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Indiana Health Insurance Exchange The Unofficial Health Exchange Resource Site


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.


Qualifying Life Events and the Affordable Care Act

Jun 12 2014

Every day, more and more information comes out about the Affordable Care Act and how it impacts Hoosiers. Let’s talk about Qualifying Life Events and how they can help you enroll for coverage.

Qualifying Life Events for family members

A Qualifying Life Event is a change in your life that makes you eligible to enroll in ACA health coverage outside of the usual enrollment period. Marriage, divorce, having a baby, adopting a child, placing a child for adoption or foster care, moving, getting citizenship status, leaving jail, losing other health coverage involuntarily, or becoming a member of an Indian tribe are all examples of Qualifying Life Events.

Qualifying Life Events and the Affordable Care Act
Getting married is a good example of a Qualifying Life Event.

The way we understand it, if one member of the family has a qualifying event, that creates a qualifying event for the entire family, and they are therefore able to apply for coverage.

Qualifying Life Event examples

An example of this: if your dependent child has a standalone individual policy and it renews in 2014, then that creates a qualifying event for the parents. So now the entire family can go onto the marketplace and elect coverage.

Here is another example that we have observed in real life: A mother does not have coverage and the dependent child loses coverage. This now creates the opportunity for the mother and child to apply for coverage on the marketplace. Remember, the marketplace makes the final determination whether this is a true qualifying event, and whether you are eligible for tax credits.

Here’s a terrific in-depth article on Qualifying Life Events and whether you might qualify for one.

We don’t know if the law was intended to be set up this way, but it has helped families here in Indiana.

Call Nefouse & Associates with questions at (800) 846-8615, or through our contact form.




Health Care Rules for Networks

Jun 10 2014

Across the country, we are starting to see states revisit health care rules that impact access to care — rules that are being revisited because of the Affordable Care Act rollout. With this ACA rollout, we saw the development of the skinny network or narrow network. The narrow network was created to try to control costs here in Indiana. Judging by the Anthem single-digit rate increase for next year, I would say it was successful.

The Narrow Network

What is a narrow network? Under the ACA, network plans may restrict access to doctors and medical services depending on where you live. The equation the carriers use for the narrow network has to do with participating doctors in a certain mile radius to the insured. In some of these equations, the radius may be 50 miles, especially in rural communities in Indiana. This is not a new problem for these communities.

How does the ACA Narrow Network impact rural and border Hoosiers?
Warning: Narrow network ahead.
We could see lawmakers step in to try and change that equation. We could see an emphasis on types of services versus types of providers. For example, many nurse practitioners and physician’s assistants provide a significant amount of primary care. Hoosiers use med checks and urgent care centers instead of scheduling an office visit. Currently, hospitals have been a main focus for networks, but the reality is almost every service they provide can be provided somewhere else. Typically, these shifts in attitudes will most likely happen in other states before they are debated in Indiana.

Cross-State Healthcare

On the Indiana healthcare exchange networks, access to providers across state lines is a topic that has to be addressed. Right now, we are seeing many border residents faced with difficult decisions when it comes to doctors. These Hoosiers always have the option of buying a policy on the exchange that will give them access across state lines.

The Narrow Network and Open Enrollment

We hope that network contracting — the narrow network effect — is done prior to open enrollment. That way, the networks are all in place for at least a year. There is no greater frustration than having your doctors participating in the network only for them to pull out on the first of the year.

ACA Readiness

With the rollout of the ACA, no one was really ready, especially medical providers. Here at Nefouse and Associates, I had to call medical practices to give them correct information so they could file claims. There was a real lack of information give to the medical community. My clients did not have to worry as much, because we were able to resolve those issues. To find out more about Nefouse and Associates and the services we provide, please contact us.


Proposed Rate Increases for ACA In Indiana

May 29 2014

The Indianapolis Business Journal (IBJ) recently reported on possible rate increases with the current carriers who are participating on the exchange in the state of Indiana.The proposed rate increases may have been shocking to most people, but not for me.

Physicians Health Plan Raises Rates

At the top of the projected rate increase is Physicians Health Plan (PHP), our partner and also a health insurance provider based in Fort Wayne. Their minimum requested rate increase is 31% and the highest is 59%. This gives them an average rate increase of 46% overall.

Here is an excerpt from the IBJ article:

“Emerging enrollments have proven to be significantly tilted toward older ages,” David Peppler, a PHP actuary, wrote in the company’s rate increase request. “It was assumed in 2014 pricing that age mix would be similar to that of group insurance populations. … In this case, the older-than-anticipated age mix is resulting in premium deficiencies as the older-age premium adjustment factors are insufficient to provide for the full older-age morbidity.”

health insurance rates

In the quote, morbidity refers to those diagnosed and being treated for a disease. PHP does not have much experience with individual health insurance in the state of Indiana, so basing projections off of groups is incorrect.

Here at Nefouse and Associates, we are contracted with PHP and feel they are a good option for Northern Indiana residents. Unfortunately, the proposed rate increase doesn’t look good for them. They could be projecting that their Indiana exchange block will be operating at a loss.

Second Highest Rate Increase

The second highest rate increase is MDwise at 35%. Their rate increase is based on the new rules that were recently released by the Centers for Medicare & Medicaid Services.

Lowest Rate Increase

Anthem Blue Cross Blue Shield has the lowest rate increase at 9.7% on their health exchange business. A single digit rate increase is more bearable than a double digit. Anthem is attributing this rate increase to the average age of 42 of their exchange members. Here at Nefouse & Associates, we feel that Anthem is the best option on the exchange. This has to do with their resources, technology, history and most importantly, leadership. The single rate increase proves this.

Impact on Marketplace Policyholders

If you are on a Bronze plan, your healthcare plan will have a major impact. If you currently have a zero-premium policy, you will have a monthly cost starting in 2015. If you have a low cost Bronze plan, you are going to be subject to a much higher rate increase if you are not with Anthem. If you currently have a Bronze plan that is not with Anthem, then during open enrollment, you may want to consider moving that plan over to Anthem.

If you have a Silver plan and have been approved for tax credits, then there should be no impact to your monthly cost. This is because the ACA states that you are only to pay a percentage of your monthly income towards the premium.

Here at Nefouse & Associates, we can help you, not just with changing plans, but actually explaining how the health insurance works. Contact me, Tony Nefouse, at (800) 846-8615.


Healthy Indiana Plan’s (HIP) 2.0 Impact on Exchange Plans

May 27 2014

Governor Pence unveiled his Healthy Indiana Plan 2.0 earlier this month to provide consumer-driven health care coverage for uninsured Hoosiers. The Healthy Indiana Plan was created to help insure Hoosiers that fall into the coverage gap of the Affordable Care Act.

Gaps in Coverage

As you may know, since Indiana did not expand Medicaid, Hoosiers with income below the 133% Federal Poverty Level are not eligible for tax credits. The HIP 2.0 looks to address this issue.

This change could impact your existing coverage. In some situations, we have been able to appeal tax credit declines on the Marketplace. In those situations, we have seen clients become eligible for the tax credits. The appeals that were won are when Hoosiers had been turned down by Medicaid. In most of these situations, we had multiple people in the family. The Hoosiers that did not win the appeal were the ones that were single with income between $11,000-$14,000.

If you were left out of affordable coverage because of low income, the HIP 2.0 may be your answer. If you won an appeal with the Marketplace because of a letter of denial, then you may have to move to the HIP 2.0 in 2015. This could be a big issue for many Hoosiers.

Our Medicaid & HIP departments are going to have to integrate with the Federal Exchange for a somewhat smooth transition. Currently, the Marketplace is unable to send applications to these departments electronically. This has added a lot of frustration for many people.

If you are going to be under the 133% of Federal Poverty Line in 2015, then this is an issue you may have to address soon. Contact me, Tony Nefouse, and we can see what options you may have.