DOL Penalties Increase for 2023

The Department of Labor (“DOL”) has published the annual adjustments for 2023 that increase certain penalties applicable to employee benefit plans. As always, please contact your Total Benefit Solutions health insurance specialists with any questions or concerns today at (215)355-2121.

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Four Key Changes in the Biden Administration’s Final Rule on Medicare Enrollment and Eligibility

The Centers for Medicare & Medicaid Services (CMS) issued a final rule on October 28, 2022, to implement several changes in Medicare enrollment and eligibility that were included in the Consolidated Appropriations Act of 2021 (CAA). These changes are designed to minimize gaps in coverage for people who sign up for Medicare and improve access to care by shortening the gap between Medicare enrollment and coverage; creating new Special Enrollment Periods for individuals whose coverage would otherwise be delayed due to challenging circumstances, such as a natural disaster; and extending coverage of immunosuppressive drugs for certain beneficiaries with end-stage renal disease (ESRD) who would otherwise lose coverage for these drugs… Read More

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What Are Medicare Guaranteed Issue Rights?

Please contact your Total Benefit Solutions Inc Medicare health insurance specialists today at (215)355-2121 with any questions.

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Inflation Reduction Act: Requires Drug Manufacturers to Pay Rebates for Drug Price Increases Above Inflation

Requires drug manufacturers to pay a rebate if drug prices increase faster than the rate of inflation (CPI-U) for: Single-source drugs and biologicals covered under Medicare Part B All covered drugs under Medicare Part D except those where average annual cost is <$100 2021 is the base year for measuring cumulative price changes relative to inflation The rebate amount is based on units sold in Medicare multiplied by the amount that a drug’s price in a give year exceeds the inflation-adjusted price Price changes are measured based on the average sales price (for Part B drugs) or the average manufacturer price (for Part D); these measures include prices charged in… Read More

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Total Benefit Solutions, Inc appoints with Lasso Medicare Medical Savings Accounts Plans for 2022-2023 Open Enrollment Season

What is a Medicare Medical Savings Account (MSA) Plan? – A Medicare Medical Savings Account (MSA) plan is a type of Medicare Advantage plan that combines a high-deductible health plan with a medical savings account. Enrollees of Medicare MSA plans can initially use their savings account to help pay for health care, and then will have coverage through a high-deductible insurance plan once they reach their deductible. Medicare MSA plans can provide Medicare beneficiaries with more control over health care utilization, while still providing coverage against catastrophic health care expenses. Ask your Total Benefit Solutions, Inc. Medicare health insurance specialist of a Medicare Medical Savings Account could be worth considering… Read More

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Inflation Reduction Act: Establishing the Negotiated “Maximum Fair Price” for Medicare

The upper limit for the negotiated price of a drug (the “maximum fair price”) is equal to the lower of: The drug’s enrollment-weighted negotiated price (net of all price concessions) for a Part D drug; The average sales price for a Part B drug; or A percentage of the non-federal average manufacturer price (i.e., the average price wholesalers pay manufactures for drugs distributed to non-federal purchasers), depending on FDA approval date: 75% for small-molecule drugs more than 9 years but less than 12 years beyond FDA approval; 65% for drugs between 12 and 16 years beyond FDA approval; and 40% for drugs more than 16 years beyond FDA approval Financial… Read More

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A new group health insurance offering for small businesses. Introducing CIGNA + Oscar

We’ve partnered with Cigna + Oscar to deliver small business health insurance that brings together Cigna’s most popular provider networks and Oscar’s tech-driven approach to customer service and care navigation. Cigna + Oscar plans are available in the Philadelphia 5 county area beginning with effective dates starting January 1 2023. Your Total Benefit Solutions, Inc health insurance specialists are available to help you quote and compare plans. Call us today to get your quote and compare these newest plans to your current renewal. You might be surprised at the competitive cost and plan designs! (215)355-2121

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Final Rules Adopt Administrative Changes to the No Surprises Act

On August 26, 2022, the Departments of Labor, Health and Human Services, and the Treasury (together, the “Departments”) published final rules on the No Surprises Act, making changes to the administrative duties of insurance carriers, HMOs, third-party administrators, out-of-network healthcare providers, and certain other entities responsible for the Act’s implementation. The new rules, which take effect on October 25, 2022, are narrow in scope, and include the following changes:• During processing of claims under the No Surprises Act, if “down-coding” occurs (i.e., the group medical plan alters or replaces the medical billing codes chosen by the out-of-network healthcare provider, resulting in a lower claim payment), then the final rules impose… Read More

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Turning 26: Your Guide to Health Insurance

Turning 26: Your Guide to Getting Your New Health Insurance:https://totalbenefits.net/turning-26-your-guide-to-health-insurance/

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2022 MLR Rebate Checks to Be Issued Soon to Fully Insured Plans

As a reminder, insurance carriers are required to satisfy certain medical loss ratio (“MLR”) thresholds. This generally means that for every dollar of premium a carrier collects with respect to a major medical plan; it should spend 85 cents in the large group market (80 cents in the small group market) on medical care and activities to improve health care quality. If these thresholds are not satisfied, rebates are available to employers in the form of a premium credit or check. If a rebate is available, carriers are required to distribute MLR checks to employers by September 30, 2022. Click the link below to download the full bulletin.

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Additional Guidance on New Prescription Drug Reporting Requirement

As previously reported in 2021, Section 204 of the Consolidated Appropriations Act, 2021 (“CAA”) requires plan sponsors of group health plans to submit informationannually about prescription drugs and health care spending to Centers for Medicare and Medicaid Services (“CMS”) on behalf of the Departments of Health and Human Services(“HHS”), Labor (“DOL”), and the Treasury (collectively, the “Departments”). The first deadline is December 27, 2022. CMS recently updated guidance related to this reporting requirement that provides some helpful clarification. Click the link below to download this bulletin. As always please contact your Total benefit Solutions, Inc health insurance specialist at (215)355-2121 if you have any further questions or concerns.

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New Prescription Drug Reporting Requirement

As previously reported in December 2021, Section 204 of the Consolidated Appropriations Act, 2021 (“CAA”) requires plan sponsors of group health plans to submit information annually about prescription drugs and health care spending to Centers for Medicare and Medicaid Services (“CMS”) on behalf of the departments of Health and Human Services (“HHS”), Labor (“DOL”), and the Treasury (collectively, the “Departments”). The first deadline is December 27, 2022. CMS recently updated guidance related to this reporting requirement that provides some helpful clarification. Employers with fully insured or self-funded (includes level funded) group health plans, including grandfathered plans, church plans subject to the Internal Revenue Code, and governmental plans. The term “group… Read More

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Understanding the Coding of Health Plans from MEC to Metallic

Choosing the right insurance plan for you (and your family) is not an easy task. The Affordable Care Act (ACA) has introduced major changes to the way carriers traditionally marketed their health plans to the public and introduced a volume of new terms, requirements and complexities, many of which may sound confusing to the general public. From terms like “minimum essential coverage” to the various metallic plan categories of Bronze, Silver, Gold and Platinum, a solid foundation of knowledge is essential in order to find the coverage required at an affordable price. The health insurance experts at Total Benefit Solutions Inc are well versed on these terms so when you… Read More

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What is a Qualifying Life Event or QLE?

There are 4 basic types of health insurance qualifying life events. (The following are examples, not a full list.) Loss of health coverage Losing existing health coverage, including job-based, individual, and student plans Losing eligibility for Medicare, Medicaid, or CHIP Turning 26 and losing coverage through a parent’s plan Changes in household Getting married or divorced Having a baby or adopting a child Death in the family Changes in residence Moving to a different ZIP code or county A student moving to or from the place they attend school A seasonal worker moving to or from the place they both live and work Moving to or from a shelter or… Read More

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Case Study Library

We present a few case studies to illustrate how we have helped our clients solve their complicated employee benefit challenges. Click here to learn more!

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What does ” Guaranteed Issue” health insurance mean?

Guaranteed issue A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Except in some states, guaranteed issue doesn’t limit how much you can be charged if you enroll. Not all health insurance plans are guaranteed issue. Have any questions about your health insurance? Contact your Total Benefit Solutions, Inc health insurance specialists at (215)355-2121 https://www.totalbenefits.net

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Affordability of Health Coverage

Applicable Large Employers, those with 50 or more full-time employees in the prior year, must offer their full-time employees minimum essential coverage providing minimum value that is affordable. A plan is affordable if the premium for self-only coverage does not exceed a certain percentage of the employee’s household income. The IRS sets the percentage each year. The baseline percentage was 9.5%. In 2022, the affordability percentage is 9.61%. In 2021, it was 9.83%. A plan will be considered affordable if its premium for the lowest cost, single-only plan does not exceed the identified percentage of an employee’s household income. Since household income is not readily available, employers use one of… Read More

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Health Insurance Broker Change Leads to Better Results

Watch Video The Issue A mid-sized group prospect was unhappy with their current broker and looking for a change. They thought more could be done to help control their employee benefit budget and were looking for guidance. They came to us with a 17% health insurance renewal. Our Solution Our team met with the business owner and Human Resource Director to review the following: The corporate goals and philosophy regarding employee benefits The benefit structure and costs of their present programs Options for cost containment strategies How to integrate wellness into their benefits portfolio Methods for better communication of the benefit programs to employees The Result The customer was pleased… Read More

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Is my group subject to ERISA or ERISA Exempt?

Many clients often ask the question ” Do I need to comply with ERISA? ” The answer is almost always yes! Just because you are a smaller business does not exempt you from ERISA. This from the US Department of Labor: ERISA applies to private-sector companies that offer pension plans to employees. This includes businesses that: Are structured as partnerships, proprietorships, LLCs, S-corporations and C-corporations. No matter how your employer has structured his or her business, it is covered by ERISA if it is a private entity. Who is not subject to ERISA?In general, ERISA does not cover group health plans established or maintained by governmental entities, churches for their employees, or… Read More

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Health Insurance Nondiscrimination Rules Small Business Owners Need to Know

Group health plans and tax-favored accounts—including health savings accounts (HSAs), health flexible spending arrangements (health FSAs), and health reimbursement arrangements (HRAs)—are subject to numerous nondiscrimination provisions under federal law. The most common nondiscrimination provisions are described. Please download the entire bulletin for details. As always please contact your Total Benefit Solutions, Inc group account manager at (215)355-2121 with any questions or concerns. This bulletin covers the following topics: Overview General Rules Section 125 Nondiscrimination Rules for Cafeteria Plans Section 105 Nondiscrimination Rules for Self-Insured Plans HIPAA Nondiscrimination Rules Nondiscrimination Rules Related to Medicare-Eligible Individuals Other Nondiscrimination Rules Additional Information

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2022 PCOR Fee Filing Reminder for Self-Insured Plans

The Patient-Centered Outcomes Research (PCOR) fee filing deadline is August 1, 2022, for all self-funded medical plansand HRAs for plan years ending in 2021. The IRS issued Notice 2022-04 announcing the adjusted fee amount for this year. please download the bulleting below for more details and contact your Total Benefit Solutions, Inc. health insurance specialist at (215)355-2121.

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6 Questions to ask your Benefits Broker

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