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

Why Minimum Value Plans are a Game Changer for Home Health Agencies

Ed MacConnell

For home health agencies (HHAs) across the United States, the business landscape has never been more challenging. Between shifting Medicare reimbursement models, a persistent shortage of skilled nursing talent, and the ever-present pressure of the Affordable Care Act (ACA) mandates, many agency owners feel like they are being squeezed from every direction. At Total Benefit Solutions Inc, we spend a significant amount of time speaking with agency owners who are struggling to find a balance. They want to provide quality benefits to attract and retain caregivers, but they also need to maintain a bottom line that allows the agency to stay operational. The margins in home health are notoriously thin,… 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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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

MVP vs. MEC: The Compliance Difference That Could Cost You Thousands

Ed MacConnell

If you’ve been following our blog recently, you know we’ve been diving deep into the world of Minimum Value Plans (MVP). We’ve talked about compliance and why your plan needs to actually meet these standards. But here is where things usually get messy for HR managers and business owners: the alphabet soup of the ACA. Specifically, the difference between MEC (Minimum Essential Coverage) and MVP (Minimum Value Plan). To the untrained eye, they sound like the same thing. They both start with "Minimum," they both deal with health insurance, and they both keep the IRS off your back, right? Not exactly. Confusing these two isn't just a minor clerical error;… 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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A new Special Enrollment Period has been created allowing select beneficiaries in Pennsylvania to shop for coverage until April 30

Lily Dalton

A new Special Enrollment Period (SEP) has been opened for certain Pennsylvania UnitedHealthcare Medicare Advantage beneficiaries, allowing them to shop for new coverage through April 30 due to a contract dispute with Lehigh Valley Health Network that eliminated in-network access for affected members as of January 26, 2026. This SEP is separate from the standard Medicare Advantage Open Enrollment Period, which ends March 31. Last week, the Shapiro Administration announced an SEP for UnitedHealthcare Medicare Advantage beneficiaries using Lehigh Valley Health Network Providers. This SEP is a result of contract disputes between Lehigh Valley Health Network and UnitedHealthcare. As of January 26, 2026, over 5,400 UnitedHealthcare Medicare Advantage members lost in-network access… 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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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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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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Exiting news! Prior authorization reforms are set to simplify health insurance.

Loramei 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

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How will Aetna’s departure affect ACA exchanges?

Loramei 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

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Reminder for Medicare Part D CMS

Loramei 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

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WellSpan part ways with United Healthcare’s commercial network

Loramei 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

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WELLSPAN CONTINUES TO BE IN NETWORK WITH UHC!

Loramei 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.

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Departments Issue Final MHPAEA Regulations

Mirasol 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

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

Mirasol 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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2025 Part D Changes and Employer Sponsored Group Health Plans

Mirasol Bandong

Employers must inform the Centers for Medicare and Medicaid Services (“CMS”) and participants and beneficiaries who qualify for Medicare Part D of the creditable or non-creditable status of the group health plan prescription drug plan(s). When prescription medication coverage meets or exceeds Medicare Part D, it is considered creditable. Any coverage that falls short of Medicare Part D’s quality standards is deemed non-creditable As previously reported, the Inflation Reduction Act of 2022 (“IRA”) changed aspects of the Medicare Part D program to enhance and improve Medicare Part D coverage. The changes include: As a result of these changes, some employer sponsored prescription drug coverage may no longer qualify as creditable… Read More

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Wellcare PDP Plans: Contract Termination: Important Change!!

Ed MacConnell

Total Benefit Solutions, Inc has been notified by Wellcare PDP plans that our contract is being terminated without cause beginning immediately. Due to the changes in coverage mandated by the Inflation Reduction Act, Wellcare is terminating our agreement for the purposes of not paying bew or renewal business commissions. What does that mean for our clients?Beginning immediately, we will no longer be able to enroll new customers onto Wellcare PDP plans. Further moving forward, we will be unable to provide service to our existing clients already on Wellcare or who choose to renew with a Wellcare PDP plan for 2025. Our experts are standing by to answer your questions or… Read More

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Disaster Special Election Periods in several states

Mirasol Bandong

This is an important announcement for customers in Arizona, California, Florida, Iowa, Kansas, Maryland, Minnesota, New Mexico, North Carolina, Oregon, Texas and West Virginia 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… Read More

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Medicare Part D’s new $2,000 annual cap on out-of-pocket prescription costs.

Mirasol Bandong

There are significant changes coming to Medicare Part D plans in 2025. In 2024 once your out-of-pocket spending on prescriptions tops about $3,300, you qualify for Medicare’s “catastrophic coverage” and pay nothing for your covered Part D drugs for the rest of the year. (In 2023, once you hit catastrophic coverage, you still owed 5% of your drug costs.) But come 2025, people with Part D plans won’t have to pay more than $2,000 in out-of-pocket costs, thanks to a provision in the Inflation Reduction Act of 2022.  This new rule applies only to medications covered by your Part D plan, though, and does not apply to out-of-pocket spending on… Read More

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Special Enrollment Period Extended: Florida Emergency Declaration – Hurricane Idalia

Mirasol 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

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