Individual Mandate – Total Benefit Solutions Inc

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

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.

Notice For: Braven Health and Horizon NJ TotalCare (HMO D-SNIP)

February 5, 2025February 4, 2025Loramei Romeo

For: Braven Health and Horizon NJ TotalCare (HMO D-SNIP) Hackensack Meridian Health Remains In-Network for Braven Health and Horizon DSNP MembersAs of June 1, 2025, Hackensack Meridian Health (HMH) terminated their hospital from Horizon Hospital Network unless Horizon agrees to increase prices for services and cares at their facilities. This change does not impact Braven Health or Horizon NJ TotalCare (HMO D-SNP). Braven Health and Horizon TotalCare (HMO D-SNP) members can continue using HMH providers and hospitals. Why is this not impacting Braven Health and DSNP and will it soon?Only certain Horizon members are affected by the change in hospital network status. Braven Health and Horizon TotalCare (HMO D-SNP) members… Read More

Reminder for Medicare Part D CMS

January 28, 2025January 28, 2025Loramei 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

Horizon and Braven Health Prescription Drug Benefits

January 27, 2025January 27, 2025Loramei Romeo

IMPORTANT NOTICE: Horizon and Braven Health Prescription Drug Benefits GLP-1 medications like Ozempic and Mounjaro are covered by the prescription drug benefits of Horizon Medicare Blue Rx (PDP) and Braven Health Medicare Advantage plans. GLP-1 medications are used to treat obesity and type 2 diabetes. Medicare, however, only covers these medications for diabetes. Prior authorization is also required for GLP-1 medications. This implies that before we agree to cover the medication, the member or their practitioner must obtain plan approval. To guarantee pharmaceutical safety and assist in directing the proper use of specific medications, prior permission is implemented. The medication may not be covered by the plan if the member DOES… Read More

Federal Poverty Guidelines Announced for 2025

January 24, 2025January 24, 2025Loramei Romeo

The 2025 federal poverty guidelines were recently released by the Department of Health & Human Services (HHS), they provide the federal poverty level (FPL) affordability safe harbor for the purposes of the employer mandate under the Affordable Care Act (ACA). The 2025 FPL safe harbor is $117.63/month in the lower 48 states and DC, $146.95/month in Alaska, and $135.22/month in Hawaii for plan years starting on February 1, 2025, or later. To qualify for the FPL affordability safe harbor, a plan may employ poverty rules that are in force six months prior to the start of the plan year. The lower 48 states and DC utilize $113.20/month for plans with… Read More

Important Update Regarding the Distribution of Form 1095-B for Tax Year 2024

January 24, 2025January 24, 2025Loramei Romeo

Horizon BCBSNJ is constantly searching for methods to make working with us more convenient and easier. For this reason, Horizon has modified the way they provide Form 1095-B to their members who are fully insured this year. What is Form 1095-B?The names, residences, Social Security numbers, and number of months that each member of a fully insured health plan was covered from January 1 to December 31 of each calendar year are reported on Form 1095-B. Form 1095-B is explained in greater detail here. How Is Distribution Changing This Year? In previous years, Form 1095-B was sent by mail to all subscribers enrolled in a Horizon fully insured plan. However,… Read More

Main Line Health and Lifeline Medical Associates

January 8, 2025Loramei Romeo

Highmark Medicare Advantage participants will no longer have in-network access to Main Line Health providers and facilities as of January 1, 2025. In the beginning of October, Highmark notified members who were affected by this disruption that Main Line Health might become out-of-network. Members should contact the member services number shown on the back of their ID card if they have any issues concerning continuity of care or how to locate another in-network provider or facility. For FEP, ACA, and CHIP members of Highmark, Main Line Health remains in-network. Lifeline Medical Associates (DE): Highmark ACA Members’ Out-of-Network Date Is Extended to March 2, 2025, Subject to Ongoing Negotiations We spoke… Read More

Changes for Prescription Drug Coverage

January 7, 2025Loramei Romeo

SJRA and Larchmont Facilities returns to Horizon’s Network

January 3, 2025January 3, 2025Loramei Romeo

South Jersey Radiology Associates (SJRA) which includes Larchmont Medical Imaging has made an agreement with Horizon BCBSNJ. On January 1, 2025, they will return to the network. *SJRA services are regarded as out of network if they are provided between April 1, 2024, and December 31, 2024. There will be no retroactive processing of claims. 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.

Independence – Update regarding ID Cards for January 1st IBX Customers

January 2, 2025January 2, 2025Loramei Romeo

The IBX Team has provided us the following update regarding ID Cards for January 1st Customers. Due to the large volume of cards being processed and mailed for January, members may not receive their physical ID cards before January 1. To ensure uninterrupted access to care for members with ID cards processing in the second half of December, letters are being mailed to plan subscribers containing their new member ID numbers and ID numbers for all covered dependents. The sample letter is attached, and it’s important to note these members can access their ID cards on the portal until they receive the physical card. We’re just trying to be proactive… Read More

FAQ 68 Addresses Preventive Care and Mastectomy Coverage

December 24, 2024December 24, 2024Loramei Romeo

Coverage of PrEP Certain preventive care services must be offered by health insurance companies and non-grandfathered group health plans without any cost-sharing obligations under the Affordable Care Act (ACA). The United States Preventive Services Task Force (USPSTF) and other agencies and advisory groups recommendations form the basis of the list of preventive care services. If a preventive care service or item requirement omits information on the frequency, manner, treatment, or setting to administer the preventive care service, plans and carriers are permitted to employ reasonable medical management practices. Coding and Claims Management Plans and carriers are also reminded by FAQ 68 of the significance of correctly coding claims for preventive… Read More

New Jersey Releases 2025 Disability and Family Leave Amounts

December 20, 2024December 20, 2024Loramei Romeo

New Jersey has announced the 2025 contribution rates and benefit level parameters for the Temporary Disability Insurance (TDI) and Family Leave Insurance (FLI) programs. Temporary Disability Insurance 2025 For qualified New Jersey workers who are unable to work due to a non-work-related illness, injury, or other disability, or for specific public health emergencies, TDI offers benefits. Employees must have worked 20 weeks and earned at least $303 per week (Base Week Amount) or earned $15,200 (Alternative Earnings Test) in the four quarters (base year) before taking vacation to be eligible for TDI. 85% of an employee’s average weekly pay, up to a maximum of $1,081, is the weekly TDI benefit… Read More

New PCOR fee Announced

December 20, 2024December 20, 2024Loramei Romeo

The IRS released Notice 2024-83 on December 3, 2024, which states that the PCOR fee which is determined by the adjusted applicable dollar amount used for plan years that starts on or after October 1, 2024, and before October 1, 2025, is $3.47. For self-funded medical plans which includes level funding and some HRAs including ICHRAs for plan years ending in 2024 the PCOR filing deadline is July 31, 2025. For insured policies the carriers are responsible for paying. Employer Action: There are no further required actions for employes with self-funded health plans (or an HRA) as of the moment. Reminders will be sent in mid-2025 for the fee and… Read More

ACA Compliance for Forms 1094-C + 1095-C

December 19, 2024December 19, 2024Loramei Romeo

In terms of ACA reporting of minimum essential coverage (MEC), you are probably an Applicable Large Employer (ALE) if you had an average of fifty (50) full-time equivalent employees in the previous calendar year or if you are an employer of any size that provides a level funded or self-insured plan. The deadlines are: Employees must submit their 1095-C forms by March 3, 2025, at the latest. IRS-required copies of 1094-C and 1095-C forms are due by March 31, 2025, if filing online, or February 28 if filing on paper. We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated Total Benefit Solutions health… Read More

Required Attestation regarding the Gag Clause by December 31, 2024

November 14, 2024November 14, 2024Loramei Romeo

By December 31st of each year, insurance companies and plans sponsor of group health plans are required to provide the Centers for Medicare and Medicaid Services (CMS) with information certifying that their plan or policies do not include illegal gag provisions. The due date for the subsequent attestation is December 31, 2024. Clients are receiving notifications from carriers and TPAs regarding their plan to adhere to the Gag Clause Prohibition Compliance Attestation. Once more, it appears that the different carriers/TPAs will not handle the attestation requirements the same way. For fully insured plans both the plan and carrier must file attestation if the group health plan is fully insured; however,… Read More

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

September 13, 2024September 13, 2024Mirasol 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

Tower Health is back!

July 26, 2024July 23, 2024Mirasol Bandong

Tower Health is back in Cigna Medicare Advantage network in Pennsylvania! After productive negotiations with Tower Health in Pennsylvania, Cigna is happy to announce that they are back in their Medicare Advantage network effective June 1, 2024. This includes Phoenixville and Pottstown Hospital, all Primary Care Physicians (PCPs), specialists, ancillary providers, and other hospitals that were previously in-network. 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.

Special Enrollment Period Extended: Florida Emergency Declaration – Hurricane Idalia

June 28, 2024June 28, 2024Mirasol 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

IRS Addresses Tax Treatment Of Work-Life Referral Services

May 7, 2024May 6, 2024Mirasol Bandong

The Internal Revenue Service (“IRS”) clarified the tax treatment of several work-life referral (“WLR”) services offered by employers in a new Fact Sheet FAQ. According to the FAQ, the value of the WLR services may be deducted from employees’ salary as a de minimis fringe benefit in cases when they are included in employee assistance programs (“EAPs”) or are otherwise bundled with other services. WLR Programs WLR services are offered to qualified employees through the employer-funded WLR program. WLR services are informative and referral consultations that help staff members locate, engage, and bargain with life-management providers to find answers to personal, professional, or family problems. Generally speaking, unless a part… Read More

Claim Processing Delays and Invoice Updates

March 27, 2024March 26, 2024Mirasol Bandong

On February 21, 2024, MVP stopped doing business with Change Healthcare and its subsidiaries, as well as all digital interactions. This was due to a cyber security breach. In compliance with national and state regulations, MVP is implementing innovative business solutions and restoring affected service functionality as needed. Processing Delays for Provider Claims : New York State Department of Financial Services encourage issuers and pharmaceutical benefit managers (PBMs) to take into account granting provider requests to halt or reverse specific administrative processes. MVP is assessing each provider’s request for suspension and tolling individually and determining whether a certification is necessary. To read more click HERE We are dedicated to providing… Read More

Cleveland Clinic will remain in our MA network in Florida and Ohio

March 25, 2024March 21, 2024Mirasol Bandong

We are pleased to announce that Cleveland Clinic will stay part of our Medicare Advantage (MA) network in Florida and Ohio after successful negotiations! This covers all specialists, ancillary providers, hospitals, and primary care physicians (PCPs). Once a contractual agreement is achieved, Cleveland Clinic services will continue to be accessible without interruption. Customers will receive letters in the upcoming weeks letting them know that Cleveland Clinic is still in network and that they don’t need to take any action right now. The PCP assignments at Cleveland Clinic are all still the same. Have any questions? call us at (215) 355-2121 or click Cigna healthcare provider directory to view the most… Read More

UnitedHealthcare – RxDC Information Required by Deadline

March 22, 2024March 21, 2024Mirasol Bandong

Please assist us in answering the required questions in the CAA Pharmacy Data Collection request information that is located in the employer/broker portal. It will make sure that UnitedHealthcare can successfully submit the data report. In order for us to prepare the data for submission to CMS by June 1, 2024, we must get the information by April 10, 2024, thus your prompt answer is extremely important. To read more click HERE 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… Read More

IRS News Release: Nutrition, Wellness, and General Health Expenses

March 19, 2024Mirasol Bandong

The Internal Revenue Service (IRS) is informing taxpayers that costs associated with wellness, diet, and overall health are unlikely to be covered by Internal Revenue Code section 213 reimbursement for medical expenses. The IRS published a press statement and a list of commonly asked questions the IRS: The IRS is worried that individuals might not be aware of the situations in which spending related to diet or wellness can qualify as medical costs. The IRS reminded people in a news release on March 6, 2024, that personal expenses cannot be reimbursed through FSAs, HSAs, or HRAs in a way that is tax-favored. Employers should be wary of vendors who advertise… Read More

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