Direct Primary Care – Total Benefit Solutions Inc

Main Line Health and Lifeline Medical Associates

January 8, 2025Loramei Romeo

Highmark Medicare Advantage participants will no longer have in-network access to Main Line Health providers and facilities as of January 1, 2025. In the beginning of October, Highmark notified members who were affected by this disruption that Main Line Health might become out-of-network. Members should contact the member services number shown on the back of their ID card if they have any issues concerning continuity of care or how to locate another in-network provider or facility. For FEP, ACA, and CHIP members of Highmark, Main Line Health remains in-network. Lifeline Medical Associates (DE): Highmark ACA Members’ Out-of-Network Date Is Extended to March 2, 2025, Subject to Ongoing Negotiations We spoke… Read More

Changes for Prescription Drug Coverage

January 7, 2025Loramei Romeo

SJRA and Larchmont Facilities returns to Horizon’s Network

January 3, 2025January 3, 2025Loramei Romeo

South Jersey Radiology Associates (SJRA) which includes Larchmont Medical Imaging has made an agreement with Horizon BCBSNJ. On January 1, 2025, they will return to the network. *SJRA services are regarded as out of network if they are provided between April 1, 2024, and December 31, 2024. There will be no retroactive processing of claims. 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.

Independence – Update regarding ID Cards for January 1st IBX Customers

January 2, 2025January 2, 2025Loramei Romeo

The IBX Team has provided us the following update regarding ID Cards for January 1st Customers. Due to the large volume of cards being processed and mailed for January, members may not receive their physical ID cards before January 1. To ensure uninterrupted access to care for members with ID cards processing in the second half of December, letters are being mailed to plan subscribers containing their new member ID numbers and ID numbers for all covered dependents. The sample letter is attached, and it’s important to note these members can access their ID cards on the portal until they receive the physical card. We’re just trying to be proactive… Read More

Changes for Prescription Drug Coverage

December 27, 2024December 27, 2024Loramei 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.

FAQ 68 Addresses Preventive Care and Mastectomy Coverage

December 24, 2024December 24, 2024Loramei Romeo

Coverage of PrEP Certain preventive care services must be offered by health insurance companies and non-grandfathered group health plans without any cost-sharing obligations under the Affordable Care Act (ACA). The United States Preventive Services Task Force (USPSTF) and other agencies and advisory groups recommendations form the basis of the list of preventive care services. If a preventive care service or item requirement omits information on the frequency, manner, treatment, or setting to administer the preventive care service, plans and carriers are permitted to employ reasonable medical management practices. Coding and Claims Management Plans and carriers are also reminded by FAQ 68 of the significance of correctly coding claims for preventive… Read More

New Jersey Releases 2025 Disability and Family Leave Amounts

December 20, 2024December 20, 2024Loramei Romeo

New Jersey has announced the 2025 contribution rates and benefit level parameters for the Temporary Disability Insurance (TDI) and Family Leave Insurance (FLI) programs. Temporary Disability Insurance 2025 For qualified New Jersey workers who are unable to work due to a non-work-related illness, injury, or other disability, or for specific public health emergencies, TDI offers benefits. Employees must have worked 20 weeks and earned at least $303 per week (Base Week Amount) or earned $15,200 (Alternative Earnings Test) in the four quarters (base year) before taking vacation to be eligible for TDI. 85% of an employee’s average weekly pay, up to a maximum of $1,081, is the weekly TDI benefit… Read More

New PCOR fee Announced

December 20, 2024December 20, 2024Loramei Romeo

The IRS released Notice 2024-83 on December 3, 2024, which states that the PCOR fee which is determined by the adjusted applicable dollar amount used for plan years that starts on or after October 1, 2024, and before October 1, 2025, is $3.47. For self-funded medical plans which includes level funding and some HRAs including ICHRAs for plan years ending in 2024 the PCOR filing deadline is July 31, 2025. For insured policies the carriers are responsible for paying. Employer Action: There are no further required actions for employes with self-funded health plans (or an HRA) as of the moment. Reminders will be sent in mid-2025 for the fee and… Read More

ACA Compliance for Forms 1094-C + 1095-C

December 19, 2024December 19, 2024Loramei Romeo

In terms of ACA reporting of minimum essential coverage (MEC), you are probably an Applicable Large Employer (ALE) if you had an average of fifty (50) full-time equivalent employees in the previous calendar year or if you are an employer of any size that provides a level funded or self-insured plan. The deadlines are: Employees must submit their 1095-C forms by March 3, 2025, at the latest. IRS-required copies of 1094-C and 1095-C forms are due by March 31, 2025, if filing online, or February 28 if filing on paper. We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated Total Benefit Solutions health… Read More

Binder Payment Deadline for January 1 Effective Dates

December 6, 2024December 6, 2024Loramei Romeo

New members with a plan must make their first payment by December 31, 2024, and their plan would be effective on January 1, 2025. The payment is a must to activate their coverage and begin using their benefits. To maintain their coverage, members from Florida and Indiana who are registered in a 2024 Bronze| Silver| Gold (Core) network plan and are subsequently enrolled in a 2025 Premier network plan must make a binder payment by December 31, 2024. Auto Pay is worry free and saves time. To ensure they always make their payment on time, members can set up a monthly recurring payment. Members can register via the Ambetter App… Read More

Deadline for Small Employer Open Enrollment is approaching

December 4, 2024December 4, 2024Loramei Romeo

We would like to remind you about the Small Employer Open Enrollment Period for fully insured health plans in every state, even though this has been in effect for years. Each year the period for Small Employer Open Enrollment Period is from November 15 to December 15. Employers who fit the carrier’s definition of a small employer but do not fulfill the participation or contribution requirements will be eligible to enroll in a small employer plan with an effective date of January 1. Employer groups participating during the Small Employer Open Enrollment Period must submit completed applications to carriers after November 15th and by noon December 15th. We are dedicated… Read More

Gag Clause Prohibition Attestation Under the Consolidated Appropriation Act

November 25, 2024November 25, 2024Loramei Romeo

Under the Consolidate Appropriations Act (CAA), health plans are prohibited from signing contracts that limit the precise data and information they can provide to third parties. Every year, plans are required to provide an attestation confirming that they have not entered any prohibited contractual restrictions. According to Excellus BlueCross BlueShield (Excellus BCBS) we will be completing the attestation on behalf of our fully insured and minimal premium groups for the duration they had with Excellus BCBS coverage in 2024. Please inform these groups that we will be finishing the attestation on their behalf by the deadline of December 31, 2024, if you hear any questions from them regarding gag clause… Read More

Main Line Health may part ways with Medicare Advantage network in Pennsylvania

November 22, 2024November 22, 2024Loramei Romeo

Main Line Health in Pennsylvania has a long relationship with Cigna Healthcare Medicare Advantage (MA). Unfortunately, negotiation has not been reached between Cigna Healthcare Medicare Advantage and Main Line Health in Pennsylvania, because of this effective on January 1, 2025, Main Line Health in Pennsylvania will not be a part of MA network. Customers have been notified via letter. A new Primary Care Physician (PCP) recommendation will be included to customers who are assigned to PCP from Main Line Health. To change to another PCP customers can contact Cigna Healthcare MA. Customers would be reassigned to the recommended PCP if they do not contact Cigna Healthcare. Customers with a PCP… Read More

WellSpan part ways with United Healthcare’s commercial network

November 21, 2024November 21, 2024Loramei Romeo

As of Nov 1, 2024 the facilities, hospitals, and physicians of WellSpan Health are out of network for UnitedHealthcare employer-sponsored commercial plans. WellSpan declined the proposals to extend the contract to ensure continued access to the health system while continuing to negotiate. Also, proposals that would ensure WellSpan Health to be reimbursed at more reasonable rates. WellSpan Health continued to seek unsustainable price increases, with its facilities costing over 30% more than the average of all other hospitals in south-central and eastern Pennsylvania that are members of our commercial network. A cost-effective solution that restores WellSpan Health’s network connectivity is still our top priority, and we will continue to negotiate… Read More

In 2025, would you like more?

November 21, 2024November 21, 2024Loramei Romeo

HSA funds are carried over each year. Why not increase your savings? Additionally, if you contribute to your HAS before the year ends, you can lower your income that is subject to taxes. For self-only coverage, the maximum contribution in 2024 is $4,150, and for family coverage, it is $8,300. Moreover, if you are at least 55, you will receive an additional $1,000 catch-up contribution. Employer contributions, direct transfers, and payroll deductions are all included in the annual cap. We’re sure you are as excited about this as we are! Please reach out if you have any questions. We are dedicated to providing exceptional service, so please do not hesitate… Read More

Guide to more savings and benefits & Letters to MA customers

November 18, 2024November 18, 2024Loramei Romeo

Guide to more savings and benefits The discounts for the Medicare supplements insurance provides savings that can be used by customers to reinvest in additional coverage. The discount is up to 20% with combined household discounts which are, discount for more than one member of the household holds a policy is 14% and discount when a customer lives with one or more people is 6%. The supplemental benefits are fit for client’s needs in cancer treatment, choice accident, dental, vision, hearing, hospital indemnity, lump sum cancer, lump sum heart attack, and stroke. Letters mailed to Medicare Advantage customers There are different versions of Benefits at a Glance (BAAG), letters regarding… Read More

WELLSPAN CONTINUES TO BE IN NETWORK WITH UHC!

November 15, 2024Loramei Romeo

We are excited to announce that as of 12/1/2024, Wellspan Health will continue to be a partner in care for UnitedHealthcare’s DSNP and ISNP members. We have also expanded the DSNP network to include ALL Wellspan Providers. We’re sure you are as excited about this as we are! Please reach out if you have any questions. 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.

Required Attestation regarding the Gag Clause by December 31, 2024

November 14, 2024November 14, 2024Loramei Romeo

By December 31st of each year, insurance companies and plans sponsor of group health plans are required to provide the Centers for Medicare and Medicaid Services (CMS) with information certifying that their plan or policies do not include illegal gag provisions. The due date for the subsequent attestation is December 31, 2024. Clients are receiving notifications from carriers and TPAs regarding their plan to adhere to the Gag Clause Prohibition Compliance Attestation. Once more, it appears that the different carriers/TPAs will not handle the attestation requirements the same way. For fully insured plans both the plan and carrier must file attestation if the group health plan is fully insured; however,… Read More

Tower Health is back!

July 26, 2024July 23, 2024Mirasol Bandong

Tower Health is back in Cigna Medicare Advantage network in Pennsylvania! After productive negotiations with Tower Health in Pennsylvania, Cigna is happy to announce that they are back in their Medicare Advantage network effective June 1, 2024. This includes Phoenixville and Pottstown Hospital, all Primary Care Physicians (PCPs), specialists, ancillary providers, and other hospitals that were previously in-network. 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.

Special Enrollment Period Extended: Florida Emergency Declaration – Hurricane Idalia

June 28, 2024June 28, 2024Mirasol Bandong

Please be advised that a state of emergency was extended for certain Florida counties. This declaration allows for a one-time Special Enrollment Period (SEP), in the event beneficiaries were unable to make an election during another qualifying election period. Please reference the following guidelines for the incident period. This DST-SEP applies to the Florida counties listed below. Important Compliance Information Who is eligible: This SEP opportunity is ONLY available to beneficiaries who: Details : Impacted Counties: Alachua, Baker, Bay, Bradford, Brevard, Calhoun, Charlotte, Citrus, Clay, Collier, Columbia, DeSoto, Dixie, Duval, Flagler, Franklin, Gadsden, Gilchrist, Gulf, Hamilton, Hardee, Hernando, Hillsborough, Jefferson, Lafayette, Lake, Lee, Leon, Levy, Liberty, Madison, Manatee, Marion, Nassau, Orange, Osceola, Pasco, Pinellas,… Read More

Disaster Special Election Periods in several states

June 24, 2024June 20, 2024Mirasol Bandong

This is an important announcement for customers in Arizona, Arkansas, Colorado, Florida, Idaho, Mississippi, Nevada, Oklahoma and Texas and for those with business in these states. The counties below are under a federal or state designated SEP due to an emergency. Applications for disaster SEP are only accepted as long as the SEP declaration is in place. For the most recent information, if a deadline is not specified below, please use Producers’ University’s Ongoing SEP tracker. Applications for SEPs submitted after the declaration date of that SEP will not be accepted. IMPORTANT : Please be aware The SEP begins on the date of the incident’s start, if that occurs earlier, or on the declaration date. The SEP… Read More

Cigna+Oscar Announcement

May 15, 2024May 14, 2024Mirasol Bandong

Oscar and Cigna Healthcare have made the decision not to renew Cigna + Oscar Small Group plans nationally as of December 15, 2024. They will continue to provide coverage for Cigna + Oscar Small Group services through the end of each member’s policy, and specific timing is dependent on each groups’ enrollment date. Dates: As per the federal and state deadlines, Cigna + Oscar will inform plan sponsors and insured persons about the discontinuation. Oscar will stay active in the individual market and concentrate on that area of the company’s operations. To see ARTICLE We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated… Read More

IRS Addresses Tax Treatment Of Work-Life Referral Services

May 7, 2024May 6, 2024Mirasol Bandong

The Internal Revenue Service (“IRS”) clarified the tax treatment of several work-life referral (“WLR”) services offered by employers in a new Fact Sheet FAQ. According to the FAQ, the value of the WLR services may be deducted from employees’ salary as a de minimis fringe benefit in cases when they are included in employee assistance programs (“EAPs”) or are otherwise bundled with other services. WLR Programs WLR services are offered to qualified employees through the employer-funded WLR program. WLR services are informative and referral consultations that help staff members locate, engage, and bargain with life-management providers to find answers to personal, professional, or family problems. Generally speaking, unless a part… Read More

United Healthcare and Mount Sinai Renew Relationship

March 28, 2024March 27, 2024Mirasol Bandong

In accordance with a new multi-year agreement between UnitedHealthcare and Mount Sinai Health System, individuals participating in employer-sponsored and individual plans, such as the Oxford Health Plan, will once again have network access to the system’s hospitals. Additionally, the agreement guarantees continuous, uninterrupted access to the doctors at Mount Sinai. for more information click HERE 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.

Health Care Cyberattack

March 26, 2024June 27, 2024Mirasol Bandong

Although it does not yet know when the recovery from the Change Healthcare hack last month will be completed, UnitedHealth is testing the system to restore it. This week, the care giant said that it is testing technology for processing medical claims. It already has mostly restored systems for handling drug claims and processing payments. The technology utilized to file and handle insurance claims is provided by Change Healthcare. It works with claims from many insurers and processes around 14 billion transactions annually. Some patients might be directed to different pharmacies where billing issues are less of a concern. Industry executives have stated that delays in patient bills are possible. Progress:… Read More

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