Medicare – Total Benefit Solutions Inc

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

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

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

How will Aetna’s departure affect ACA exchanges?

May 19, 2025Loramei Romeo

Aetna’s decision to withdraw from the Affordable Care Act (ACA) marketplaces in 17 states by the end of 2025 raises questions about the stability and future of these exchanges. While it’s uncertain if other carriers will follow Aetna’s lead, the history of the ACA marketplace has been marked by a dynamic pattern of exits and entries. We understand that navigating the ever-changing regulations and economic challenges can be daunting for consumers seeking health insurance. The future of health insurance exchanges is uncertain, which is why it’s crucial to emphasize policy stability and market adaptability. The ACA exchanges play a vital role in providing access to health insurance, but they do… Read More

Stretching Your Healthcare Dollars

April 2, 2025April 3, 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.

Compliance Checklist for Calendar Year 2025

March 26, 2025March 25, 2025Loramei Romeo

The calendar year 2025 has released its deadline for small groups (less than 50), some deadlines may change depending on the plan start date that is not January 1st. The calendar shows the Section 6055/6056 filing deadline to the dates with Medicare part d notice. Have Questions? and want to read more about the changes click Calendar Year Compliance Checklist for more details. 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.

Kroger pharmacy is back in MA and PDP network

February 28, 2025February 28, 2025Loramei Romeo

Kroger and affiliated pharmacies have rejoined Medicare Advantage (MA) and Prescription Drug Plan (PDP) network which are effective on February 5, 2025. Kroger is included in the network for all our PDP plans, such as Saver Rx, Extra Rx, and Assurance Rx. Starting February 5, 2025, all claims from Kroger pharmacies will be processed as in-network. Claims made before this date will not be reimbursed. Below is a list of Kroger and its affiliated pharmacies that are now in our MA and PDP network. Bakers Pharmacy Dillon Pharmacy Gene Maddy Kroger Owen’s Pharmacy QFC Pharmacy City Market Fred Meyer Pharmacy Gerbes Pharmacy Mariano’s Pharmacy Payless Pharmacy Ralphs Pharmacy Copps Food… Read More

Premium Only Plan Document (POP) Section 125

February 7, 2025February 6, 2025Loramei Romeo

What is a Section 125 Premium Only Plan?The Revenue Act of 1978 introduce IRS Section 125, which allows employers to reduce payroll taxes by adjusting the payroll process. Also, Section 125 Premium Only Plan employees can choose from pre-tax or tax-free basis pay for their portion of premium insurance rather than after-tax basis, which creates saving for both the employer and employee. How Employees Benefit from a Premium Only Plan.Section 125 premium deductions can save employees 20 or 40% of their pre-tax. The tax savings are on city, state, and federal income taxes, including Social Security and Medicare taxes on money used to pay for their portion of insurance premiums… Read More

Individual Coverage HRA: Choice and affordability

February 4, 2025January 31, 2025Loramei Romeo

QSE-HRA or Qualified Small Employer HRA Companies with fewer than 50 employees are qualified for $199 small employer HRA plan document a group health insurance alternative. What is QSE-HRA? To establish a QSE-HRA for qualified groups with less than 50 employees offering no group health plan the plan documents are available for $199 in Basic PDF email version. Qualified Small Employers can offer Health Reimbursement Arrangement (HRA) if they do not offer a group health plan, HRA uses tax-free dollars to reimburse employees who individual health plans. Employers cannot offer another group health plan to qualify QSE-HRA, which includes any other HRA, Health Care Flexible Spending Accounts (FSA), Limited Health… Read More

Reminder for Medicare Part D CMS

January 28, 2025January 28, 2025Loramei Romeo

Employers who sponsoring a group health plan, whether they are self-insured or insured, are required to notify the Centers for Medicare and Medicaid Services (CMS) of the creditable (or non-creditable) status of the plan’s prescription drug coverage. Employers must go to CMS’s online reporting system at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/CreditableCoverage/CCDisclosureForm.html. to provide this information. Just a friendly reminder that notice needs to be given by the following dates: • Within 30 days following the prescription drug plan’s termination. • Within 60 days following the start of each plan year. • Within 30 days following any modification to the prescription drug plan’s creditable coverage status. If an employer-sponsored prescription drug plan’s creditable coverage status changes… Read More

Horizon and Braven Health Prescription Drug Benefits

January 27, 2025January 27, 2025Loramei Romeo

IMPORTANT NOTICE: Horizon and Braven Health Prescription Drug Benefits GLP-1 medications like Ozempic and Mounjaro are covered by the prescription drug benefits of Horizon Medicare Blue Rx (PDP) and Braven Health Medicare Advantage plans. GLP-1 medications are used to treat obesity and type 2 diabetes. Medicare, however, only covers these medications for diabetes. Prior authorization is also required for GLP-1 medications. This implies that before we agree to cover the medication, the member or their practitioner must obtain plan approval. To guarantee pharmaceutical safety and assist in directing the proper use of specific medications, prior permission is implemented. The medication may not be covered by the plan if the member DOES… Read More

Federal Poverty Guidelines Announced for 2025

January 24, 2025January 24, 2025Loramei Romeo

The 2025 federal poverty guidelines were recently released by the Department of Health & Human Services (HHS), they provide the federal poverty level (FPL) affordability safe harbor for the purposes of the employer mandate under the Affordable Care Act (ACA). The 2025 FPL safe harbor is $117.63/month in the lower 48 states and DC, $146.95/month in Alaska, and $135.22/month in Hawaii for plan years starting on February 1, 2025, or later. To qualify for the FPL affordability safe harbor, a plan may employ poverty rules that are in force six months prior to the start of the plan year. The lower 48 states and DC utilize $113.20/month for plans with… Read More

Important Update Regarding the Distribution of Form 1095-B for Tax Year 2024

January 24, 2025January 24, 2025Loramei Romeo

Horizon BCBSNJ is constantly searching for methods to make working with us more convenient and easier. For this reason, Horizon has modified the way they provide Form 1095-B to their members who are fully insured this year. What is Form 1095-B?The names, residences, Social Security numbers, and number of months that each member of a fully insured health plan was covered from January 1 to December 31 of each calendar year are reported on Form 1095-B. Form 1095-B is explained in greater detail here. How Is Distribution Changing This Year? In previous years, Form 1095-B was sent by mail to all subscribers enrolled in a Horizon fully insured plan. However,… Read More

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

CIGNA PDP: New customer onboarding program

December 20, 2024December 20, 2024Ed MacConnell

Learn how our onboarding program supports our new customers. At Cigna HealthcareSM, we understand that nurturing strong relationships with your existing customers is not only vital for your business growth, but it is often easier than acquiring new clients.That’s why we’ve developed a comprehensive new customer onboarding program designed to support our customers and your retention goals. As you can see from the below activities, we are taking several steps to ensure our customers feel valued and well taken care of as they transition to one of our Medicare Advantage (MA) plans. New customer onboarding program Welcome calls Cigna Healthcare calls new customers to review benefits and ensure they have… 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

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

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.

December and January renewals deadlines

November 11, 2024November 11, 2024Loramei Romeo

Clients renewing in December, November 12 is the deadline to complete the enrollments, after this the enrollment will still be accepted but there will be delays with the member ID cards. Which includes small and large groups whether they are fully insured, self-funded clients, with both active and passive renewals. When enrolling later than November 12 after receiving completed enrollment the ID cards will be mailed after ten business days. To access new member ID number online it will take six business days after receiving complete enrollment. Clients renewing in January, Because of the anticipated volume of enrollment changes and new enrollments which adds additional processing time the deadline is… Read More

Departments Issue Final MHPAEA Regulations

October 11, 2024October 11, 2024Mirasol Bandong

The final rules for the Mental Health Parity and Addiction Equity of 2008 (MHPAEA) were released on September 9, 2024, by the Department of Health and Human Services, Labor, and the Treasury in order to guarantee that those seeking treatment for mental health (MH) or substance use disorder (SUD). MHPAEA provides nonquantitative treatment limitations (NQTLs) cannot be applied to MH/SUD unless they are equivalent and applied no more strictly for MH/SUD benefits than for medical/surgical benefits. The final rules amend the definitions of definition of “medical/surgical”, “mental health benefits”, and “substance use disorder benefits” by removing a reference to the state guidelines. The most recent edition of the Diagnostic and Statistical… Read More

New Medicare Part-D Changes Affecting Employers for 2024-25

September 13, 2024September 13, 2024Mirasol Bandong

Dear Valued Client: We wanted to alert you to an upcoming change that could have a significant impact on Medicare-eligible employees and dependents who currently have group health coverage. Starting in 2025, Medicare Part D plans will have a $2,000 out-of-pocket limit. As CMS explains, this change, which is part of the Inflation Reduction Act, also includes measures like a $35 cap on insulin and new authority for Medicare to negotiate prices for certain high-cost drugs. The new $2,000 cap for Part D is particularly important because it could alter the status of many employer group health plans that currently provide drug coverage. Each year, employers must determine whether their prescription drug… Read More

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