affordable care act – Page 3 – Total Benefit Solutions Inc

Gag Clause Prohibition Attestation Under the Consolidated Appropriation Act

November 25, 2024November 25, 2024Loramei Romeo

Under the Consolidate Appropriations Act (CAA), health plans are prohibited from signing contracts that limit the precise data and information they can provide to third parties. Every year, plans are required to provide an attestation confirming that they have not entered any prohibited contractual restrictions. According to Excellus BlueCross BlueShield (Excellus BCBS) we will be completing the attestation on behalf of our fully insured and minimal premium groups for the duration they had with Excellus BCBS coverage in 2024. Please inform these groups that we will be finishing the attestation on their behalf by the deadline of December 31, 2024, if you hear any questions from them regarding gag clause… Read More

Main Line Health may part ways with Medicare Advantage network in Pennsylvania

November 22, 2024November 22, 2024Loramei Romeo

Main Line Health in Pennsylvania has a long relationship with Cigna Healthcare Medicare Advantage (MA). Unfortunately, negotiation has not been reached between Cigna Healthcare Medicare Advantage and Main Line Health in Pennsylvania, because of this effective on January 1, 2025, Main Line Health in Pennsylvania will not be a part of MA network. Customers have been notified via letter. A new Primary Care Physician (PCP) recommendation will be included to customers who are assigned to PCP from Main Line Health. To change to another PCP customers can contact Cigna Healthcare MA. Customers would be reassigned to the recommended PCP if they do not contact Cigna Healthcare. Customers with a PCP… Read More

WellSpan part ways with United Healthcare’s commercial network

November 21, 2024November 21, 2024Loramei Romeo

As of Nov 1, 2024 the facilities, hospitals, and physicians of WellSpan Health are out of network for UnitedHealthcare employer-sponsored commercial plans. WellSpan declined the proposals to extend the contract to ensure continued access to the health system while continuing to negotiate. Also, proposals that would ensure WellSpan Health to be reimbursed at more reasonable rates. WellSpan Health continued to seek unsustainable price increases, with its facilities costing over 30% more than the average of all other hospitals in south-central and eastern Pennsylvania that are members of our commercial network. A cost-effective solution that restores WellSpan Health’s network connectivity is still our top priority, and we will continue to negotiate… Read More

In 2025, would you like more?

November 21, 2024November 21, 2024Loramei Romeo

HSA funds are carried over each year. Why not increase your savings? Additionally, if you contribute to your HAS before the year ends, you can lower your income that is subject to taxes. For self-only coverage, the maximum contribution in 2024 is $4,150, and for family coverage, it is $8,300. Moreover, if you are at least 55, you will receive an additional $1,000 catch-up contribution. Employer contributions, direct transfers, and payroll deductions are all included in the annual cap. We’re sure you are as excited about this as we are! Please reach out if you have any questions. We are dedicated to providing exceptional service, so please do not hesitate… Read More

Guide to more savings and benefits & Letters to MA customers

November 18, 2024November 18, 2024Loramei Romeo

Guide to more savings and benefits The discounts for the Medicare supplements insurance provides savings that can be used by customers to reinvest in additional coverage. The discount is up to 20% with combined household discounts which are, discount for more than one member of the household holds a policy is 14% and discount when a customer lives with one or more people is 6%. The supplemental benefits are fit for client’s needs in cancer treatment, choice accident, dental, vision, hearing, hospital indemnity, lump sum cancer, lump sum heart attack, and stroke. Letters mailed to Medicare Advantage customers There are different versions of Benefits at a Glance (BAAG), letters regarding… Read More

WELLSPAN CONTINUES TO BE IN NETWORK WITH UHC!

November 15, 2024Loramei Romeo

We are excited to announce that as of 12/1/2024, Wellspan Health will continue to be a partner in care for UnitedHealthcare’s DSNP and ISNP members. We have also expanded the DSNP network to include ALL Wellspan Providers. We’re sure you are as excited about this as we are! Please reach out if you have any questions. 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.

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

Communications from providers about temporary ID cards

November 13, 2024November 13, 2024Loramei Romeo

Temporary member ID cards were mailed to members from large group with fully insured clients the transition of enhanced operation began in July. The cards contain the new member’s ID number. Our provider communications team has sent out messages to our contracted providers to let them know that these cards should be accepted. Which also includes instructions on how to process bills and how to confirm member’s eligibility when: In order to reinforce this message and give them more guidance, we redistribute this content the week of October 28 after it had previously been disseminated through our regular communication channels. Have Questions? and want to read more about the changes? Provider… Read More

December and January renewals deadlines

November 11, 2024November 11, 2024Loramei Romeo

Clients renewing in December, November 12 is the deadline to complete the enrollments, after this the enrollment will still be accepted but there will be delays with the member ID cards. Which includes small and large groups whether they are fully insured, self-funded clients, with both active and passive renewals. When enrolling later than November 12 after receiving completed enrollment the ID cards will be mailed after ten business days. To access new member ID number online it will take six business days after receiving complete enrollment. Clients renewing in January, Because of the anticipated volume of enrollment changes and new enrollments which adds additional processing time the deadline is… Read More

Small Employer Open Enrollment Period November 15 through December 15

October 24, 2024October 24, 2024Ed MacConnell

While this has been in place for a number of years, we would like to remind you about the Small Employer Open Enrollment Period for fully insured health plans in all states. The Small Employer Open Enrollment Period is the period from November 15 through December 15 each year. During this period, employers that meet the definition of small employer but do not meet the carrier’s participation or contribution requirement will be accepted for a small employer plan with a January 1 effective date. Additionally, select carriers in New York may allow for a December effective date if applicable. Carriers require that employer groups enrolling under the Small Employer Open Enrollment Period submit completed applications… Read More

Adjustments for Annual Out-of-Pocket Maximum Announced for 2026

October 24, 2024October 24, 2024Mirasol Bandong

Payment parameters were published by The Department of Health Services (HHS) for the Annual Notice of Benefit and Payment Parameters for 2026. The guidelines specify the yearly out-of-pocket limits (deductibles, co-payments, and other amounts, but not premiums) for non-grandfathered group medical plans for plan years starting in 2026 for employer-sponsored health plans. The Department also published the proposed Annual Notice of Benefit and Payment Parameters rule for 2026. HHS indicates, besides Departments of Labor and the Treasury, future rulemaking to address the applicability of drug manufacturer support to the annual limitation on cost-sharing is expected, something that will impact employer-sponsored coverage. Group that are non-grandfathered medical plans, out-of-pocket limits should… Read More

Cybersecurity Guidance Regarding Health and Welfare Benefits

October 17, 2024October 17, 2024Mirasol Bandong

In Compliance Assistance Release No. 2024-01, the U.S. Department of Employee Benefits Security Administration (EBSA) affirmed that all ERISA covered health and welfare plans are subject to the cybersecurity guidance which was published in 2021. Regarding cybersecurity best practices on April 2021, EBSA issued a cybersecurity guidance for benefit plan fiduciaries and service providers. ERISA requires plan fiduciaries to take necessary safety measures to reduce cybersecurity risk, EBSA’s three types of guidance are directed at benefit plan sponsors, fiduciaries, record keepers, and participants. With the new guidelines EBSA clarifies that cybersecurity guidance applies to ERISA covered health and welfare plans. EBSA clarifies that ERISA plan sponsors and fiduciaries, as well… Read More

Final 2024 ACA Reporting Instructions and Forms Issued

October 14, 2024October 14, 2024Mirasol Bandong

Forms 1094-C, 1095-C, 1094-B, and 1095-B are among the final instructions and forms that the IRS has made available for calendar year 2024 ACA reporting. As a reminder, since good faith relief from penalties is no longer available, it is crucial to make sure the forms are accurate, timely, and submitted to the IRS. There are no significant changes to the 2024 forms Forms 1094-C/1095-C Applicable large employers (ALEs) must provide Form 1095 to full time employees and Form 1094-C and 1095-Cs will be filed with the IRS. Covered employees or other primary insured individuals in the self-funded health plan must also receive Forms 1095-C from ALEs that offer a… Read More

Departments Issue Final MHPAEA Regulations

October 11, 2024October 11, 2024Mirasol Bandong

The final rules for the Mental Health Parity and Addiction Equity of 2008 (MHPAEA) were released on September 9, 2024, by the Department of Health and Human Services, Labor, and the Treasury in order to guarantee that those seeking treatment for mental health (MH) or substance use disorder (SUD). MHPAEA provides nonquantitative treatment limitations (NQTLs) cannot be applied to MH/SUD unless they are equivalent and applied no more strictly for MH/SUD benefits than for medical/surgical benefits. The final rules amend the definitions of definition of “medical/surgical”, “mental health benefits”, and “substance use disorder benefits” by removing a reference to the state guidelines. The most recent edition of the Diagnostic and Statistical… Read More

Medicare Annual Pre-Enrollment Checklist

September 30, 2024Ed MacConnell

Before making an enrollment decision, it is important that you fully understand your benefits and rules. Download this handy form below when planning your Medicare enrollment. Please contact us at (215)355-2121 to schedule your annual Medicare review.

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

2025 Part D Changes and Employer Sponsored Group Health Plans

September 9, 2024September 5, 2024Mirasol Bandong

Employers must inform the Centers for Medicare and Medicaid Services (“CMS”) and participants and beneficiaries who qualify for Medicare Part D of the creditable or non-creditable status of the group health plan prescription drug plan(s). When prescription medication coverage meets or exceeds Medicare Part D, it is considered creditable. Any coverage that falls short of Medicare Part D’s quality standards is deemed non-creditable As previously reported, the Inflation Reduction Act of 2022 (“IRA”) changed aspects of the Medicare Part D program to enhance and improve Medicare Part D coverage. The changes include: As a result of these changes, some employer sponsored prescription drug coverage may no longer qualify as creditable… Read More

Ready for another year of helping clients who get their health insurance through Pennie!

September 8, 2024September 8, 2024Ed MacConnell

Ready for another year of helping clients who get their health insurance through Pennie! Open enrollment starts November 1st 2024 and ends January 15th 2025! (215)355-2121 https://lnkd.in/bhhqqAJ

Individual Health Insurance help is available for employer groups!

September 6, 2024September 6, 2024Ed MacConnell

Why do group clients need help with an Individual health insurance expert? Here are some scenarios when groups need individual solutions:

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

CMS Releases 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration

August 2, 2024August 2, 2024Ed MacConnell

The Centers for Medicare & Medicaid Services (CMS) is releasing preliminary technical Medicare Part D bid information for contract year 2025 to help Part D plan sponsors finalize their Part D and Medicare Advantage (MA) offerings and prepare for Medicare Open Enrollment. Additionally, CMS is announcing a voluntary demonstration to support implementation of the redesigned Part D benefit and improve stability for people with Medicare in 2025. The preliminary average Part D premiums will be released later this summer. CMS will release the 2025 landscape in mid-to-late September, as in past years, once all offerings are finalized. Final average MA premiums and deductibles, along with other key information, are released annually in September with the… 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.

Disaster Special Election Periods in several states

July 15, 2024July 12, 2024Mirasol Bandong

This is an important announcement for customers in Arizona, California, Florida, Iowa, Kansas, Maryland, Minnesota, New Mexico, North Carolina, Oregon, Texas and West Virginia and for those with business in these states. The counties below are under a federal or state designated SEP due to an emergency. Applications for disaster SEP are only accepted as long as the SEP declaration is in place. For the most recent information, if a deadline is not specified below, please use Producers’ University’s Ongoing SEP tracker. Applications for SEPs submitted after the declaration date of that SEP will not be accepted. IMPORTANT : Please be aware The SEP begins on the date of the incident’s start, if that occurs earlier, or on… Read More

Medicare Part D’s new $2,000 annual cap on out-of-pocket prescription costs.

July 3, 2024July 2, 2024Mirasol Bandong

There are significant changes coming to Medicare Part D plans in 2025. In 2024 once your out-of-pocket spending on prescriptions tops about $3,300, you qualify for Medicare’s “catastrophic coverage” and pay nothing for your covered Part D drugs for the rest of the year. (In 2023, once you hit catastrophic coverage, you still owed 5% of your drug costs.) But come 2025, people with Part D plans won’t have to pay more than $2,000 in out-of-pocket costs, thanks to a provision in the Inflation Reduction Act of 2022. This new rule applies only to medications covered by your Part D plan, though, and does not apply to out-of-pocket spending on… Read More

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