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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Understanding the Health Care Provisions in the Inflation Reduction Act

The Inflation Reduction Act includes several landmark health care provisions that would lower prescription drug costs for people with Medicare, reduce Medicare drug spending and extend enhanced subsidies for Affordable Care Act marketplace coverage. On Thursday, August 11, a panel of KFF experts held a web briefing to explain these provisions and how they would affect people and federal health spending, followed by a Question and Answer session. Click here to open article and view Web Event video. The legislation for the first time would require the U.S. Secretary of Health and Human Services to negotiate directly with drug manufacturers over the price of some high-cost drugs in the Medicare… Read More

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CMS Updates Medicare Enrollment Rules for 2023

On April 22, 2022, the Centers for Medicare & Medicaid Services (CMS) proposed implementation of parts of the Consolidated Appropriations Act, 2021 (CAA) to simplify Medicare enrollment. According to Medicare.gov, these changes will go into effect January 1, 2023. Generally speaking, the new Medicare enrollment rules will allow for a more straightforward enrollment process that reduces potential gaps in coverage. They also allow for more Special Enrollment Periods and extend some Part B coverage to certain beneficiaries. But, what are the specifics? All facts and figures can be found in CMS’ fact sheet on the provisions, unless specifically linked elsewhere. Current Medicare Enrollment Rules Currently, when Medicare coverage actually starts after enrollment… Read More

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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 FAQ Addresses NSA and TiC Rules

he Departments of Labor, Health and Human Services and the Treasury (collectively, “the Departments”) issued FAQ Part 55, providing guidance as it relates to certain aspects of the No Surprises Act (“NSA”) and the Transparency in Coverage (“TiC”) final regulations. FAQ 55 includes 23 questions and answers. The guidance is lengthy and very detailed. Below you will find some of the key highlights of the guidance. Please download the bulletin below for details and contact your Total Benefit Solutions, Inc health insurance specialists at (215)355-2121 with any additional questions or concerns.

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Additional Guidance Issued on Surprise Billing Protections

The Consolidated Appropriations Act of 2021 introduced numerous protections against surprise billing for plan participants that impact group health plans, health insurance issuers, & providers. The Consolidated Appropriations Act of 2021 (CAA) introduced numerous protections against surprise billing for plan participants that impact group health plans, health insurance issuers, and providers. The federal Departments of Health and Human Services, Labor, and Treasury recently released a document discussing frequently asked questions (FAQs) about these surprise billing protections that provides clarity on a number of topics within the regulations. The key points from this guidance are outlined below. Application to Reference Based Pricing PlansIt has been unclear how the surprise billing rules apply to… Read More

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Further Guidance Issued on Contraceptive Coverage

On July 28, 2022, the Departments of Labor, Health and Human Services and the Treasury (collectively, “the Departments”) issued FAQ Part to clarify protections for contraceptive coverage under the Affordable Care Act (the “ACA”). In January 2022, the Departments had issued guidance on the ACA Preventive Care Mandate, including contraception. The Departments issued FAQ Part 54: In response to reports that individuals continue to experience difficulty accessing contraceptive coverage without cost sharing; To clarify application of the contraceptive coverage requirements to fertility awareness-based methods and to emergency contraceptive; and To address federal preemption of state law. Employers sponsoring non-grandfathered group health plans should review the various preventive care requirements effective… Read More

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Inflation Reduction Act – Health Care Considerations

On August 16, 2022, President Biden signed the “Inflation Reduction Act” into law. The legislation includes key health care, tax, and climate change components. Click the link below to download the bulletin which highlights the health care changes ! As always please contact your Total Benefit Solutions, Inc health insurance expert with any additional questions, (215)355-3121.

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IBC: Understanding your network

The type of health plan you choose determines the network of providers you can visit. In-network providers are the doctors and hospitals in your plan’s network. You’ll save the most money by visiting network providers. Out-of-network providers are those not in your plan’s network. You may pay more for out-of-network services, and some services may not be covered at all. Know your options — before you need them When you need care and your primary care doctor isn’t available, remember you have other options that don’t involve a trip to the emergency room. Using virtual care, retail clinics, or urgent care centers can save you time and money. https://www.ibx.com/get-care/find-doctors-and-healthcare-providers/where-to-go-for-care Click here for links to your network and more… Read More

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What is an excepted benefit HRA?

Businesses that offer an employer-sponsored group health plan to workers now have another way to save money while designing a health benefit package with more choices for employees – the Excepted Benefit HRA. The new EBHRA is a Health Reimbursement Arrangement designed to pay premiums and related expenses for eligible excepted benefits like dental and vision coverage. And, while an employer is required to offer a traditional group health plan, an employee can participate in the EBHRA even if they decline participating in the employer’s group health plan. That’s going to open up a lot of premium savings for workers who are eligible for coverage under a spouse’s or parent’s… Read More

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Celebrity Medicare Sales Pitches Are Toned Down After Scrutiny

Soaring complaints and aggressive sales efforts result in tighter rules from regulators From WSJ.COM: If it’s football season, you can count on seeing Joe Namath on television, along with William Shatner and Jimmie “J J” Walker. They are the most prominent pitchmen for what has become an annual fall selling frenzy for Medicare Advantage policies.  After a surge in consumer complaints, and stiffer government rules, the sales pitches will likely be tamer this year. If there is confusion, “we’ll change things so it satisfies everybody and eliminates the confusion,” said Mr. Shatner, best known for his role as Captain Kirk in the “Star Trek” franchise  The federal Centers for Medicare and Medicaid Services toughened its… Read More

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IRS Announces 2023 ACA Affordability Indexed Amount

The IRS recently announced in Revenue Procedure 2022-34 that the Affordable Care Act (“ACA”) affordability indexed amount under the Employer Shared Responsibility Payment (“ESRP”) requirements will be 9.12% for plan years that begin in 2023. This is a notable decrease from the 2022 percentage amount (9.61%) and below the original 9.5% threshold. Rev. Proc. 2022-34 establishes the indexed “required contribution percentage” used to determine whether an individual is eligible for “affordable” employer-sponsored health coverage under Section 36B (related to qualification for premium tax credits when buying ACA Marketplace coverage). However, the IRS explained in IRS Notice 2015-87 that a percentage change under Section 36B will correspond to a similar change… 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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Independence Blue Cross and Amerihealth: Behind on your health insurance payments?

Please do not assume that your payment is on the way or has been made and that the insurance company will handle it. Our health insurance specialists can assist you with a conference call. Getting reinstated after a cancellation is a long and difficult process and is not always available! If your payments are behind we need to ask for termination suppression BEFORE you are cancelled. First, Please always contact the Billing Department at 215-567-3357 or 1-800-444-6301. When calling, please have your group name, billing account number and address for verification purposes. The Billing Department will not approve an account for termination suppression due to checks mailed, promise to pay… Read More

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Aetna AFA now allows PEO Employers!

From Aetna: We’re now treating small businesses who use the services of a PEO ( Professional Employer Organization) the same as any other group. This excludes any group headquartered in California or New York, or any group currently on an Aetna PEO master health plan. Here are some important details: 1. We no longer require small businesses to terminate their PEO relationship or fill out extra forms for us during the new business process.2.The entire group must move to Aetna –small businesses can’t move some employees to Aetna and leave the rest on the PEO master health plan. What does this mean to groups? If your company is already part… 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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What is the Employer Shared Responsibility Provision?

Under the Affordable Care Act, governments, insurers, employers and individuals are given shared responsibility to reform and improve the availability, quality and affordability of health insurance coverage in the United States. The estimator is specifically designed to help you determine if the employer shared responsibility provision (IRC Section 4980H) applies to you and, if it does, will help you determine the maximum amount of the employer shared responsibility payment that could apply to you under either section 4980H(a) or 4980H(b) based on the number of full-time employees that you report. The provision applies to employers called applicable large employers that employ on average at least 50 full-time employees (including FTEs)… 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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Section 125 Tax-Saving POP plan document

In this video, we feature our most popular product, the $99 Section 125 Tax-Saving POP plan document package (Core 125). It explains how employees save up to 40% in taxes while employers eliminate on average 8% of matching payroll tax when the company has a Section 125 POP (Cafeteria) plan document in place, as required by the IRS to pre-tax benefits. As always contact your Total Benefit Solutions, Inc group health insurance specialists at (215)355-2121 to find out more! Click here for more information or to order a document online.

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