2023 RxDC Reporting Instructions Released

The Centers for Medicare and Medicaid Services (“CMS”) recently updated its Prescription Drugs Data Collection (“RxDC”) reporting instructions for 2023 data. There are some noticeable differences. As previously reported, group health plan sponsors (typically employers) are required to submit information to CMS on prescription drugs and health care spending on an annual basis (“RxDC reporting”). The first reporting deadline for calendar years 2020 and 2021 was December 27, 2022 (extended to January 31, 2023). The next deadline for reporting on calendar year 2023 is June 1, 2024, which, despite being a Saturday, is a firm date. It should be noted that carriers, pharmacy benefit managers (“PBMs”), and third-party administrators (“TPAs”)… Read More

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Medicare: Your Essential Guide

Understanding Medicare is crucial for making informed decisions about your healthcare coverage. Whether you choose Original Medicare or Medicare Advantage (Part C), knowing the basics empowers you to select the plan that best suits your needs. Original Medicare comprises Part A and Part B, covering hospital stays, doctor visits, and other essential services. Supplemental plans like Medicare Part D for prescription drugs and Medigap for additional coverage can enhance your benefits and reduce out-of-pocket expenses. Alternatively, Medicare Advantage plans offer a comprehensive alternative, bundling Parts A, B, and often D into a single package. These plans may extend coverage to dental, vision, and other services, providing a more holistic approach… Read More

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Navigating the Basics of Medicare: Understanding the Four Parts

Medicare, a vital healthcare program for seniors and certain disabled individuals, comprises four key parts. This post breaks down each part’s coverage, providing a concise overview for better understanding. Medicare Eligibility: Eligibility kicks in at age 65 or after receiving 24 months of Social Security Disability payments. Unlike private insurance, Medicare doesn’t have family plans, allowing individuals to make independent coverage choices. The Four Parts of Medicare: Visit the website for a deeper dive into the intricacies and benefits of Medicare. 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… Read More

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ACA’s Contraceptive Coverage: New FAQs Guide

On January 22, 2024, the Departments of Labor, Health and Human Services, and the Treasury released a fresh set of Frequently Asked Questions (FAQs), shedding light on the Affordable Care Act (ACA)’s imperative for non-grandfathered medical plans to include specific preventive services, notably contraceptives, without imposing any cost-sharing on individuals. The aim of these FAQs is to address concerns from stakeholders, facilitating a better understanding of the contraceptive coverage mandate and encouraging compliance through an alternative method. For detailed insights and further information, download the PDF below. We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated Total Benefit Solutions health insurance specialists at… Read More

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Horizon Members Get 15% Off YMCA Memberships!

Exciting news for Horizon members in New Jersey! We’re thrilled to share that you can now enjoy a 15 percent discount on monthly memberships at select New Jersey YMCAs. Plus, for new YMCA members, the initiation fee is completely waived when you present your Horizon member ID card. This fantastic offer is valid until December 31, 2024, providing you ample time to take advantage of the savings and embrace a healthier lifestyle. Whether you’re a fitness enthusiast or looking to kickstart your wellness journey, this exclusive discount is designed to make your YMCA experience even more accessible. Remember, this exclusive discount is a limited-time offer, so make the most of… Read More

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Aetna: Small Business Updates

As the year wraps up, businesses with 2 – 50 employees enrolled in Aetna Funding AdvantageSM groups need to act quickly. We’re filing 1095-B tax forms on your behalf, but it’s crucial to ensure your information is accurate. Deadline: End of December The federal deadline for 1095-B tax forms is approaching. Both businesses and customers must verify and update their details by the end of December to avoid potential IRS rejections. Why It Matters Accurate information on these forms is vital for complying with tax regulations. 1095-B forms provide essential health coverage details, impacting Affordable Care Act compliance. Any discrepancies could lead to filing complications. Review and update your information… Read More

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Case Study: A Voluntary Benefits Strategy

The Issue One of our clients approached us during a pre-renewal meeting to ask how they can further control costs without drastically impacting the well-being of their employees. Our Solution They already had done most of the things we had recommended in past years, but there was one area left that could help…voluntary benefits. We suggested they offer a portfolio of programs that included life and disability coverage, allowing them to reduce the scope of their “rich” company paid plans and enabling anyone interested to supplement the reduced benefits by purchasing the coverage on their own. This, we felt, was a great way to save premium dollars without creating too… Read More

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2023 State Health Insurance Mandates: A Quick Overview

Five states—California, Massachusetts, New Jersey, Rhode Island, and Vermont—along with the District of Columbia have implemented individual health insurance mandates, each with unique obligations. It’s crucial to understand and comply with both federal and state mandates for comprehensive adherence to regulations. State Obligations: These states require the submission of information on health insurance coverage to residents, with filings made to specific state agencies. Importantly, state requirements may differ from federal obligations, necessitating compliance with both sets of regulations. Key Deadlines for 2023 State Reporting: Note that state reporting deadlines may change, and the information presented is current as of the publication date. Stay updated for any changes. For a deeper… Read More

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Wellcare: Suspension of MAPD Plans in FL & NC

We need to inform you of a critical development affecting MAPD plans in Florida and North Carolina. Starting January 12, 2024, all enrollment and marketing activities for plans under Florida MAPD PPO Contract (H5199) and North Carolina MAPD PPO Contract (H7175) are temporarily halted. These contracts will not be renewed for Plan Year 2025 and will conclude on December 31, 2024. Key Points: Current members of these contracts’ plans DO NOT need to be transferred to alternate plans until the Annual Enrollment Period begins in October 2024. Existing members will stay enrolled in their plans for the entire Plan Year 2024. Uninterrupted access to full plan benefits continues throughout Plan… Read More

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Empire BCBS Now Anthem BCBS!

In a momentous move, Empire BlueCross BlueShield has officially transformed into Anthem Blue Cross and Blue Shield, marking a significant milestone for the renowned health insurance provider. The company is thrilled to announce the launch of Anthem Blue Cross and Blue Shield in both their downstate and upstate markets, reinforcing their commitment to enhancing the overall customer experience. The transition to the Anthem brand is not merely a change in name; it represents a strategic effort to simplify operations and reduce complexities in the market. Anthem is a nationally recognized name, offering a host of advantages for members residing out of state who are affiliated with New York-based companies. By… Read More

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IBC’s Latest Updates: Weight Loss Drug Policy

The International Benefits Consortium (IBC) has recently revamped its weight management medication coverage, responding to the FDA’s approval of Zepbound—a potent combination of GIP and GLP-1 receptors. This aligns Zepbound with existing options like Wegovy® and Saxenda® under IBC’s coverage criteria. Key Points: Weight Loss Drug Policy Update: IBC’s weight loss drug policy now includes Zepbound, showcasing their commitment to staying current with pharmaceutical advancements and ensuring robust coverage options for members. CAA Gag Clause Attestation: Addressing transparency concerns, IBC acknowledges the CAA’s impact on healthcare communication by eliminating “gag clauses” that restrict information exchange between providers and patients. Healthy You Program Options: IBC introduces new program options for self-funded… Read More

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Cigna Healthcare and Tower Health Contract Updates

In a recent development, Tower Health is no longer part of the network as of January 1, 2024. Negotiations for a contract extension are ongoing, but Tower Health has not committed to continuing collaboration. The main point of contention is significant rate increases demanded by Tower Health, which could lead to higher healthcare costs for clients and their members. To assist affected customers, the healthcare provider assures support in finding alternative, in-network providers nearby. One Guide representatives are available 24/7 at the number on Cigna ID cards or (800) 244-6224. Online tools on myCigna.com and the myCigna mobile app help locate in-network hospitals and providers. Members have been proactively notified… Read More

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Alert: Chicago Employers, Brace for Paid Leave Shifts in 2024

In a recent development, the Chicago City Council has made significant changes to the Paid Leave, Paid Sick, and Safe Leave Ordinance, pushing the effective date from December 31, 2023, to July 1, 2024. This delay provides employers with additional time to adapt to the impending modifications. Key amendments include a redefined “Covered Employee,” now requiring a minimum of 80 hours worked within any 120-day period in the city. Employers must communicate their time-off policies in writing, emphasizing clarity in the primary language of each Covered Employee. Medium-sized employers benefit from a partial payout period extension until July 1, 2025, allowing more time for adjustment. Additionally, irrespective of Covered Employee… Read More

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Case Study: Achieving Success Through Broker Change

In the dynamic landscape of employee benefits, staying complacent can hinder progress and cost an organization significant financial resource. At Total Benefit Solutions, we take pride in our proactive approach to addressing complex employee benefit challenges. In this blog post, we highlight a case study that exemplifies our commitment to providing innovative solutions and delivering tangible results for our clients. Broker Change Leads to Better Results The Challenge: A mid-sized group prospect approached us with a pressing issue – dissatisfaction with their current benefits broker. Faced with a 17% health insurance renewal, the client felt that their existing broker was not adequately exploring cost containment strategies. Seeking guidance, they turned… Read More

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House Passes Health Care Transparency Law

In a significant move towards increased transparency and cost reduction in the healthcare sector, the U.S. House of Representatives voted 320-71 to pass the Lower Costs, More Transparency Act on December 11, 2023. The bipartisan legislation aims to address the pressing issue of rising healthcare costs by implementing crucial changes, particularly affecting employers sponsoring group health plans. Transparency in Coverage Regulations The bill codifies existing transparency in coverage regulations, requiring the posting of machine-readable files (MRF) and making certain cost information available. Notably, changes include specific timing for posting the MRF, scheduled for the 10th day of each month. If enacted, this provision would come into effect for the first… Read More

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Decisions for someone who is nearing age 65

As you near age 65, you need to learn about Medicare coverage choices and make several important enrollment decisions. This fact sheet will give you a list of the steps you shouldtake and tell you about resources to help you make your Medicare enrollment decisions. There can be penalties if you do not enroll on time, so it is best to complete these tasksat least 3 months BEFORE you turn 65. Please note you can enroll on Medicare Parts A & B with Medicare about 90 days before your 65th birthday. IF YOU ARE STILL WORKING and your company has less than 20 employees you still MUST enroll on Medicare… Read More

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DOL Settlements Prompt Life Insurance Carriers to Adopt Claim Reforms

Recent settlements between the Department of Labor (DOL) and major life insurance carriers have brought attention to the denial of claims due to missing evidence of insurability (EOI). These agreements spotlight the potential liabilities faced by carriers and employers even after collecting employee premiums for coverage. Employers commonly offer basic life insurance coverage without charge, while employees can purchase additional coverage through payroll deductions. Approval for supplemental coverage often depends on carriers accepting evidence of insurability (EOI) submitted by the insured individual. DOL Investigations: The DOL’s investigations revealed that carriers, such as Prudential and United, consistently denied claims for missing EOIs despite collecting premiums. Employers, tasked with collecting EOIs and… Read More

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2024 Benefits Breakdown: Your Wallet Will Thank You!

As we step into the new year, the IRS has unveiled the much-anticipated cost of living adjustments for 2024 under various provisions of the Internal Revenue Code. These adjustments bring changes that may impact your employee benefit plans. Let’s delve into some key areas affected by these adjustments. Cafeteria Plans – Health Flexible Spending Arrangements: For plan years beginning in 2024, the annual contribution limitation under Code Section 125(i) for voluntary employee salary reductions to health flexible spending arrangements (health FSAs) has increased to $3,200 from $3,050. Additionally, for plans allowing the carryover option, the maximum unused amount from a health FSA plan year that begins in 2024 and can… Read More

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Massachusetts Paid Family and Medical Leave Updates for 2024

The Massachusetts Department of Family and Medical Leave (DFML) has announced significant changes to the Massachusetts Paid Family and Medical Leave (PFML) program, effective January 1, 2024. These updates include adjustments to the contribution rate, State Average Weekly Wage, and maximum weekly benefit amount. Employees can also supplement their PFML benefits with accrued paid leave, beginning on November 1, 2023. Contribution Rate Changes In 2024, the contribution rate on eligible wages will increase from 0.63% in 2023 to 0.88%. Individual contributions are capped by the Social Security income limit, which is expected to rise significantly. Employer and Employee Contributions Employers with a minimum of 25 covered individuals in Massachusetts will… Read More

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Open Enrollment 2023: Key Reminders and Deadline

Are you ready for Open Enrollment? If not, don’t worry – we’ve got you covered with all the key information you need to make the most of this opportunity to secure health coverage for you and your loved ones. Open Enrollment for 2023 is just around the corner, beginning on November 1. However, it’s crucial to mark your calendars with the DEADLINE REMINDER: December 15th is the last day to enroll for coverage that kicks in on January 1st. For current Pennie customers, here are some important reminders: For those who are potential Pennie customers, here’s what you need to know: Why choose Pennie for your health coverage? Pennie offers… Read More

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Updated No Surprises Act and IDR Guidance

Recent developments in healthcare legislation have brought changes to the No Surprises Act’s independent dispute resolution (IDR) process. Issued by the Departments of Labor, the Treasury, and Health and Human Services (HHS), FAQ Part 62 provides essential updates regarding the qualifying payment amount (QPA) calculation methodology and the disclosure requirements for out-of-network (OON) air ambulance services. Moreover, the federal IDR portal has reopened, streamlining the resolution of billing disputes. The No Surprises Act Overview The No Surprises Act, a part of the Consolidated Appropriations Act, 2021, aims to protect patients from surprise medical bills. It places limits on out-of-network cost-sharing and bans balance billing in various situations, such as emergency… Read More

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New Federal Rules: HHS 2023 Penalty Hike

In the world of healthcare compliance, staying up to date with federal regulations and guidelines is crucial to avoid costly penalties. One such regulation that affects healthcare providers and group health plans is the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015, commonly known as the “Inflation Adjustment Act.” This act directs federal agencies to adjust civil monetary penalties to account for inflation. In a recent development, the Department of Health and Human Services (HHS) issued final rules on October 6, 2023, updating the civil monetary penalties for inflation. Understanding the Updated Penalties The adjusted penalties are applicable to penalties assessed on or after October 6, 2023. It’s… Read More

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Affordable Dental Insurance: A Key Player in Oral Health

Dental health is a crucial aspect of overall well-being, and a recent survey has shed light on the satisfaction levels of Americans with their dental insurance plans. The results, published in a press release by AHIP (America’s Health Insurance Plans) on September 26, 2023, provide an insightful perspective on the state of dental insurance in the United States. The survey, conducted by Global Strategy Group (GSG) on behalf of AHIP, focused on individuals who have dental insurance and have visited dental specialists, including dentists, oral surgeons, and orthodontists, in the past year. The findings from the survey paint a positive picture of Americans’ experiences with their dental insurance plans. Key… Read More

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Financial Support Soars for Mental Health Integration

Mental health is an essential component of overall well-being, and every American deserves access to quality mental health and substance use disorder treatment. Access to mental health care can be a transformative step in managing and coping with mental health concerns, allowing individuals to lead more fulfilling lives. This article explores the importance of integrating mental health services into other care settings and highlights the Collaborative Care Model (CoCM) as a promising approach to enhance access to mental health care. Expanding Access Through Integration Integrating mental health into broader healthcare settings is a pivotal strategy to increase accessibility and support for patients. The Collaborative Care Model, often abbreviated as CoCM,… Read More

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2023 Rule Alert: How Will It Affect Fixed Indemnity Plans?

In today’s world, the rising costs of healthcare have left many Americans grappling with the financial burden of medical expenses. While comprehensive health insurance is essential, fixed indemnity health insurance has emerged as a valuable supplemental resource, offering financial protection to individuals when they need it the most. This blog explores the concept of fixed indemnity health insurance and its importance in providing financial peace of mind to Americans. Fixed Indemnity Insurance: This supplemental insurance differs from major medical plans. It pays a fixed sum directly to you when specific medical events, like doctor visits or hospital stays, occur. While it doesn’t cover all the essential health benefits mandated by… Read More

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