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Indiana Health Insurance Exchange The Unofficial Health Exchange Resource Site


What are Tax Credits and How Do They Impact You?

Aug 28 2014

Tax credits can help make health insurance coverage purchased through the Marketplace more affordable. These credits are determined by your annual household income, the size of your family covered by the plan, and the costs of other plans available. If you’re eligible for tax credits – your income is below 400 percent of the Federal Poverty Level – you can then apply them toward your qualified health plan (QHP) premiums on a monthly basis, or claim the total of the credits on your annual tax returns.

2014 Federal Poverty Guidelines

 Household Size  100%  133%  150% 200% 250%  300% 400%


$11,670 $15,521 $17,505 $23,340 $29,175 $35,010 $46,680


15,730  20,921 23,595   31,460 39,325 47,190 62,920


19,790  26,321 29,685   39,580 49,475 59,370 79,160


23,850  31,721 35,775   47,700 59,625 71,550 95,400


27,910  37,120 41,865   55,820 69,775 83,730 111,640


31,970  42,520 47,955   63,940 79,925 95,910 127,880


36,030  47,920 54,045   72,060 90,075 108,090 144,120


40,090  53,320 60,135   80,180 100,225 120,270 160,360

Source: familiesusa.org

How large your tax credits are depends on the plan you purchase through the Marketplace. You may choose to have your credits applied directly to your monthly premium, reducing the amount you pay out of pocket. You may choose to pay the full amount up front and take the deduction on your taxes. As your representative in the Marketplace, I can help you determine the strategy that’s going to provide the greatest financial benefit while ensuring you receive the best coverage.

To learn more about tax credits, your potential eligibility, and how they impact you, contact us today.


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 primaries, 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 finally 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 have been waiting for a call like this since the exchanges launched. 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.

To take the worry out of your next ER visit, especially if you happen to be out of your network at the time, contact Nefouse & Associates in advance at (800) 846-8615, or through our contact form.


Anthem Adds Eight Franciscan Hospitals to the ACA Marketplace in Indiana

Aug 05 2014

Anthem Blue Cross Blue Shield of Indiana has announced that is has added eight hospitals in Northern Indiana to the Pathway X POS/HMO plans via the exchange network. This is big news!

Under the agreement, the following Franciscan Alliance hospitals have joined Anthem’s hospital network:

  • Franciscan St Elizabeth Health – Crawfordsville, Lafayette Central and Lafayette East
  • Franciscan St. Anthony Health – Crown Point and Michigan City
  • Franciscan St. Margaret Health – Dyer and Hammond
  • Franciscan Healthcare – Munster

In addition, more than 300 Franciscan Alliance physicians in the following counties are now part of the Anthem network for plans purchased on the health insurance marketplace:

  • Montgomery, Tippecanoe, and White counties in western Indiana
  • Jasper, Lake, La Porte and Porter counties in northern Indiana

Eight Franciscan Alliance hospitals are now part of the exchange in Indiana.

Anthem members now can use these providers in-network.

The addition of the Franciscan Network could have a positive impact on the expansion of Anthem’s network in Central Indiana.

These narrow, or slim networks may be the wave of the future for the individual health plans in Indiana. The hospitals will have to join these networks or face losing patients. There has been a trend all year long of patients on individual marketplace plans who risk losing their doctors or hospitals because these providers refuse to take these individual plans. Hopefully, this expansion will change things.

For more information about this or any other individual Affordable Care Act plan, please contact Nefouse & Associates at (800) 846-8615, or through our contact form.


Conflicting Rulings On Legality Of ACA Subsidies

Jul 24 2014

We had conflicting rulings on July 22 from two different courts on the Affordable Care Act.  Conflict goes hand and hand with the ACA.

In the first ruling, the D.C. Circuit Court of Appeals said the ACA does not permit the IRS to distribute premium subsidies on exchanges established by the federal government. Indiana has one of those exchanges.

Then, the 4th Circuit Court of Appeals came to the opposite conclusion, ruling that the IRS, in fact, has the authority to issue the subsidies on federal-run exchanges because of ambiguity in the law.

Lobbyists and others against the ACA want to strip the tax credits from states that did not develop state-based exchanges. They also argue that those states would not eligible for the employer mandate or individual mandate.  They’re arguing that the ACA is bad for businesses, because of the mandated coverage and the penalties for not having health insurance.

Conflicting Rulings On Legality Of ACA Subsidies
Conflicting rulings seem to be pulling the ACA in different directions.

In Indiana, we had about 130,000 people take advantage of the new healthcare law by getting health insurance through the federal exchange. Again, there was no specific state-based exchange set up in Indiana. A further 90% of those enrolled were found eligible for tax credits. These tax credits reduced the cost of health insurance by nearly 79%.

Thanksfully, these rulings will have no immediate  impact on Hoosiers who are receiving tax credits or who will be applying for tax credits during this open enrollment. The D.C. ruling will likely be reversed on appeal, meaning none of your tax credits should be at risk.

Being an agency that facilitates plans on the federal exchange, we know firsthand that conflict comes with the ACA. We have helped so many Hoosiers get affordable healthcare because of the new law, and we find it highly unlikely that the government can put the toothpaste back in the tube.  That is why Nefouse & Associates will continue to help as many  Hoosiers as possible benefit from the new law. For more information, please contact Nefouse & Associates at (800) 846-8615, or through our contact form.


Prescription Drug Exceptions for Non-Formulary

Jul 17 2014

If you have been insured on a federal marketplace insurance plan for Indiana, you may have experienced some prescription drug issues.

Mostly, the prescription coverage through the exchange may be much slimmer than traditional health insurance plans. Some Hoosiers have experienced no coverage for certain brand-name drugs. This is because the drug does not fall on the carrier’s drug formulary list, and may be considered a non-formulary drug.

However, under the Affordable Care Act, you may actually be eligible to get that drug covered under your health plan.

Prescription Drug Exceptions for Non-Formulary
Whether your ACA plan covers medication depends whether it’s formulary or non-formulary.

Here is some of the criteria for the exception:

  1. Request for coverage of a drug that is not on the formulary list. This criteria alone gives you the ability to get that drug covered.
  2. There is a dosage limit/quantity Limit.  This is very common, where the drug plan will only cover a certain amount or a set does.
  3. Step therapy requirements or other pre-authorization requirements which are not covered. Step therapy is when you have to take a different drug first before they will approve the other drug. This is very common with anti-acid drugs: you are prescribed Nexum but the insurance company wants you to take Dexlant first. You may be approved for exception is if the other drugs create adverse side effects.
  4. Brand exclusion: This would give you the ability to get the drug covered because it’s not covered in the first place.

There are many more exceptions that you can try for.
Here is the bad news — the approval of the exception can take up to one year. If you were to apply for an exception, make sure you are going to stay on the plan for awhile.

I will go into detail on each exception in four more blog posts, but if you need info right now on this, please contact Nefouse & Associates at (800) 846-8615, or through our contact form.


Healthcare.gov Requesting Additional Information

Jul 10 2014

If you were one of the 132,000+ Hoosiers that purchased health insurance through the marketplace, you may be asked to provide additional information to the Department of Health and Human Services.

The government is asking people to verify citizenship, income, social security numbers, as well as coverage through an employer. If you don’t provide this information, you may be at risk of losing your tax credit and may have to pay it back. And the last thing you want is to owe money to the government.

80% of Hoosiers received a tax credit through the exchange, so its important to provide any information that is requested. The government may say, for example, “The information on your application does not match our records.”

Healthcare.gov Requesting Additional Information
It might be difficult for some to have to pay back tax subsidies they thought they earned.

You may have already submitted the requested information, but you could be asked to submit it again. A lot of the documents that were uploaded to the marketplace have been misplaced by the system, or unlinked to your application. There’s a reason for that.

The company that the government contracted to handle these matters is Serco, who has a location in London, KY. They’re a non-U.S. company. Serco was not able to transfer the uploaded documents that members provided, meaning they had to manually type in the information. A task that should have taken five minutes took hours. This was a result of the government not building the platform to transfer the documents.

At any rate, be on the lookout for communications from the marketplace — either by e-mail, phone or regular mail. It is very important to provide the requested information, or risk losing the tax credit.

For more questions on this additional request or any other aspect of Affordable Care Act exchange coverage, contact Nefouse & Associates at (800) 846-8615, or through our contact form.


The ACA and Contraceptive Coverage in Indiana

Jul 03 2014

If you’re in the market for an oral contraceptive and have an Affordable Care Act compliant health plan, then you may have experienced something at the pharmacy that took you by surprise. Your contraceptive was covered at 100% with no cost to you.  Under the Affordable Care Act, there is a mandate for contraceptives. Certain oral contraceptives are covered at no cost to the member — also know as “no-cost share.”

There has not been a lot of information on this aspect of the ACA. It’s really been kept quiet. Earlier this week, the department of Health and Human Services released information that women saved $483 million dollars last year on contraceptive drugs.  It’s interesting that the HHS released this information on the same day as the Hobby Lobby case.

Hobby Lobby had the Supreme Court rule in its favor, leading to wide national implications. The case was about religious for-profit organizations that don’t want to cover certain contraceptives.  Despite what the media states, this decision will have little to no impact on most Indiana residents — at least for now. It will have even less impact on you if you stick with your individual ACA plan, rather than an employer plan.

The ACA and Contraceptive Coverage in Indiana
Oral contraceptives are covered 100% under ACA-compliant plans in Indiana.

If you are happy with your current contraceptive coverage,  you should not be impacted. If your current oral contraceptive is not being paid at 100%, then you may want to look at your insurance provider’s drug list. Speak with your doctor to see if one of the “no cost” drugs could work for you.

When it comes to health insurance, it’s about getting the most out of your premium dollars.

Note that if you have ACA-compliant coverage and work for a religious employer in Indiana, your contraceptives might be exempt from this 100% coverage. Please check with your insurance company and your employer to be sure.

To find out more about the ACA exchange in Indiana, especially as we’re heading toward another Open Enrollment period, contact Nefouse & Associates at (800) 846-8615, or through our contact form.







Health Insurance Impact from Indiana Ruling on Gay Marriage

Jun 26 2014

US District Court Judge Richard Young ruled on June 25 that the same-sex marriage ban in Indiana was unconstitutional. This ruling will be appealed and the debate could go on for years.

What impact does this have on health insurance in our state?

If the same-sex marriage ban is reinstated:

Nothing will change in Indiana. Currently, individual health plans in Indiana do not cover same-sex marriage. This is also the case on small-group health plans with less than 50 employees.

The federal marketplace plans for Indiana don’t cover same-sex marriage either. The marketplace states that the marriage has to be considered legal in the state in which the insured lives, in order to be eligible for coverage as a same-sex married couple.

On large-group health plans, however, there is coverage available if the employers elect it. Here is the catch — many times the partner will receive a 1099 on the value of the coverage, negating any benefit from it.

If same-sex marriage stays legal:

Indiana based health insurance contracts would have to cover the spouse. It could be an individual or group health plan, and it would have to provide coverage. For large group, self-funded plans, the employer may still have the option to choose to provide coverage, then continue to 1099 the benefits.

How does the gay marriage ruling impact health insurance in Indiana?
Legal same-sex marriage has wide-ranging healthcare implications.

The IRS code for same-sex marriage

As far as the IRS code is concerned, even on the exchange where same-sex marriage is legal, the couple has to be filing taxes jointly to qualify for tax credits. It would be interesting to have a tax expert chime in on the treatment of same-sex marriage under the IRS. The tax code directly impacts your qualification for reduced premiums.

As always, feel free to respond in the comments with any thoughts, or contact Nefouse & Associates at (800) 846-8615, or through our contact form.


Medicaid rejection is a Qualifying Life Event

Jun 20 2014

As a reminder, a Qualifying Life Event is a life circumstance change that allows you to apply for Affordable Care Act insurance coverage outside of the usual enrollment period. These life events can include marriages, deaths, births, new jobs, job loss, and so on. We posted a blog last week on the subject of Qualifying Life Events.

Here is another Qualifying Life Event that Hoosiers should know about. If you applied for Medicaid coverage before March 31st and were turned down, that gives you the option to take an insurance policy on the exchange.

At the end of open enrollment this year, we had a lot of Hoosiers that did not qualify for the Marketplace plans because the marketplace said they were eligible for Medicaid. These marketplace decisions were based on household income. If your income was under 133% of the federal poverty level, then the marketplace may have said you were eligible for Medicaid. If you have a family and your income is under 250% of the federal poverty level, then you children could have been shifted to the Medicaid market.

Medicaid rejection is a Qualifying Life Event
It takes a long time to determine whether you qualify for Medicaid.

A lot of these applications for Medicaid can take more than 90 days to complete. We are now starting to see people get declined by Medicaid, but the good news again is this is a Qualifying Life Event, in which you can apply for coverage on the exchange. You are therefore eligible for tax credits and cost sharing reductions. Even better, when one person in the family has a Qualifying Life Event, the creates one for the entire family. If you were approved for the marketplace but your kids were not, for example, and then the kids were declined for Medicaid, you can now add the kids to your plan. This will change your tax credits and could be a benefit.

If you have been declined for Medicaid, then you may be eligible for a health policy through the federal exchange.

Contact Nefouse & Associates for more information on this and other health exchange benefits in Indiana: (800) 846-8615, or through our contact form.