Consumer Driven Health Plans – Total Benefit Solutions Inc

Highmark – Important Update Regarding Plan Availability on External Enrollment Platforms

August 29, 2025August 29, 2025Ed MacConnell

At Highmark, we value the trust you place in us and are committed to providing timely and transparent information. As we look ahead to 2026, we want to inform you that we are adjusting plan availability on external quoting and enrollment platforms. This decision has been carefully considered to ensure that our broker partners are prioritizing plans that offer a long-tenure with Highmark. Further details regarding our 2026 plan offerings will be shared as we approach AEP. 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… 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

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

Big changes to Medigap plans start January 1, 2026!

June 12, 2025June 18, 2025Loramei Romeo

Attention to all current Medigap groups: As of July 1, 2025, new enrollments for MedigapSecurity and 65 Special products will no longer be accepted. It is crucial for future retirees to be aware that they will need to transition to a MedigapFreedom product. As we approach 2026, it’s essential for businesses and retirees to understand the upcoming changes to Medigap enrollment. If your Medigap group renewal dates fall between January 1 and June 1, 2025, you can continue enrolling future retirees into MedigapSecurity or 65 Special throughout 2025. However, starting January 1, 2026, any future retiree from an existing group will need to select from the MedigapFreedom products. As we… Read More

The 2025 PCORI Fee is on the horizon!

June 10, 2025July 21, 2025Loramei Romeo

The recent reauthorization of PCORI fees by the Federal Government will continue to support the Patient-Centered Outcomes Research Institute through 2029. These fees play a crucial role in funding vital health research, which helps inform healthcare decisions and improve patient outcomes. As a reminder, the fee associated with your health plan is due by July 21, 2025. This deadline is crucial as it follows the calendar year immediately after the end of the applicable plan year. Staying compliant with these deadlines is essential for effective health insurance management. For plan years ending on or after October 1, 2023, and before October 1, 2024, the fee will be $3.22 multiplied by… Read More

Zepbound coverage for obstructive sleep apnea ends August 1 for current prescriptions.

June 6, 2025June 4, 2025Loramei Romeo

As part of ongoing adjustments in health insurance coverage, we want to inform that starting August 1, 2025, Independence Edge will remove Zepbound from the Select/Value formularies for treating obstructive sleep apnea for those with existing prescriptions. This change is already in effect for new prescriptions as of May 1, 2025. The decision to terminate Zepbound coverage for OSA treatment was made based on the fact that there are no clinical studies to prove that the drug treats OSA through any other mechanism and its benefit is limited to only weight loss. From August 1, those who continue Zepbound will bear the full cost, although it may be Health Savings… Read More

Tax Favored Accounts Summary Page

June 5, 2025May 23, 2025Loramei Romeo

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

IRS just announced the 2026 Health Savings Account Contribution Limits

May 12, 2025May 7, 2025Loramei Romeo

As we look ahead to 2026, it’s important to understand the new contribution limits for health plans. The self-only contribution limit has increased to $4,400, while the family limit is now $8,750. Additionally, the annual deductible for high-deductible health plans has also seen increases, with self-only coverage now requiring a deductible of at least $1,700 and family coverage at $3,400. Staying informed about these changes is crucial for optimizing employee benefits and promoting financial well-being. How is your organization adapting to these new health plan regulations? 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… Read More

ACA Individual Market Highmark

May 8, 2025May 6, 2025Loramei Romeo

On May 2, 2025, Crozer Health located in Delaware PA, will be closing, which includes Crozer-Chester Medical Center and Taylor Hospital. In the last year 4,600 Highmark Commercial and Medicare members have used services at Crozer Health. Members who used any services from Crozer health in the last year will be notified and be assisted in helping finding providers and facilities. Through logging in on the member portal online or the MyHighmark app members can find alternative in-network doctors. The 2025 Agent Field Guide is a comprehensive resource for doing business with Highmark, covering technical processes, commissions, compliance, agent oversight, and detailed product information for MA, D-SNP, and ACA lines of business.… Read More

Aetna CVS Health will exit the ACA Marketplace, as of December 31,2025

May 6, 2025May 6, 2025Loramei Romeo

There has been an important update about ACA customers coverage. Aetna CVS Health has decided to exit the Individual and Family Plan business, as of December 31,2025. There will be no change to customer’s current plan for 2025. Therefore, you can count on the same service you have today for the rest of 2025. By July 1,2025, you will receive a letter from Aetna CVS Health with more information and next steps. During the fall Open Enrollment season, members will need to choose a new health insurance plan with a different company to be covered in 2026. We are dedicated to providing exceptional service, so please do not hesitate to… Read More

Next Year Cost for Pennie Customers May Increase

April 29, 2025April 29, 2025Loramei Romeo

Pennie has announced that enrollees receiving advance premium tax credits will likely face higher costs in 2026 due to the expiration of enhanced federal tax credits at the end of 2025. This change will result in increased monthly premiums for most enrollees unless Congress acts to extend these credits. Pennie is committed to keeping customers informed through various communications, including postcards, emails, and text messages, to help them understand the upcoming changes and find the lowest costs on high-quality health coverage. The enhanced tax credits, introduced in 2021, have provided significant financial savings, but their expiration means reduced savings for many enrollees starting January 2026. We are dedicated to providing… Read More

Benefits 101 Comparison HSAs HRAs FSAs

April 4, 2025April 3, 2025Loramei Romeo

Have Questions? and want to read more about the changes click HSA FSA HRA Comparison Chart 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.

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.

Updated Guidance Offers More Information on Form 1095-C Reporting Relief

March 7, 2025March 7, 2025Loramei Romeo

The IRS released Notice 2025-15, providing guidance on an alternative method for furnishing Forms 1095-C and 1095-B under the Affordable Care Act. This new method allows employers to provide these forms only upon request, given they meet specific notice requirements, including clear communication and accessibility on their website. Employers must post the notice by March 3, 2025, and ensure it remains accessible through October 15 of the following year. Despite this change, employers are still required to file all 2024 Forms 1095-C with the IRS electronically by March 31, 2025. Employers should review their current delivery policies and decide whether to adopt this new method while ensuring compliance with any… Read More

Message for our valued partners from IBX

March 4, 2025March 4, 2025Loramei Romeo

IBX, mission is to improve the health and well-being of those we serve. We are committed to innovation to reduce costs, provide equitable, holistic health care, and simplify the user experience for everyone we have the privilege to serve. To achieve these objectives, we embarked on an ambitious plan two years ago to transition our business to a more modern, flexible platform. This plan aims to streamline processes, enhance accuracy, and improve plan configurability, resulting in a more modern, personalized, and enhanced user experience. We appreciate your support and partnership in this ambitious endeavor. We acknowledge that some of these changes have presented challenges, and your understanding and support have… Read More

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

Latest Developments in the Johnson & Johnson ERISA Fiduciary Case

February 24, 2025February 21, 2025Loramei Romeo

The U.S. District Court of New Jersey recently dismissed claims in a class action lawsuit against Johnson & Johnson (J&J) regarding the management of their prescription drug benefits. The plaintiffs alleged that J&J breached its fiduciary responsibilities under ERISA, resulting in higher payments for prescription drugs, premiums, deductibles, coinsurance, and copays, as well as lower wages and limited wage growth. However, the court ruled in J&J’s favor on the fiduciary breach claims, stating that the plaintiff lacked Article III standing due to speculative allegations about higher premiums and insufficient evidence of redressable injury. Despite this, the court did not dismiss the claim that J&J failed to furnish requested plan documents,… Read More

New Guidance Released for the No Surprises Act and Gag Clause Prohibition

February 20, 2025February 18, 2025Loramei Romeo

The new guidance on the No Surprises Act (NSA) and gag clause prohibition, detailed in FAQ Part 69, clarifies the requirements for open negotiation, notice, and disclosure for plans, issuers, and providers related to the Independent Dispute Resolution (IDR) process. It addresses the coordination of surprise billing rules and plan sponsor responsibilities regarding gag clauses. The NSA protects against surprise medical bills for out-of-network costs, limiting individual cost-sharing to an amount based on the Qualified Payment Amount (QPA). The federal IDR process resolves disputes on reimbursement amounts, with FAQ 69 addressing recent litigation impacts on QPA calculation and other NSA implementation questions. The gag clause prohibiting compliance requires agreements to… Read More

One Employer or Spouse, Section 105 HRA

February 18, 2025February 14, 2025Loramei Romeo

What is a Section 105 HRA for 1 Employee or Spouse? Employers with small businesses that only have one employee or hire their spouse, Section 105 HRA are designed specifically for them. With Section 105 HRA spouse or employee/s can reimburse for family health insurance and medical expenses tax-free, indirectly the employers also benefit from as a dependent of the spouse/employee or as tax-deductible expenses to the business and employee. IRS Letter Ruling 9409006 and Section 105 of the Internal Revenue Code, Revenue Ruling 71-588 made this plan possible. Any health plan with 2 or more employees he annual and lifetime dollar limit is eliminated because of the Affordable Care… Read More

Annual Update for 2025 for New Jersey Policyholders

February 17, 2025February 17, 2025Loramei Romeo

This letter is intended to provide you with information on New Jesey Temporary Disability Benefits (TDB) changes for 2025. This Annual Update should be included in the employee posting. Please note that this information must not only be posted at the same place of employment, but must also be provided to the employee under the following circumstance: The following NJ TDB changes are applicable January 1, 2025, until December 31, 2025: Maximum Contribution amounts: Maximum Weekly Benefit: 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… Read More

Health FSA Plan Document Section 125

February 13, 2025February 11, 2025Loramei Romeo

Employees have the potential to save up to $1,280, while employers may realize savings of as much as $320. Health Flexible Spending Account (FSA) Plans are designated tax-exempt accounts that permit employees to access up to $3,300 in 2025 in pre-tax funds for out-of-pocket medical, dental, and vision expenses that are not covered by other insurance plans. What is a Health Flexible Spending Account (FSA)? A Health Flexible Spending Account enables employees to set aside pre-tax funds for medical expenses that are not covered by their insurance. These Health FSA plans can also be integrated with a Premium Only Plan (POP) and/or a Dependent Care FSA. The FSA acts as… Read More

Section 125 POP (Premium Only Plan) With HSA Module

February 10, 2025February 10, 2025Loramei Romeo

Section 125 Premium Only Plan can be pre-taxed HAS Savings Employers prefer High Deductible Health Plans (HDHP) and offering their employees’ Health Savings Accounts (HSA). The problem is whether the HSA portion (saving component) qualifies as a pretax payroll deduction through the Section 125 Premium Only Plan. HSA savings component allows to be pre-taxed because a $30 HSA module for the $149 Section 125 Premium Only Plan was developed. Employers can obtain all necessary materials to set up an HSA Section 125 for a fee of $179.00 for the Basic PDF version sent via email, or $229 for the PDF version along with a Deluxe 1-inch Binder delivered by USPS. This… 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

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