Using your health insurance coverage & getting emergency care

In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can’t charge you more for getting emergency room services at an out-of-network hospital. I’m having an emergency. Should I go straight to the hospital or do I need to call my insurer first? In a true emergency, go straight to the hospital. Insurers can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network. What does it mean that insurance companies can’t charge me more? Insurance plans can’t make you pay… Read More

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Blue KC: Three hospitals added to BlueSelect Plus, BlueSelect networks

The BlueSelect Plus and BlueSelect networks have expanded their footprints. On November 15, three hospitals – Providence Medical Center, St. Joseph Medical Center, and St. Mary’s Medical Center – joined the networks, increasing the number of hospitals to 16 in BlueSelect Plus and 14 in BlueSelect. The addition of these hospitals applies to: Hospitals in BlueSelect Plus network The BlueSelect Plus network includes: AdventHealth College Boulevard; AdventHealth Shawnee Mission; AdventHealth South Overland Park; Cameron Regional Medical Center; Children’s Mercy Hospital; Children’s Mercy Hospital – South; Liberty Hospital; North Kansas City Hospital; Olathe Medical Center; Providence Medical Center; St. Joseph Medical Center; St. Mary’s Medical Center; University Health Truman Medical Center;… Read More

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What are Qualified Medical Expenses?

Qualified Medical Expenses are generally the same types of services and products that otherwise could be deducted as medical expenses on your yearly income tax return. Some Qualified Medical Expenses, like doctors’ visits, lab tests, and hospital stays, are also Medicare-covered services. Services like dental and vision care are Qualified Medical Expenses, but aren’t covered by Medicare. Qualified Medical Expenses could count toward your Medicare MSA Plan deductible only if the expenses are for Medicare-covered Part A and Part B services. Each year, you should get a 1099-SA form from your bank that includes all of the withdrawals from your account. You’ll need to show that you’ve had Qualified Medical… Read More

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What is the total cost estimate for health coverage?

The total amount you may have to pay for health plan coverage, which is estimated before you actually have the coverage and have health expenses under the coverage. Generally, your total cost is your premium + deductible + out-of-pocket costs + any copayments/coinsurance. When you preview plans at Healthcare.gov, you’ll see an estimate of your total costs, but your actual expenses will likely vary. Have any questions regarding this notice? Please contact your Total Benefit Solutions health insurance specialists at (215)355-2121.

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Beam Teams with Angle Health to Deliver Dynamic Employee Benefits

Beam Dental is partnered with Angle Health, a digital-first healthcare benefits providers for the modern employee. Through the partnership with Beam, Angle can now attach best-in-class dental benefits to their innovative healthcare products, creating a more comprehensive and robust benefits package for employers. “There is tremendous activity and innovation in the small group health space right now. Angle is an exciting addition to this space,” said Andy Hutter, Beam’s Director of Digital Distribution. “Angle’s vision for modernizing healthcare aligns well with Beam’s own vision, and we are very excited to deliver a powerful combination of innovative coverage to the market.” Beam is changing and modernizing the dental insurance industry by… Read More

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Open Enrollment Tips from Total Benefit Solutions!

As always, please contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.

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Inflation Reduction Act: Eliminates Cost Sharing for Adult Vaccines in Medicare Part D and Improves Access to Adult Vaccines in Medicaid & CHIP

Medicare Part D: Eliminates cost sharing for adult vaccines covered under Medicare Part D that are recommended by the Advisory Committee on Immunization Practices (ACIP), such as for shingles Medicaid and CHIP: Requires state Medicaid and CHIP programs to cover all approved vaccines recommended by ACIP and vaccine administration, without cost sharing Have any questions regarding this notice? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.

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Inflation Reduction Act: Expands Eligibility for Full Benefits Under the Medicare Part D Low-Income Subsidy Program

The Part D Low-Income Subsidy (LIS) Program helps beneficiaries with their Part D premiums, deductibles, and cost sharing. Beneficiaries qualify for full or partial benefits depending on their income and resources. Current law: Beneficiaries qualify for full LIS benefits if they have income up to 135% of poverty and lower resources (up to $9,900 individual, $15,600 couple in 2022) Beneficiaries qualify for partial LIS benefits if they have income between 135-150% of poverty and higher resources (up to $15,510 individual, $30,950 couple in 2022) Inflation Reduction Act: Expands eligibility for full LIS benefits to individuals with incomes between 135% and 150% of poverty and higher resources (at or below the… Read More

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Inflation Reduction Act: Limits Monthly Copayments for Insulin in Medicare

Beginning in 2023, limits copayments to $35 per month per prescription for covered insulin products in Medicare Part D plans and for insulin furnished through durable medical equipment under Medicare Part B, with no deductible. For 2026 and beyond, limits monthly Part D copayments for insulin to the lesser of: $35 25% of the maximum fair price (in cases where the insulin product has been selected for negotiation) 25% of the negotiated price in Part D plans Please call your Total Benefit Solutions Medicare health insurance specialists with any questions or concerns at (215)355-2121.

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Reminder: New Cost-Sharing Disclosure in 2023

Another compliance deadline is quickly approaching. For plan years that begin on or after January 1, 2023, group health plans must provide for advance disclosure of cost-sharing information to enrollees seeking health services, upon request and to the extent practicable. The format of the disclosure is through an internet-based self-service tool, telephone, or paper format (upon request). The tool allows the enrollee to compare the amount of cost-sharing that he or she would be responsible for with respect to a discrete covered item or service by billing code or descriptive term. The required information relates to geographic region and in-network and out-of-network providers and initially addresses 500 items and services.… 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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What Insulin Drugs are Covered Under the Part D Senior Savings Model?

Part D sponsors are required to include at least one vial and pen dosage form for each of the different types of Model insulins, where available – rapid acting, short-acting, intermediate-acting and long-acting – at a maximum $35 copay for a one-month supply through the deductible, initial coverage, and coverage gap phases of the benefit. Part D sponsors are encouraged to include additional insulin formulations, such as concentrated insulins, at the same $35 copay for a one-month supply. The Model doesn’t affect the cost sharing of insulin covered under Part B. For a full list of the insulin drugs covered by each plan, as well as which drugs are covered… Read More

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2018 Individual Health Insurance Open Enrollment: PA Independence Individual Consumer Plans and Rates

  Individual Health Insurance Open Enrollment 2018! Don’t do it yourself! Our dedicated professionals are here to help you take the fits out of the benefit planning process!  One mistake and you could be stuck with a bad plan all year! We work with all available plans both on the healthcare.gov marketplace and off! Have your own expert help you! Our experts are trained to help you Choose between on and off exchange options Maximize any subsidy eligibility. Help you understand the cost sharing subsidies Help you choose the plan that is the best fit for you Explain the differences between the plan design and your out of pocket expectations Fill… Read More

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SHOP Rules Finalized, Enrollment Forms Simplified

The Small Business Health Options Program’s (SHOP) place along the Affordable Care Act’s (ACA) timeline. It’s now being packaged for mass consumption and soon will be stocked on store shelves across all 50 states. Click here to read more…

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New York Health Exchanges Offer 50% Drop in Premiums

Empire State approves plans to be sold by 17 insurers and lower expected premiums may ease fears that next year’s implementation of the biggest parts of the Affordable Care Act would send prices soaring… Click here to read the story

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IBC: Important change to claims processing for PPO plans

Independence Blue Cross (IBC) will begin notifying customers later this week regarding a change in how claims for certain out-of-network providers will be processed under their IBC Personal Choice® PPO health plan. This change impacts fully insured, self-funded, and Individual commercial Personal Choice® PPO plans only. There is no impact to Medicare plans. Effective November 1, 2013, members who have claims submitted by providers who participate in the Highmark Blue Shield (Highmark) professional provider network inside IBC’s five-county service area will be subject to higher out-of-pocket costs and may also be subject to balance billing. Currently, claims submitted by a participating Highmark professional provider are processed as out of network and applied… Read More

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Health Reform: Research Filing Fees Due July 31

The Research Fee filing deadline is July 31, 2013 for self-funded medical plans and HRAs  Insurance carriers will report and pay the Fee for fully insured plans.  If an employer has several self-insured arrangements with the same plan year, they are subject to a single fee.  An HRA integrated with a self-funded plan providing major medical coverage will not incur a separate fee specific to the HRA if the HRA and plan are established or maintained by the same plan sponsor.  Click below to download the bulletin   Research Fees Due    Interested in our free Health Care Reform Checklist? send an email  

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Health Reform: Aetna to distribute MLR rebates

By August 1st, Aetna is scheduled to mail rebate notices and checks to policyholders and subscribers whose plans are due a rebate under the Minimum Medical Loss Ratio provision of the Affordable Care Act. For group plans, rebate checks will be sent to the policyholder, with few exceptions. Please click the link below to download the bulletin. Click to download

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NJDOBI Issues Amendments to Rating Rules under PPACA

NJDOBI Issues Amendments to IHC and SEH Rating Rules under PPACA For rates applicable to all rating periods beginning on or after January 1, 2014, carriers are directed to: Formulate rates in the IHC market to achieve a required 300 percent maximum ratio between premiums for the highest rated individual policyholder and the lowest rated individual policyholder in the State. Age factor categories should be in the following increments: children ages 0 through 20, one-year age bands for adults ages 21 through 63, and a single age band for adults ages 64 and over; Formulate rates in the SEH market without regard to gender. Age factor categories should be in… Read More

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Healtcare Reform Law

Health Insurance Marketplaces (Exchanges): Informational Video

Beginning in 2014, individuals and small businesses with up to 50 employees can purchase insurance through online exchanges, also called “health insurance marketplaces.” Each exchange will offer a choice of health plans that meet certain benefit and cost standards. In 2016, businesses with up to 100 employees will be able to participate. Coventry Health/Aetna recently released this easy to understand video that may help you understand the new exchange or” marketplace” system of buying health insurance. Click here to watch the six minute long video.

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Medicare: What Will Happen to Doctors’ Fees and Income Under the Affordable Care Act (ACA)?

Q:What Will Happen to Doctors’ Fees and Income Under the Affordable Care Act (ACA)? A: Business income has increased for doctors because many people on Medicare are now using free screenings and an annual “wellness visit” provided through the Affordable Care Act (ACA). Through Oct. 6, 2011, the government said, 20.5 million people enrolled in Medicare had received the free screenings or the annual visit, which is also free. Medicare is now offering a 10 percent bonus payment on the fees charged for primary care services, and a 10 percent bonus payment to surgeons who work in areas where there are shortages of doctors. For 2013 and 2014, Medicaid payments… Read More

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Total Benefit Solutions Newest Brochure

  Download our latest brochure to read all about the valuable services we provide for our clients! Download our latest employee benefits brochure

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PPACA employer mandate delayed until 2015

PPACA employer mandate delayed until 2015 The Obama administration unexpectedly announced Tuesday it is delaying the employer mandate under the Patient Protection and Affordable Care Act until 2015. The mandate — which requires mid-sized and large employers to offer health insurance coverage to their workers — was one of the main requirements of the health care overhaul that was set to go into effect Jan. 1, 2014. But the Treasury Department announced Tuesday that it would delay its enforcement an entire year after hearing numerous concerns from employers about the challenges of its implementation. “We have heard concerns about the complexity of the requirements and the need for more time to implement… Read More

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Prodigy Learning Center’s Executive Director is a Happy Client

Hi Ed, I just wanted to let you know how great (our account manager) has been with our insurance issues. She has been so helpful to me. I don’t know if people take the time to tell you when your staff is doing a great job, but I wanted to let you know. She is great!!   Thanks. Christine Viteo, R.N. Executive Director Prodigy Learning Center Philadelphia, Pa.19132

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