Medicare Secondary Payer Rules

Medicare Secondary Payer Rules: 15 Things You Need to Know to Avoid Penalties.

Ed MacConnell

So, your business is growing, your team is aging like a fine wine, and suddenly, you’ve got employees hitting that magical number: 65. Congratulations! You’ve reached the level of the “Medicare Secondary Payer” (MSP) boss fight. If that sounds intimidating, it’s because it can be. Medicare Secondary Payer rules are essentially the government’s way of saying, “We aren’t paying for this if someone else can.” At Total Benefit Solutions Inc, we spend our days navigating these regulatory minefields so you don’t have to step on a $1,000-per-claim landmine. Whether you’re offering group health insurance for employers or looking into affordable group health insurance options, understanding MSP is non-negotiable. Here are… Read More

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The Ozempic Odyssey: Navigating Medicare Coverage Without the Headache

Ed MacConnell

If you’ve turned on a television or scrolled through social media lately, you’ve heard the names: Ozempic, Wegovy, Zepbound. These GLP-1 medications have completely transformed the conversation around weight management and chronic disease. But for those of us on Medicare, the conversation has often been a short one: "No, Medicare doesn't cover weight loss drugs." For years, that 2003 federal law (the Medicare Modernization Act) has acted like a brick wall, explicitly banning coverage for medications used solely for weight loss. At Total Benefit Solutions Inc, we don't like the word "no." Neither does our resident expert, Dr. Ben E. Fitz. Today, we’re breaking down the complex odyssey of Medicare… Read More

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Blue Card PPO

Why Everyone Is Talking About Blue Card PPO (And Why Your Remote Team Needs It)

Ed MacConnell

If you’re a small business owner or an HR manager in 2026, you’ve likely noticed that the traditional office is a thing of the past. Your lead developer might be coding from a cabin in Colorado, while your head of marketing is based in a suburban home in Pennsylvania. While this geographic flexibility is a huge win for talent retention, it often creates a massive headache when it comes to group health insurance for employers. How do you provide a health plan that works just as well for someone in rural Montana as it does for someone in downtown Philadelphia? The answer that more and more savvy businesses are turning… Read More

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Why Everyone Is Talking About the New Medicare GLP-1 Bridge (And You Should Too)

Ed MacConnell

If you’ve turned on a television, scrolled through social media, or even just sat in a doctor’s waiting room lately, you’ve heard the names. Ozempic. Wegovy. Zepbound. These GLP-1 medications (Glucagon-like peptide-1 receptor agonists) have basically become the “iPhone” of the medical world, everybody wants one, but the price tag can make your eyes water. For years, if you were on Medicare, the conversation usually ended with a polite but firm “No.” Federal law literally forbade Medicare from covering drugs specifically for weight loss. It was a frustrating “Catch-22” (a situation where you can’t win because of contradictory rules): you were encouraged to get healthy, but the most effective tools… Read More

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A man turning age 26 who needs health insurance

The Birthday Scaries: Turning 26 and Losing Your Parents’ Health Insurance

Ed MacConnell

Happy birthday! You’ve finally hit the big 2-6. You’re officially a “real” adult in the eyes of the healthcare world. While that usually means a nice dinner or a weekend getaway, for many, it also brings a sudden, cold realization. The “Birthday Scaries” are real, and they usually hit right when you realize you are officially off your parents’ health insurance plan. One day you’re covered, and the next, you’re staring at a world of deductibles (the amount you pay out of pocket before insurance kicks in) and premiums (your monthly bill) all on your own. Don’t panic. At Total Benefit Solutions Inc, we’ve helped thousands of young professionals navigate… Read More

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7 Mistakes Contractors Make with Group Health Benefits (And How to Fix Them)

Ed MacConnell

In the construction world, your reputation is built on the quality of your work and the reliability of your crew. As of April 13, 2026, the labor market for skilled trades remains incredibly tight. Finding a good foreman or a reliable HVAC technician is hard enough; keeping them is an entirely different challenge. One of the most powerful tools you have to retain talent is your benefits package. However, many contractors view health insurance as a "necessary evil": a line item on the P&L statement that only goes up every year. Because of this, we often see business owners in the construction industry make critical errors that cost them tens… Read More

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Delaware Paid Leave: What Small Businesses Need to Know in 2026

Ed MacConnell

If you’re a business owner in the First State, you’ve likely spent the last few months (or years) hearing whispers about the "Healthy Delaware Families Act." Well, the future is officially here. As of January 1, 2026, the Delaware Paid Family and Medical Leave (PFML) program is fully operational, and benefits are being paid out to eligible employees across the state. At Total Benefit Solutions Inc, we’ve been fielding calls daily from small business owners who are somewhere between confused and concerned. I get it. Managing a business is hard enough without having to navigate new state mandates, payroll deductions, and employee leave requirements. But here’s the good news: This… Read More

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The Big Insurance Lie: Why your small business is probably overpaying for “peace of mind” (and how to stop)

Ed MacConnell

Let’s have a straight-talk conversation. If you are a small business owner, you’ve probably been told that the "safest" way to handle employee benefits is to sign up for a traditional, fully-insured plan from one of the big-name carriers, pay your monthly premium, and put the whole headache out of your mind. They call it "peace of mind." At Total Benefit Solutions Inc, we call it the "Big Insurance Lie." The truth is, many small businesses are overpaying for their health coverage by anywhere from 15% to a staggering 80%. When you consider that health insurance is often the second largest expense on a balance sheet after payroll, that "peace… Read More

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Medicare Secondary Payer Rules: A Quick-Start Guide for Employers with 65+ Staff

Ed MacConnell

As we move further into 2026, the landscape of the American workforce continues to shift. More than ever, we are seeing valued team members choose to work well past the traditional retirement age of 65. While having that experience and institutional knowledge on your team is a massive win for your business, it does introduce a specific layer of complexity regarding your employee benefits strategy. The biggest question we get here at Total Benefit Solutions Inc is often some variation of: "My top salesperson just turned 65. Do they have to go on Medicare, and who pays their medical bills first?" The answer lies within the Medicare Secondary Payer (MSP)… Read More

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HRAs Growing for Small Businesses

Lily Dalton

Health Reimbursement Arrangements (HRAs) are becoming an increasingly popular option for small businesses looking to provide affordable healthcare benefits. These employer-funded accounts allow companies to contribute tax-free dollars that employees can use to cover qualified medical expenses or purchase individual health insurance. There are several types of HRAs available, including the General HRA, which works alongside group insurance to cover out-of-pocket costs like co-pays, dental, and vision; the Individual Coverage HRA (ICHRA), which reimburses employees for insurance they purchase on their own; and the Qualified Small Employer HRA (QSEHRA), designed specifically for businesses with fewer than 50 employees that do not offer group plans. One of the main advantages of… Read More

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ACA Employer Mandate penalties are the highest ever

Ed MacConnell

ACA Employer Mandate penalties are the highest they have been since passage of the ACA. Here is a quick refresher for appliable large employers (or those close to hitting the 50 FTE threshold) on determining ALE status and tracking hours of its employees.

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Total Benefit Solutions #healthinsurance, #healthinsuranceNJ, #horizonbluecross, #IndividualMandate #healthinsurance, #medical #medicare #medicalplans #Medicaid #healplans #totalbenefitsolutions #employee benefits #healthinsurance, #aca, #aca, #obamacarealternatives, #cobra, #pennie, #getcoveredNJ, #medicareadvantage, #medicaresupplements, #totalbenefits #independence #bluecross, #aetna, #unitedhealthcare, #amerihealth, #nippon, #unitedconcordia, #horizon, #AmericanHealthInsurance, #aflac, #aetna, #ICHRA, #HRA, #healthreimbursement, #buckscounty, #healthinsurancenearme, #healthinusrancebuckscounty, #healthinsurancebuckscounty, #healthinsurancenearby, #healthonsurancephiladelphia, #healthinsuranceinPA, #healthinsuranceNJ, #PENNIE, #PENNIEHEALTHINSURANCE, #cobraalternatives, #turning26, #turning65, #adultinghealthinsurance, #healthinsurancenearme, #healthinsurancenearby, #healthinsurancefeasterville, #healthinsurancephilly, #bluecardppo, #minimumessentialplans, #minimumvalueplans, #shorttermhealthplan, #bluecross

Medicare Secondary Payer Rules: 7 Mistakes Employers Are Making (And the CMS Penalties You Can’t Ignore in 2026)

Ed MacConnell

If you're an employer with 20 or more employees, you need to understand Medicare Secondary Payer rules, because CMS isn't asking nicely anymore. 2026 is shaping up to be a major enforcement year. CMS is tightening scrutiny on employers who mess up Medicare coordination, and the penalties aren't slaps on the wrist. We're talking mandatory reimbursements to Medicare, civil money penalties, and potential lawsuits that can drain your budget faster than any premium increase. The problem? Most employers have no idea they're even at risk until CMS comes knocking. At Total Benefit Solutions, we fight these battles every day, pushing back when carriers get the rules wrong, advocating when employers… Read More

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Gag Clause Attestation Due December 31, 2025

Aris Herrera

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

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2026 Cost of Living Adjustments

Aris 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

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Trump Administration Issues Final Rule Impacting the ACA’s Marketplace

Loramei 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

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Discover key insights from the recent Medicare Advantage hearing!

Loramei 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

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Cigna Healthcare Medicare has officially rebranded to HealthSpring.

Loramei 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

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Attention: The coverage for OneTouch diabetic supplies ends August 3

Loramei 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

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