Author: Ed MacConnell

Beginning January 1, 2027, Nationwide is changing the company that administers pharmacy benefits for its employer groups: pharmacy benefit administration will move from Cigna to Express Scripts Pharmacy Benefit Services, Evernorth Health Services’ pharmacy benefit services business. The change affects pharmacy benefits only; medical and all other benefits under affected employer-sponsored health plans remain unchanged. A pharmacy benefit administrator runs the prescription drug side of a health plan. This can include the pharmacy ID card, the formulary (the list of covered prescription drugs), copays (the amounts members pay for prescriptions), and the pharmacy network (the pharmacies that participate in the plan). Evernorth is Cigna’s health services division, so Express Scripts… Read More

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Total Benefit Solutions now represents the AmeriBenefit Plan Association (ABP), a non-profit association serving small businesses, self-employed professionals, independent contractors and entrepreneurs nationwide since 1994. For you, that means a new opportunity to explore big-group benefits without having to be a big company. Why association benefits may matter to you Running a small business or working for yourself can mean handling everything from finding customers to managing expenses. Health coverage and retirement planning are part of that picture, too, but individual professionals and small teams may not have the same group buying power as a large employer. ABP brings members together through one association. Its membership provides access to benefit… Read More

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Certain GLP-1 weight-management drugs are now available to eligible people with Medicare for $50 per one-month supply through the Medicare GLP-1 Bridge. This temporary, nationwide program runs from July 1, 2026, through December 31, 2027, and covers Foundayo tablets, Wegovy injections or tablets, and Zepbound KwikPen only. The Bridge is a separate CMS program, not regular Medicare Part D drug coverage. That distinction matters: the $50 copay has different cost rules from the amounts you normally pay through your Part D plan. Here’s what you need to know about eligibility, costs, and how to get started. Who may qualify for the Medicare GLP-1 Bridge? You must meet one of the… Read More

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If you use Grand View Hospital, check its status under your 2027 Medicare Advantage plan before choosing coverage for next year. According to a recent Jefferson Health Plans provider network update, Grand View Hospital, now part of St. Luke’s University Health Network, will no longer participate in the Jefferson Health Plans Medicare Advantage network effective January 1, 2027. There is reassuring news, too: Chestnut Hill Hospital, part of Temple Health, remains in network for Jefferson Health Plans Medicare Advantage plans. Temple Health has also announced its agreement with Jefferson Health Plans to continue participation. Why this update matters during Medicare Annual Enrollment Medicare Annual Enrollment runs October 15 through December… Read More

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The Social Security Administration announced a 3.6% cost-of-living adjustment (COLA) for 2027 on October 14, 2026. The increase will raise Social Security benefits, but the amount that lands in your pocket can also depend on Medicare Part B premiums and, for some people, an income-related surcharge. That’s why it helps to look beyond the percentage. Your COLA may increase your Social Security benefit, while Medicare costs may also change, and the timing and rules for those changes are not the same. What the COLA means for your monthly check A COLA adjusts Social Security benefits to account for changes in living costs. The announced 3.6% adjustment applies to Social Security… Read More

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The 2027 standard Part D deductible is $700, up from $615 in 2026. That’s one reason to take a fresh look at your prescription coverage instead of letting your current plan renew without comparing it with next year’s options. Medicare Open Enrollment runs October 15 through December 7, 2026. This is your opportunity to review coverage for 2027. It is different from the Medicare Advantage Open Enrollment Period, which runs January 1 through March 31; that is a separate period for people enrolled in Medicare Advantage to review their options under that period’s rules. Three 2027 numbers to know These figures describe the standard Part D benefit and premium benchmark.… Read More

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If you run a business by yourself or with one other person, you may have been told that group health coverage is out of reach because you do not have a conventional employee group. A small group with only an owner can be difficult for insurers to handle as a group plan: there is no broader workforce to spread participation across, and the rules may not require an insurer to offer a one-person plan outside an eligible association. Arizona has now created a clearer legal route for some owners to seek coverage through an association. What Arizona changed Arizona House Bill 2693, titled “insurance; bona fide associations; qualifications,” amends Arizona… Read More

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The fourth quarter is when your benefits calendar becomes crowded. Open enrollment is underway, new hires are being onboarded, plan years are renewing, and Form 5500 season and the calendar-year wrap-up are ahead. Before you close out 2026, check one document that is often missing from an otherwise complete benefits file: the ERISA Summary Plan Description (SPD). Your health insurance carrier’s booklet, Certificate of Coverage, or Summary of Benefits and Coverage (SBC) may explain the coverage. However, those materials generally do not satisfy the employer’s ERISA Summary Plan Description requirement by themselves. A Wrap SPD is the document that closes that gap. The year-end question: Do you have an ERISA… Read More

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A $0-premium Medicare Advantage plan can look appealing at first glance. You may see no monthly plan premium and assume your costs will be minimal. But the premium is only one part of the financial picture. The number you should read just as carefully is the plan’s maximum out-of-pocket limit (MOOP). The most you may have to pay for covered services under the plan during the year. For contract year 2027, the maximum in-network MOOP limit Medicare Advantage plans may charge is $8,850. Plans may set a lower limit, and many do. The important point is that a $0 premium does not mean $0 cost sharing. What the $8,850 maximum… Read More

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The IRS has published the ACA affordability percentage for plan years beginning in 2027: 10.22%. That is up from 9.96% for 2026, according to IRS Revenue Procedure 2026-26. The percentage has moved higher in recent years, and this latest increase matters immediately if you are in the middle of a 2027 renewal. The practical question is not simply whether your carrier’s renewal rate increased. It is whether the contribution you are asking employees to pay still passes the affordability test after the new premium and contribution structure are applied. The 2027 number applies based on your plan year The 10.22% affordability percentage applies to plan years beginning in calendar year… Read More

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Open enrollment is only weeks away, and the 2027 Health Savings Account (HSA) limits are already published. If your employee communications still show last year’s figures, now is the time to update them. The Internal Revenue Service published the 2027 amounts in Revenue Procedure 2026-24. These figures affect your plan design, employer contribution strategy, payroll communications, and the way employees evaluate their health coverage. For small and midsized employers, an HSA-eligible plan can be a valuable benefits tool. But the plan must meet specific requirements, and employees need clear education to understand how the account works. The 2027 HSA limits at a glance For calendar year 2027, the annual HSA… Read More

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As fall scheduling decisions approach, you may be looking for ways to control overtime exposure, manage labor costs, or adjust staffing around seasonal demand. That is a reasonable business exercise. But when you reduce an employee’s hours, you may also move that person across an important health benefits threshold. The result can be a 30-hour cliff: a point at which a scheduling change affects not only payroll, but also health plan eligibility, ACA obligations, employee communications, and workforce trust. The conversation is receiving additional attention because of the pending proposed Thirty-Two Hour Workweek Act. That proposal is not law, and you should not base your current benefits strategy on its… Read More

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If you’re a small or mid-sized business owner, you’ve probably already started thinking about 2027 renewals. Premium pressure is still real, employee expectations are not getting any lower, and plan design decisions now can affect recruiting, retention, and compliance later. That is exactly why Minimum Value matters. This is not just an Insurance 101 concept. For employers, especially those near the 50 full-time equivalent (FTE) line, Minimum Value is a practical benchmark for building coverage that is both defensible and useful. At Total Benefit Solutions Inc, we help employers compare options with an advocate’s eye, not just a quoting spreadsheet. We do not work for one carrier. We work for… Read More

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If you employ 50 or more people in New Jersey, a new state Medicaid fee needs to be part of your 2027 budget planning now. Under New Jersey P.L. 2026, c.23 (A5324/S4533), the state imposed an annual fee on employers connected to employees and dependents enrolled in the state Medicaid program. The fee is assessed per enrolled person, not only per employee. The law took effect July 1, 2026. The first employer notification is due by March 1, 2027, and payments are due by April 15, 2027. That timing makes this a 2027 planning issue today. It should not be left in a file labeled “review next spring.” What the… Read More

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If your group health plan renews on January 1, 2027, your renewal season is already underway. The most important decisions are typically made between September and November 2026, not in December when paperwork is due. Unlike individual ACA coverage, group health insurance does not have one national open enrollment period. Your group plan follows its plan year and renewal date (the anniversary date when your current coverage renews). That gives you flexibility, but it also means you are responsible for starting the process early enough to compare options, negotiate pricing, communicate changes, and complete compliance work. At Total Benefit Solutions, we help business owners shop and compare plans, evaluate funding… Read More

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If your company sponsors a group health plan with prescription drug coverage, October 15 is a deadline you cannot treat as an administrative formality. Each year, employers must provide Medicare Part D creditable or non-creditable coverage notices to Medicare-eligible individuals covered by the plan before Medicare’s Annual Enrollment Period. The notice tells employees and their covered family members whether the employer’s prescription drug coverage is expected to pay at least as much as standard Medicare Part D coverage. The 2026 notice deadline is October 15. At the same time, employers need to prepare for an important 2027 change: CMS has retired the legacy 2009 Simplified Determination Method for plan years… Read More

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Pennsylvania regulators approved an average 15.97% increase for 2027 individual-market health insurance plans, including coverage purchased through Pennie. Small businesses will see an average approved increase of 10.28% in the small-group market. The Pennsylvania Insurance Department (PID) finalized the rates on September 18, 2026. The new rates take effect January 1, 2027. These are serious increases, but the averages are not predictions of what any one person or business will pay. Your actual premium may change by a very different amount depending on your plan, carrier, region, age, location, household income, family size, and market competition. The approved increases are lower than insurers requested For the individual market, insurers initially… Read More

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If you receive health coverage through Pennie and are lawfully present in the United States, you may receive an important notice about your 2027 financial assistance. Due to a new federal law, several categories of lawfully present immigrants will no longer qualify for federal premium tax credits beginning January 1, 2027. This is a significant change, but it is important to understand exactly what it means: the change concerns financial assistance for health coverage, not necessarily your ability to enroll in a Pennie plan. People who no longer qualify for premium tax credits may still have the option to enroll by paying the full price of coverage. Pennie has begun… Read More

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If you have Medicare, the decisions you make during the 2026 Annual Election Period (AEP) can determine how your coverage works throughout 2027. The AEP runs from October 15 through December 7, 2026. Any change you make during this window generally takes effect on January 1, 2027 (your plan must receive your enrollment request by December 7). This year, reviewing your coverage is especially important because Medicare beneficiaries may see changes to prescription drug plans, negotiated drug prices, premiums, formularies, and access to certain GLP-1 medications. At Total Benefit Solutions, we help you review your options, compare plans, understand the fine print, and advocate for the benefits you are entitled… Read More

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If you manage employee benefits for a small to medium-sized business, you are likely all too familiar with the relentless pressure of rising healthcare costs. Traditional group health plans often force employers into a difficult corner: either absorb double-digit premium hikes or shift more financial burden onto your employees through higher deductibles and copays. Fortunately, innovative financing models combined with breakthrough supplementary coverage programs are changing the game. By integrating zero copay coverage into level-funded group health plans, you can dramatically lower out-of-pocket costs for your workforce while protecting your bottom line. At Total Benefit Solutions Inc., we specialize in helping businesses navigate complex insurance structures. As independent advocates, we… Read More

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A new proposal in Congress could change how many employers schedule and compensate hourly workers. The Thirty-Two Hour Workweek Act, introduced this week by Senator Bernie Sanders (I-VT) and Representative Mark Takano (D-CA), would gradually lower the federal overtime threshold from 40 hours to 32 hours. The proposal has received attention because supporters argue that employees should share in productivity gains from artificial intelligence, automation, and other technology. Opponents, including Senator Bill Cassidy, have warned that the change could increase labor costs, raise prices, reduce hiring, and encourage offshoring. For small and midsized employers, however, the most overlooked issue may not be the schedule. It may be the impact on… Read More

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As a growing business owner or HR leader, offering competitive employee health benefits is vital for talent attraction and retention. But when your workforce expands across state lines, or when key employees frequently travel for client meetings, traditional regional health plans quickly become a administrative headache. If your company sponsors a Preferred Provider Organization (PPO) plan through a Blue Cross Blue Shield (BCBS) affiliate (such as Anthem, Highmark, or Horizon), you likely have access to one of the most powerful network tools in the industry: the BlueCard PPO program. Yet, despite its prevalence, many employers and employees do not fully understand how nationwide network access actually works behind the scenes.… Read More

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If you are a business owner or an HR manager, you probably think you’re doing everything right. You pay your premiums on time, you distribute those glossy insurance carrier booklets to your employees, and you keep your records organized. But there is a hidden compliance trap lurking in your filing cabinet, one that could cost your company $110 per day, per participant. This isn't just a hypothetical scenario; it’s a federal requirement under ERISA (the Employee Retirement Income Security Act of 1974). Many employers mistakenly believe that the "Certificate of Insurance" or the "Summary of Benefits and Coverage" (SBC) provided by their insurance carrier satisfies their legal obligation to provide… Read More

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You may hear the words referral, preauthorization, prior authorization, precertification, and preapproval when arranging medical care. Because these terms sound similar, it is easy to assume they mean the same thing. They do not. A referral generally determines whether your primary care provider (PCP) has directed you to see another doctor or specialist. A preauthorization determines whether your health insurance company must approve a specific service, procedure, medication, or piece of medical equipment before you receive it. Depending on your plan and the care you need, you may require one, the other, or both. Missing a required referral or preauthorization can result in a denied claim, delayed treatment, or a… Read More

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Timely update (September 3, 2026): Employers may now hear the term CHOICE Arrangement instead of ICHRA. CMS and the SBA rebranded ICHRA as the Custom Health Option and Individual Care Expense Arrangement (CHOICE Arrangement), but the benefit itself has not changed. All existing rules, compliance standards, and reimbursement mechanics remain the same. Designing a competitive and sustainable employee benefits package is one of the most critical financial and operational decisions you will make as a business owner or human resources leader. For decades, the default choice for small and medium-sized businesses (SMBs) was a traditional group health insurance plan. However, rising premium costs and diverse workforce demographics have sparked a… Read More

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