UCR vs MAC Dental plans. What’s the difference?

  When members use an OON (out-of-network) provider, the cost of their procedures may vary from that which they’d see INN (in-network). UCR (Usual, Customary and Reasonable) and MAC (Maximum Allowable Cost) determine how their dental insurance will pay for the procedures. UCR (Usual, Customary and Reasonable)If a member has a UCR-based plan, providers charge a fee that has been set as the most commonly charged amount for that procedurein that location. This reimbursed amount is determined by analyzing claims data in a specific geographic location. MAC: Maximum Allowable ChargeIf a member has a MAC-based plan, providers charge any fee that they have set for a procedure. The reimbursed amount… Read More

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HHS Extends Public Health Emergency until July 20, 2021

The COVID-19 pandemic Public Health Emergency, scheduled to expire on April 21, 2021, was renewed. This will once again extend the period for an additional 90 days and as a result, numerous temporary benefit plan changes will remain in effect. Click to Download _HHS_Extends_Public_Health_Emergency_until_July_20_2021

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IBC: MLR Additional Rebates

Notice from Independence Blue Cross: Health insurance premium rebates for 2017 Small Group policyholders and 2018 Consumer policyholders As a result of a United States Supreme Court decision last year, Independence received additional payment from the Federal Government that impacted our Medical Loss Ratio (MLR) for 2017 and 2018. Beginning the week of May 17, Small Group policyholders from 2017 and Consumer policyholders from 2018 will receive checks that are a rebate for a portion of their health insurance premiums for that year. What is MLR? The Affordable Care Act requires that all health insurers spend a percentage of each premium dollar received towards paying claims, clinical services, and activities that improve health care quality for… Read More

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5 reasons you may want to switch Medigap policies

Switching Medigap policies 5 reasons you may want to switch Medigap policies You’re paying for benefits you don’t need. You need more benefits. You want to change your insurance company. You want a policy that costs less. Can I switch policies? In most cases, you will not have a right under federal law to switch Medigap policies, unless one of these applies: You’re eligible under a specific circumstance or guaranteed issue rights You’re within your 6-month Medigap open enrollment period You don’t have to wait a certain length of time after buying your first Medigap policy before you can switch to a different Medigap policy. Note As of January 1, 2020,… Read More

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BCBS Antitrust Litigation and Tentative Settlement –Impact on Group Health Plans

    BCBS Antitrust Litigation and Tentative Settlement – Impact on Group Health Plans   This material was updated on March 22, 2021, to include new information posted on the settlement website. Please refer to the BCBS settlement page and/or materials from the specific BCBS carrier for more information. Antitrust litigation that commenced against the Blue Cross Blue Shield Association and member companies1 in 2012 appears to be coming to a settlement. In short, plaintiffs alleged that Blue Cross Blue Shield companies across the country entered into agreements not to compete with each other for customers of health insurance. On November 30, 2020, the court preliminarily approved a proposed settlement… Read More

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What is a Medicare Medical Savings Account Plan?

A Medicare Medical Savings Account plan (MSA) is a special type of Medicare Advantage plan (Part C). This type of plan may offer the freedom of choice for people who want more control over their health care dollars and decisions. And along with the autonomy come some responsibilities. There are two important parts to a Medicare MSA plan. A special bank savings accountA high-deductible health plan The Medicare Savings Account Plan Special Bank Savings Account The savings account part of a Medicare MSA plan is self-managed like any other bank savings account. One main difference is that the account is funded with money from Medicare versus by you. Medicare beneficiaries… Read More

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Update on COVID-19 Vaccine and Vaccine Administration Cost

Update on COVID-19 Vaccine and Vaccine Administration Cost Medicare has increased and simplified its payment rate for administration of the COVID-19 vaccine to $40 per dose. This change may impact group health plans with respect to their payment rate to providers. Non-grandfathered group health plans are required to cover, without cost sharing, the COVID-19 vaccine. This obligation extended to coverage associated with administering the vaccine. The federal government continues to pay for the vaccine itself through funding authorized by the CARES Act.For vaccines administered in-network, plans will pay the rate negotiated with in-network providers, and that continues to be true. For vaccines administered out-of-network, however, group health plans must reimburse… Read More

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Indy Medicare Part D Health Plan Terminated

Indy Health Insurance Company, a stand-alone Part D plan in Arkansas, Pennsylvania, West Virginia, Illinois, and Georgia has been terminated.

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Tax Advantaged Benefit Documents

The IRS Code has numerous provisions designed to help employers provide essential benefits to their employees tax-free. This saves the employee approximately 30% in income taxes on expenses they’re already paying for, and because the employees have reduced their taxable income, the employer realizes a reduced matching payroll tax liability of approximately 8%. Everybody saves money.    To take advantage of these tax deductions the IRS requires that the employer have a written plan document and the Department of Labor and ERISA law require that every employee receive a summary plan description (SPD) explaining the new benefit in easy to understand language.   This site is dedicated to providing employers… Read More

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COVID-19 PPE Now a Qualified Medical Expense

On March 26, 2021, the IRS issued IRS Announcement 2021-7, which clarifies that amounts paid for certain personal protective equipment (“COVID-19 PPE”) used to prevent the spread of COVID-19, including masks, hand sanitizer and sanitizing wipes can be treated as amounts paid for medical care under § 213(d) of the Internal Revenue Code. Accordingly, because these amounts are expenses for medical care under § 213(d) of the Internal Revenue Code, these amounts can also be eligible expenses under a health flexible spending account (health FSA), health savings accounts (HSAs), health reimbursement arrangements (HRAs) and Archer medical savings accounts (Archer MSAs). Note, that if the amount is paid or reimbursed under… Read More

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Heard of Reference Based Pricing Health Insurance?

Reference-based pricing is a payment system that replaces or enhances a health plan’s traditional “usual and customary” pricing for contracted claims. Rather than calculating the average charge of providers in a geographic area or a pre-contracted cost, a health plan utilizing reference-based pricing instead arbitrates its allowable amount for medical claims based on its chosen method (most commonly Medicare rates, or a certain percentage above those rates), which is a price that the payor deems reasonable. In other words the employer, the payor brings their rates with them into the health care agreement, not the other way around. This represents a much more independent framework for determining sensible health care… Read More

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What are Commuter or Transit Benefits (Section 132)?

Commuter or Transit Benefits (Section 132) Parking & mass transit expenses may be paid for with pre-tax dollars through a commuter plan. This plan is a straightforward way for participants to reduce their commuting costs and for employers to gain additional payroll tax reductions. Some states, like NY and NJ have mandated the inclusion of commuter benefit plans over the last few years. A commuter benefit plan is typically offered as one component of a Flexible Spending Account (Section 125) What expenses qualify as commuter/transit benefits? Commuter highway vehicle: A commuter vehicle is any highway vehicle that seats at least 6 adults (not including the driver). In addition, you must reasonably… Read More

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How Safe Is it to Return to Work Once You Are Vaccinated?

There are a lot of things we don’t know yet. Answer by Kara Govro, Senior HR Law Analyst With vaccines rolling out among select populations, can employers start to bring back vaccinated employees into the office? originally appeared on Quora, the place to gain and share knowledge, empowering people to learn from others and better understand the world. As long as employers are complying with state and local law, they can bring employees back whenever they think is prudent… Click here for the full storyhttps://apple.news/A3Zt-q6uTReW37kaI3Z4O8A

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How Does Level Self Funded Health Insurance Work?

We have received a lot of questions regarding the new level funding health benefit programs so we prepared this video to make it a little easier to understand. Ask us today if Level Funding your group’s health insurance might be a good for for your health plan! Contact your Total Benefit Solutions Account manager at (215)355-2121.

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Can Employers Legally Mandate The COVID Vaccine To Return To Work?

Can employers mandate their employees get the COVID vaccine before coming back to the office? originally appeared on Quora: the place to gain and share knowledge, empowering people to learn from others and better understand the world.  Answer by Kara Govro, Senior HR Law Analyst, on Quora: With COVID-19 vaccinations underway and widespread availability in sight, many employers want to know whether they can require their employees to get the vaccine. Click here for the full story

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PPE and Health FSA/HRA

The IRS announced that amounts paid for personal protective equipment such as masks, hand sanitizer and sanitizing wipes for the primary purpose of preventing the spread of COVID-19 are considered amounts paid for medical care under section 213 of the Internal Revenue Code. These items are now allowed to be reimbursed from a health FSA. The IRS notice recognizes all forms of PPE as expenses medical care and does not limit the PPE to just disposable or non-disposable items. Reimbursements are permitted for expenses incurred on or after 1/1/2020 and they must be properly documented for reimbursement. If plan terms do not allow the reimbursement of PPE but the plan… Read More

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Does Medicare Cover Oral Surgery?

From our partners at HealthLine: If you’re eligible for Medicare and considering oral surgery, you have options to help cover the costs. While original Medicare does not cover dental services that are required specifically for tooth or gum health, it may cover oral surgery for medical conditions. Some Medicare Part C (Medicare Advantage) plans also offer dental coverage. Let’s explore which types of oral surgery Medicare covers and why.   Click here for the full story. Questions about this story or Medicare coverages? Please contact your health insurance specialists at Total Benefit  Benefit Solutions, Inc (215)355-2121  

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Impact of Key Provisions of the American Rescue Plan Act of 2021 COVID-19 Relief on Marketplace Premiums

there are millions of uninsured people who could be getting subsidized coverage on the ACA Marketplaces, but have not taken advantage of this financial help. In many cases, it may be that the financial help available to them is not sufficient to make the premium or the deductible affordable

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ARPA Extends Open Enrollment for Individual Coverage in PA

Pennie (PA Individual Exchange) has communicated that they will be extending the open enrollment period from May 15 until August 15, 2021. This extension is to help consumers be able to take advantage of the benefits of the American Rescue Plan. Some of the key benefits of this plan are below: There is no longer a cap on who is eligible for Pennie’s income-based tax credits, which help reduce monthly premium costs. Previously only people whose household income was under 400% of federal poverty level (about $51,000 for an individual), could qualify for a tax credit. Now, anyone may be eligible for a tax credit. The size of the tax… Read More

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Enrollment Period at Get Covered New Jersey Extended

More information on the American Rescue Plan Act changes may be found on the Get Covered New Jersey website. Contact your Total Benefit Solutions, Inc health insurance specialist to get enrolled or if you have any questions or concerns at (215)355-2121

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What is Minimum Essential Coverage or MEC health insurance?

The Affordable Care Act states that all individuals must have health benefits and all employers with 50 or more full-time employees must provide coverage to all eligible employees or they are subject to fines/penalties. This can be known as “pay or play” or employer shared responsibility. We offer Minimum Essential Coverage plans which both penalties are satisfied for the employee and the employer. MEC plans are substantially less expensive than traditional medical insurance and serve as a low-cost solution for most companies. To contain healthcare costs, many employers and other plan sponsors are considering Minimum Essential Coverage, or MEC, health insurance. MEC plans can keep your workforce healthier. Preventable diseases, gone… Read More

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Independence Blue Cross COVID-19 claim forms

Independence Blue Cross COVID-19 claim forms

Click on the proper link below to download the COVID-19 Claim form
you need !

As always please reach out to your Total Benefit Solutions, Inc
health insurance specialist at (215)355-2121 for any questions or concerns.

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How the COVID-19 Relief Bill Helps Older Adults and People with Disabilities

The recent COVID-19 relief bill, the American Rescue Plan (ARP), makes important changes to help older adults, people with disabilities, and families amid the pandemic and its economic fallout. The $1.9 trillion package signed into law by President Biden includes several of the Medicare Rights Center’s priorities and related reforms that will ease health care access and affordability, strengthen economic security, and advance equity. Key provisions include..Click here for the full story from Medicare Watch

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Copays vs Coinsurance: What is the employer impact?

In a recent study, the Employee Benefits Research Institute examined the differential effect of copayments and coinsurance on health care services. They found that coinsurance reduces inpatient care and specialist physician office visits, but copayments do not. Specifically: For inpatient health care, each 1 percent increase in coinsurance led to a 0.18 percent decrease in utilization. For specialty physician office visits, each 1 percent increase in coinsurance led to a 0.19 percent decrease in utilization. Those who were more likely to want a telehealth visit but did not receive one were more likely to have an unmet need for care because of the pandemic. There was no evidence that demand… Read More

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Health Insurance: What Do You Pay for?

What Is a Monthly Premium? Your monthly premium is the set amount you pay each month to have your plan. You pay it even if you don’t receive any medical care that month. Like other bills, this premium can rise when it’s time to renew your plan for the next year. For individual ACA compliant plans, premiums are based on a pre-approved age based grid.  When you enter a age on the grid, your premium will increase on your bill. What Are Out-of-Pocket Costs? Out-of-pocket costs are what you must pay when you get care. These costs depend on how much care you actually get and if you have a… Read More

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