Total Benefit Solutions Inc

Gag Clause Attestation Due December 31, 2025

November 3, 2025October 28, 2025Aris HerreraNo Comments

As previously reported, insurance carriers and plan sponsors of group health plans must submit information annually to the Centers for Medicare and Medicaid Services (“CMS”) attesting that their plans do not include prohibited gag clauses by December 31st each year. The next attestation is due by December 31, 2025. A gag clause is a contractual term that directly or indirectly restricts specific data and information that a plan or issuer can make available to another party. These clauses may be found in agreements between a plan or carrier and any of the following parties: A gag clause may also be found in the downstream agreements of the service provider. Carriers and… Read More

Highmark Updated Billing Addresses in Pennsylvania

October 30, 2025October 28, 2025Aris Herrera

What do I need to know? Effective immediately, we’re consolidating billing addresses across all Pennsylvania markets. This change will streamline many steps in the billing process and allow for clearer communication to the market. It applies to clients in the following Highmark companies in small and large group: Clients in Northeastern and Southeastern Pennsylvania aren’t impacted by this change – they’re already using the newer addresses. For clients who pay premium by mail: All Pennsylvania premium payments that are mailed should go the new address: PO Box 382146, Pittsburgh, PA 15251-8146. This address has been updated on invoices and throughout other materials. Premium payments sent to the old address will be… Read More

Allegheny Health Network and Heritage Valley Health System Sign Affiliation Agreement

October 27, 2025October 24, 2025Aris Herrera

Organizations Pledge Expanded Access to High-Quality Care in western Allegheny County and greater Beaver County as Heritage Valley’s Hospitals, Outpatient Clinics and Physician Practices become part of AHN and Highmark Health. Beaver, PA (Oct. 16, 2025) – Officials from Heritage Valley Health System (HVHS), the Heritage Valley Health System Foundation, Highmark Health and Allegheny Health Network (AHN) joined community leaders and hospital employees today to celebrate the signing of an affiliation agreement that will strengthen and expand the services that HVHS provides to residents in western Allegheny County, greater Beaver County and the surrounding region. Pending government approval of the transaction, the affiliation will establish Heritage Valley Beaver and Heritage Valley Sewickley as AHN’s 15th and 16th… Read More

2026 Cost of Living Adjustments

October 24, 2025October 24, 2025Aris Herrera

The IRS has released cost of living adjustments for 2026 under various provisions of the Internal Revenue Code (“Code”). Some of these adjustments may affect your employee benefit plans. Cafeteria Plans – Health Flexible Spending Arrangements Annual contribution limitation For plan years beginning in 2026, the dollar limitation under Code Section 125(i) for voluntary employee salary reductions for contributions to health flexible spending arrangements (“health FSAs”) increased from $3,300 to $3,400. Annual maximum carryover For cafeteria plans that permit the carryover option, the maximum unused amount from a health FSA that can be carried over to the following plan year is $680 for plan years beginning in 2026 (up from… Read More

Navigating Delaware Paid Family and Medical Leave

October 14, 2025October 14, 2025Aris Herrera

Think of Paid Family & Medical Leave (PFML) in Delaware as a 2-lane highway: the State Plan and the Private Plan. The destination is the same no matter which route an employer chooses, but depending upon their circumstances, employers might find that one or the other is an easier trip. Employers who haven’t decided which path to choose will need to do so soon. When considering the Private Plan route, it’s important to stay on top of state-mandated deadlines. The Private Plan application window is similar to an open enrollment window. And it’s open NOW: October 1 through December 1, 2025. This is the last opportunity for a Private Plan to go into effect at the same time… Read More

Video: Health Insurance Open Enrollment

October 8, 2025October 10, 2025Aris Herrera

Medicare Part D Notification Requirements (From IBC)

October 7, 2025October 9, 2025Aris Herrera

Below is an important notice from Independence Blue Cross regarding Medicare Part D notification requirement for 2025-2026 Dear Valued Benefits Administrator: As you may know, employers that offer prescription drug coverage to their Medicare-eligible employees, retirees, and dependents (collectively referred to as “members”) must notify them by October 15, 2025 of whether that coverage is “creditable” or “non-creditable.” We are writing to remind you that requirement and to provide you with information on the statues of Independence Blue Cross (Independence) prescription drug plans. This Requirement is Part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), which added a new prescription drug program to Medicare known as… Read More

Upcoming Important Dates

September 23, 2025September 25, 2025Aris Herrera

Mark Your Calendars! Here Are The Important Upcoming Dates You’ll Want To Keep In Mind. As always if you have any questions or concerns, please don’t hesitate to contact the experts at Total Benefit Solutions, Inc (215)-355-2121

Delaware Amends Paid Family and Medical Leave law

September 16, 2025September 19, 2025Aris Herrera

On July 30, 2025, Governor Matt Meyer signed HB 128 (“the Act”) into law, amending Delaware’s paid family and medical leave law (“PFML”). The Act was effective immediately once it was signed into law. Background Delaware’s PFML law, the Healthy Delaware Families Act, requires certain employers to provide their covered employees with up to $900 per week in paid leave for parental, family caregiving, medical, and qualified military exigency leave. Contributions to the state plan began on January 1, 2025, and benefits will begin on January 1, 2026. The Act amends several provisions of the PFML law, specifically the following:

The Uncertain Future of Medicare’s Stand-Alone Prescription Drug Plan Market

September 2, 2025September 4, 2025Aris Herrera

Ahead of Medicare’s annual mid-year announcement about the national average premium for Part D prescription drug coverage in 2026 and other plan details, two questions loom large for the insurers that sponsor Part D stand-alone prescription drug plans (PDPs) and the 23 million people in traditional Medicare who are currently enrolled in these plans. Will the Trump administration continue Medicare’s Part D premium stabilization demonstration for a second year, and what will the PDP market look like in 2026 and in subsequent years? The answer to the first question could determine whether monthly PDP premiums remain at a relatively affordable level and whether PDP availability remains stable in 2026. The answer to… Read More

Highmark – Important Update Regarding Plan Availability on External Enrollment Platforms

August 29, 2025August 29, 2025Ed MacConnell

At Highmark, we value the trust you place in us and are committed to providing timely and transparent information. As we look ahead to 2026, we want to inform you that we are adjusting plan availability on external quoting and enrollment platforms. This decision has been carefully considered to ensure that our broker partners are prioritizing plans that offer a long-tenure with Highmark. Further details regarding our 2026 plan offerings will be shared as we approach AEP. We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated Total Benefit Solutions health insurance specialists at (215)-355-2121 or fill out the contact form below. We are… Read More

Trump Administration Issues Final Rule Impacting the ACA’s Marketplace

August 12, 2025August 29, 2025Loramei Romeo

On June 25, 2025, the U.S. Department of Health and Human Services (HHS) published a final rule to implement newstandards for the Affordable Care Act’s (ACA) Marketplaces (or Exchanges). According to HHS, improper Exchangeenrollments, enabled by weakened verification processes and expanded premium subsidies, have triggered “widespreadfraud.” The final rule’s changes are intended to address these problems with the goal of improving health care affordabilityand access while maintaining fiscal responsibility. Key ChangesMany of the final rule’s changes are effective 60 days after its publication date, or Aug. 25, 2025, although some provisionshave a later effective date. Also, some changes are temporary measures that sunset at the end of the 2026 plan… Read More

Navigating PCORI Fees for Self-Insured Health Plans and HRAs

August 5, 2025August 4, 2025Loramei Romeo

The Affordable Care Act (ACA) imposes a fee on issuers of specified health insurance policies and plan sponsors of applicable self-insured health plans to help fund the Patient-Centered Outcomes Research Institute (PCORI). The IRS has provided this helpful chart for more information on whether a type of insurance coverage or arrangement is subject to the fee. Note that self-insured health plans include health reimbursement arrangements (HRAs) and level-funded arrangements. This fee applies to policy or plan years ending on or after October 1, 2012, and before October 1, 2029. Self-insured plan sponsors can satisfy their compliance obligations by completing and filling FORM 720, with its accompanying 720-v payment voucher. Although… Read More

Discover key insights from the recent Medicare Advantage hearing!

August 1, 2025Loramei Romeo

Medicare advantage (MA) has experienced a fast growth in the last few years, which has created a significant opportunity for Congress to upgrade the program to better serve beneficiaries, especially in rural areas. With over half of Medicare beneficiaries now enrolled in MA plans, these individuals enjoy lower healthcare costs, access to supplemental benefits, and improved health outcomes compared to traditional fee-for-service Medicare. Recent hearings have focused on strategies to enhance these benefits while ensuring program integrity and fiscal responsibility. Strengthening Medicare Advantage will not only improve health outcomes for seniors but also provide value for American taxpayers. Therefore, it is crucial to conduct a thorough examination of the program.… Read More

Cigna Healthcare Medicare has officially rebranded to HealthSpring.

July 23, 2025Loramei Romeo

In March 2025, the Cigna Healthcare Medicare business was acquired by Health Care Service Corporation. As Cigna Healthcare Medicare navigates this change, their focus remains on providing continuity and trust in the Medicare options you rely on. They are dedicated to renewing their brand while ensuring the same exceptional products and benefits you have come to expect. The HealthSpring brand is a well-respected name, that reflects Cigna’s commitments to providing quality benefits. With nearly a century of experience, HealthSpring signifies Cigna’s Healthcare Medicare mission to empower members to lead vibrant and healthy lives. By integrating with reputable brands, Cigna Healthcare Medicare ensures that their members receive the best support in… Read More

Stay informed on health legislation like PA Act 1 & HRSA cancer screening coverage!

July 21, 2025July 23, 2025Loramei Romeo

The recent PA state legislation, Act 1, marks a significant advancement in women’s healthcare by mandating health plans to cover supplemental diagnostic radiology services and genetic screenings for those at increased risk of breast cancer and BRCA mutations. This legislation is designed to eliminate out-of-pocket costs for these essential health services, ensuring that women who need these screenings can access them without financial barriers. In response to recent legislative changes, Independence Blue Cross has updated its coverage policies to eliminate cost-sharing for annual supplemental breast cancer screenings and genetic testing for those at increased risk. This change is vital in improving access to preventive care for individuals concerned about breast… Read More

Attention: The coverage for OneTouch diabetic supplies ends August 3

July 11, 2025July 11, 2025Loramei Romeo

As of August 3, significant changes will occur regarding preferred diabetic testing supplies for Medicare Advantage plans. LifeScan OneTouch@ products will no longer be covered, and Ascensia Contour products will be introduced as a new preferred option effective June 1, 2025. Members will still have access to a selection of preferred brands with a $0 copay, including multiple Accu-Chek and Contour products such as: Member that are currently using LifeScan OneTouch supplies will soon receive an important letter from UnitedHealthcare, outlining new options and the need for updated prescription. We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated Total Benefit Solutions health insurance… Read More

Exiting news! Prior authorization reforms are set to simplify health insurance.

June 27, 2025June 26, 2025Loramei Romeo

On June 23, 2025, health insurance plans revealed significant commitments aimed at simplifying and streamlining prior authorizations for better care access. These initiatives are built on existing efforts to enhance patient connections to necessary care while reducing the administrative burden on healthcare providers. Such changes promise to improve overall patient experience and access to evidence-based treatments, aligning with the industry’s goal of delivering affordable healthcare. In line with state and federal regulations, new commitments across insurance segments aim to enhance health coverage for 257 million Americans. The six key commitments focus on : These steps are crucial for improving the overall health insurance landscape and fostering better patient experiences. We… Read More

Big changes to Medigap plans start January 1, 2026!

June 12, 2025June 18, 2025Loramei Romeo

Attention to all current Medigap groups: As of July 1, 2025, new enrollments for MedigapSecurity and 65 Special products will no longer be accepted. It is crucial for future retirees to be aware that they will need to transition to a MedigapFreedom product. As we approach 2026, it’s essential for businesses and retirees to understand the upcoming changes to Medigap enrollment. If your Medigap group renewal dates fall between January 1 and June 1, 2025, you can continue enrolling future retirees into MedigapSecurity or 65 Special throughout 2025. However, starting January 1, 2026, any future retiree from an existing group will need to select from the MedigapFreedom products. As we… Read More

The 2025 PCORI Fee is on the horizon!

June 10, 2025July 21, 2025Loramei Romeo

The recent reauthorization of PCORI fees by the Federal Government will continue to support the Patient-Centered Outcomes Research Institute through 2029. These fees play a crucial role in funding vital health research, which helps inform healthcare decisions and improve patient outcomes. As a reminder, the fee associated with your health plan is due by July 21, 2025. This deadline is crucial as it follows the calendar year immediately after the end of the applicable plan year. Staying compliant with these deadlines is essential for effective health insurance management. For plan years ending on or after October 1, 2023, and before October 1, 2024, the fee will be $3.22 multiplied by… Read More

What It Takes to Stay Balanced While Running a Business

June 9, 2025May 29, 2025Loramei Romeo

Running a small business might be the most exhilarating decision you’ve ever made, but no one tells you it’s also an emotional woodchipper. Deadlines, payroll, unpaid invoices, looming tax forms — the pressure doesn’t clock out when you do. And the worst part? Most of the stress feels invisible, yet it colors every interaction, every strategy session, every hour of sleep you don’t get. But you don’t have to white-knuckle it through madness. There are ways to claw back a little peace. Maybe not perfect peace, but enough to make it through Thursday without screaming into a closet. Prioritize Self-Care Let’s start with the basics, the stuff you already know… Read More

Zepbound coverage for obstructive sleep apnea ends August 1 for current prescriptions.

June 6, 2025June 4, 2025Loramei Romeo

As part of ongoing adjustments in health insurance coverage, we want to inform that starting August 1, 2025, Independence Edge will remove Zepbound from the Select/Value formularies for treating obstructive sleep apnea for those with existing prescriptions. This change is already in effect for new prescriptions as of May 1, 2025. The decision to terminate Zepbound coverage for OSA treatment was made based on the fact that there are no clinical studies to prove that the drug treats OSA through any other mechanism and its benefit is limited to only weight loss. From August 1, those who continue Zepbound will bear the full cost, although it may be Health Savings… Read More

Tax Favored Accounts Summary Page

June 5, 2025May 23, 2025Loramei Romeo

Cafeteria Plans (Section 125 Plans)

June 2, 2025May 23, 2025Loramei Romeo

We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated Total Benefit Solutions health insurance specialists at (215)-355-2121 or fill out the contact form below. We are available to answer any questions or address any concerns you may have.

Medigap Plans: Comparing Costs

May 27, 2025May 22, 2025Ed MacConnell

When selecting a Medigap policy, it’s important to compare offerings from multiple insurance companies, especially if you’ve already chosen a specific standardized plan. While policies with the same letter designation provide identical benefits, premium costs can differ between insurers. For example, Policy A from Company 1 offers the same coverage as Policy A from Company 2, but the two companies may set different pricing. At Total Benefit Solutions, Inc we look at many factors besides price including length of time in market, ease of use and client service availability. When choosing a Medigap, ask what factors the Medigap insurance company uses to set your premium. The following factors may affect… Read More

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