Association Health Plans – Total Benefit Solutions Inc

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

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

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

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

Small Shifts, Big Impact: Simple Strategies to Elevate Your Overall Well-Being

May 5, 2025May 1, 2025Loramei Romeo

Feeling your best—inside and out—doesn’t always require a drastic overhaul. Sometimes, the smallest shifts in daily habits can yield the biggest results. The goal isn’t to chase perfection but rather to create a sustainable routine that fosters both physical and mental wellness. From the way you start your mornings to ensuring you have the right safety nets in place, every choice you make contributes to your overall well-being. Here are a few simple yet powerful strategies to help you feel more energized, balanced, and at peace with yourself. Begin Your Day with Purpose Mornings set the tone for the rest of your day, and a chaotic start can leave you… 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

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

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

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.

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

What is a level funded health insurance plan?

September 1, 2024September 1, 2024Ed MacConnell

A level-funded plan is a type of self-funded plan in which the employer contributes a steady monthly payment to cover costs for administration, claims payments, and stop-loss insurance. Level funding has its advantages when compared to fully insured plans and programs. Level-funded plans often cost less, making it easier for small- and mid-sized employers to offer their employees high-quality health care benefits at a more affordable price. Total Benefit Solutions, Inc offers small- to mid-sized employers an opportunity to have a level-funded plan for their business through a Self-Funded Program. We work with many different carriers who offer level funded programs. These carriers change by State. How does the plan… Read More

Cigna Changes to MA ID cards

August 26, 2024August 23, 2024Mirasol Bandong

As with the 2025 plan year, our Medicare Advantage ID cards will be altered. By utilizing our digital portals to obtain a member’s current PCP, treating providers will be encouraged to use them more efficiently, which will prevent needless treatment delays brought on by the referral process. See what’s changing below, so you’re ready to answer any customer questions this upcoming AEP. What’s changing? 2024 2025 What is staying the same? When are these changes occurring? Members in HMO plans are still required to maintain a PCP New enrollees with a 1/1/2025 effective date will start receiving ID cards without PCP information as soon as 10/15/2024. The PCP network name… Read More

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

Update on Legislation – EmblemHealth

March 29, 2024March 28, 2024Mirasol Bandong

President Joe Biden presented his budget proposal on March 11th, 2024, for the federal fiscal year that would start on October 1st. Along with raising taxes on people earning more than $400,000 annually, the budget would also help extend talks with pharmaceutical corporations to prolong the Medicare program’s financial viability. click HERE to read the whole article. 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.

United Healthcare and Mount Sinai Renew Relationship

March 28, 2024March 27, 2024Mirasol Bandong

In accordance with a new multi-year agreement between UnitedHealthcare and Mount Sinai Health System, individuals participating in employer-sponsored and individual plans, such as the Oxford Health Plan, will once again have network access to the system’s hospitals. Additionally, the agreement guarantees continuous, uninterrupted access to the doctors at Mount Sinai. for more information 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 or address any concerns you may have.

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

Medicare: Your Essential Guide

February 7, 2024February 7, 2024Ed MacConnell

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

Navigating the Basics of Medicare: Understanding the Four Parts

February 5, 2024February 5, 2024Ed MacConnell

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

Special Election Period may be available to members affected by severe weather

January 24, 2024January 29, 2024Ed MacConnell

The Federal Emergency Management Agency (FEMA) have declared a weather-related emergency or major disaster in your state. Medicare beneficiaries affected may be eligible for a Special Election Period (SEP). For marketing materials that comply with CMS marketing requirements, please visit the UnitedHealthcare Toolkit. Who is eligible? Beneficiaries who do not live in the impacted areas but receive assistance making healthcare decisions from someone who lives in one of the affected areas are also eligible; and What does this mean for beneficiaries? Enrollment Overview If a consumer contacts you as a result of this SEP, you may help them enroll in one of our plans and may be eligible for a… Read More

Horizon Members Get 15% Off YMCA Memberships!

January 24, 2024January 24, 2024Ed MacConnell

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

Aetna: Small Business Updates

January 23, 2024January 23, 2024Ed MacConnell

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

Medicare Part D – CMS Notification Reminder

January 18, 2024January 18, 2024Ed MacConnell

Employers supporting a group health plan, whether through insurance or self-insurance, are required to communicate the creditable or non-creditable status of the plan’s prescription drug coverage to the Centers for Medicare and Medicaid Services (CMS). This reporting is facilitated through access to CMS’s online reporting system here. To comply with regulations and maintain transparency, follow these key points: Access CMS Online Reporting: Employers (insured or self-insured) should use CMS’s online system to report prescription drug coverage details. Key Deadlines: 1.Within 60 days after the plan year starts. 2.Within 30 days after prescription drug plan termination. 3.Within 30 days after any creditable coverage status change. Example Deadline: For a calendar year… Read More

DOL’s 2024 Penalty Adjustments

January 17, 2024January 17, 2024Ed MacConnell

The Department of Labor (DOL) has released its annual adjustments for 2024, impacting penalties for employee benefit plans. Here’s a quick guide for employers: Key Points: 1. Employee Notices: Private employers must ensure timely delivery of required notices (SBC, CHIP, SPD, etc.) to avoid civil penalties. 2. Form 5500 Filings: File Form 5500 accurately and on time to prevent penalties associated with non-compliance. 3. Document Requests from EBSA: Respond promptly to document requests from EBSA to avoid potential penalties. Annual Penalty Adjustments for 2024 The updated penalties listed below are applicable to ERISA-covered health and welfare plans. Compliance is essential in 2024—act now to secure your organization against penalties and… Read More

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