
10% 40%
Small Group
Anthem Insurance Companies, Inc. $497.87 3.50% Submitted
to HHS
-1.80% 16.80%
Southeastern Indiana Health Organization, Inc. $549.90 8.30% Submitted
to HHS
-41% 118%
Advantage Health Solutions Incorporated $484.50 9.95% Submitted
to HHS
7.60% 17%

See a plan you’re interested in? Give us a call today and we’ll be happy to work with you to find the best insurance plan to meet your healthcare needs.


Grace Periods for Federal Exchange Health Plans

Sep 16 2014

CMS just released a bulletin on Grace Periods. This will impact any Indiana health insurance policies that was purchased through the Federal Exchange.

Under the 45 CFR 156.270 And 45 CFR 155.430, Indiana Health insurance companies may terminate the enrollment of a Individual enrolled in a qualified health plan through the marketplace if the insured fails to pay his or her portion of the premium tax credit. However, if they paid at least one full months premium during the benefit year, and then fail to pay the portion of the monthly premium, insurers must provide a three consecutive month period.

What this means for the insured?

This means after you pay your first month’s premium, no Indiana health insurance policy purchased through the exchange cancel your coverage without giving you a 3 month grace period to pay your premiums.

02I69301What does this mean for healthcare providers?

Health care providers will be very concerned with this grace period. A patient could be in their grace period and have a claim, and then the claim is not paid. I would predict that the health care providers here in Indiana will make patients sign some type of guarantee.

The future

I would not be surprised if the medical industry starts to inquire about a patients insurance and grace period status.


Same-Sex Couple Coverage Now!

Sep 12 2014

There’s a lot of confusion on health insurance coverage for same-sex couples in Indiana.  Under the Affordable Care Act, in order to apply for coverage under one policy, same-sex marriage has to be legal in the state.

Recently, we enrolled the first same-sex couple for health insurance.

What We Did

  • When we filled out the application, we listed the couple as married and filed joint taxes, which led them to qualify for tax credits.
  • We able to get tax credits for the couple but we were able to cover them under one plan

Our original strategy was to place coverage under two different policies while taking advantage of the tax credit. When we came to the end of the federal application, we were able to place the couple under one policy. This was a great moment!

The couple was able to get a policy with a $750 deductible with a total monthly cost of $123.

I feel that we were part of the equation that is Equal Rights for everyone here in Indiana.


Health Insurance for Three Generations

Sep 12 2014

A common situation here in the United States is an older parent living with a first generation American. This older parent is often not a US citizen, meaning they don’t qualify for Medicare.

Here at Nefouse & Associates we have found a solution to this problem under the Affordable Care Act. We’re able to provide health insurance for the entire family, which is great for multi-generational families living under one roof.


How This Works

As an example, let’s say we have a grandmother, mother, and children. The grandmother is not eligble for Medicare, but is eligible for health coverage through the Health Insurance Marketplace. So, what we do is take the entire household and apply tax credits at the Federal Exchange where, because the grandmother in this situation, is eligible because she is not on Medicare. The entire family may qualify for a tax credit, which is then applied to lower the monthly premium cost on all the members of the family, including the grandmother.

This is a great benefit for older immigrants that don’t qualify for Medicare because of their age. But now, we can insure the immigrant parents living with their children through the Health Insurance Market Place.

To learn how Nefouse & Associates can help provide health insurance for your entire family, contact us today!


Federal Market Place Hacked!

Sep 05 2014

HHS released that one of the servers supporting the federal market place at healthcare.gov was hacked on July 8th.

They are stating that no personal information was stolen.

HHS did not realize the breach until August 25th.

In the Broker community we are hearing different rumors.

The current rumor that is in circulation is that the hackers were able to change people income levels.  One millions subscribers receiving tax credits had their income raised above the 400% of FPL. This would then remove the tax credit.  As it stands this is a rumor.

I would advise everyone to check their accounts at healthcare.gov for any wrong doing.

Read more about the breach here. 


Insurance RX Changes

Sep 03 2014

Starting January 1st, carriers both on and off the exchange Individual plans will have RX changes.

Insurance companies post Affordable Care Act reviews and updates drug lists so they offer the most cost effective choices for prescription drug usage. Carriers will also do this to help ensure safety.  The last thing a carrier wants is an adverse reaction from a particular medication.  The main reason for this changes is costs.

Some medications will have new requirements which include:

  • Prior Authorization:  The insured doctor must contact the insurance company to get approval before a they fill or refill the medication. This means the drug is not covered unless the doctors complete the prior authorization.
  • Step Therapy:  This is when there is another medication that can treat the condition. The insurance company will demand that the cheaper drug is tried before approving the higher costing drug. If the Doctor concludes that the step therapy drug will not work, then they have to request approval from the Insurance Company.
  • Quantity Limits:  Insured members have a limit on the amount of medicines that can be filled during a period of time.  These limits are placed on some medications because of safety and to prevent misuse.
  • Level Changes:  Level changes also known as Copayment Tiers. Medications are groups into different levels.  Each tier has a different amount the member will pay for the medication. When drugs move to different levels it usually impacts the members co-pay amount.
  • Nonformulary:  If the medication does not fall onto the carrier’s drug list, it will not be covered under the plan. This means that the member would have to pick up the cost of the drug.  In these situations the insured’s Doctors can get involved and ask for an exception. The doctor then will have to prove medical necessity for the drug.

CMS Requests 310,000 to Verify Citizenship

Aug 15 2014

CMS is verifying citizenship

The Center for Medicare and Medicaid Service dropped a bombshell this week: the CMS has stated that there are about 310,000 people that must verify citizenship with them.

If the information is not received, then the policy could terminate, and all supporting documents must be submitted before September 5th.

The CMS is verifying Social Security numbers or permanent resident card numbers. This information can be uploaded into your account, or mailed into the healthcare.gov office.

CMS Request to Verify Citizenship!
The CMS is verifying citizenship for 310,000 before continuing with their plan.

SSNs were once optional — not anymore

During the initial open enrollment, applications did not have to include dependents’ Social Security numbers — or primary’s, for that matter. These were optional fields. Let’s be honest, if the marketplace states it’s optional, there is really no reason to submit that information. Turns out this is not optional information, as the application states. You do have to provide your SSN or birth certificate to qualify.

So if you were one of the early sign ups during this open enrollment, check your online account immediately or call healthcare.gov.

For permanent resident ID numbers, the application process will still not allow you to submit the number. We assisted a couple this week that had permanent residency. When you come to the section about citizenship, if you input the data from your resident card, it will state “not valid.” This has happened with every US resident we have helped. It has not made a difference if the number was issued before 1984, and the country of citizenship seems irrelevant as well. The current application process will simply not accept the ID number.

Bottom line

If you elected a health plan during open enrollment and did not provide the SSN for the entire family, check your account at healthcare.gov.

If you are a permanent resident, check your healthcare.gov account immediately.

If you can not get access to your online account, call healthcare.gov at 1-800-318-2596.

Feel free to contact me for more information on this process: (800) 846-8615, or through our contact form. Don’t wait!





In-Network Emergency Claims On Exchange Plans

Aug 13 2014

Under the Affordable Care Act, all emergency room visits must be covered as in-network claims. This claim does need to meet the definition of “ER visit” under the plan contract. Under most contracts, this would be a situation where you are admitted through the emergency room. Refer to your Certificate of Coverage for an exact clarification.

Here at Nefouse & Associates, we had a large emergency room claim come in from one of our clients. The member had a policy through the federal facilitated marketplace in Indiana. The insured client had to have emergency surgery on July 4th. The member entered a hospital that was not in the network.

Now, under the law, you would think that the hospital staff in charge of admissions would know the ACA’s laws. Not the case at all! The admission staff stated that they could not do this surgery because the client did not participate in the network. The client called me on my cellphone, because that is the the kind of service we offer. I explained to the member that this is an emergency room claim, and as long as the claim is coded this way, then everything should be covered in-network. This would include the emergency surgery and any days in the hospital.

In-Network Emergency Claims On Exchange Plans
It’s important to realize that ER visits are covered as in-network regardless of where you are.
The admission staff was still reluctant, so we then got one of the main decision-makers involved. Even this executive at the hospital did not know about the ER visit being covered in-network. You would think people involved in the healthcare industry would take the time to educate themselves on these situations. These healthcare professionals are not educating themselves yet, but I believe they will.

At this point, the executive was also reluctant about the information, so they agreed to accept the reimbursement amount from the insurance company. Initially, they wanted to stabilize the patient and then transport them to a hospital in-network. Absolutely not with one of my clients when the emergency is covered.

The surgery was successful along with two days of recovery in the hospital. I am happy to say the entire emergency was covered as in-network! I was involved with the filing of the claim to make sure it was processed correctly. I had to explain to utilization review how the claim should be processed. The total claim was $37,000 and it was all covered as it was supposed to be!

We now know how the ER claims are supposed to be processed.


A trip the emergency room is stressful enough, don’t let network uncertainty add to your stress. By contacting Nefouse & Associates in advance, you can be better prepared and know what to expect from your health insurance provider. Give us as call at (800) 846-8615 today!