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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How to File a Medicare Appeal

Medicare beneficiaries have the right to file an appeal when they or their physicians disagree with a treatment or claim denial. Luckily Medicare provides a step by step instruction guide to filing those appeals. Please click the link below to downlead the Medicare appeals guide. As always please contact your Total Benefit Solutions Inc Medicare health insurance specialist at (215)355-2121 if you have any additional questions or concerns.

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Blue KC: Members Can Soon Access Rx Savings Solutions and Find Care in One Place

In October, Rx Savings Solutions will integrate with the Find Care tool on MyBlueKC.com and the MyBlueKC mobile app. Rx Savings Solutions is a secure, online tool that helps eligible members find ways to save money on prescription drugs. Once integrated, the two tools will allow members to view medical and pharmacy in one place and better use both tools. The integration is one way we’re helping reduce the total cost of care for members, employers, and health plans. Eligible members can follow this path to Rx Savings Solutions: MyBlueKC.com Click Find Care in the left column Click Find Doctors, Specialists & Hospitals Click Medication Finder Have any questions regarding… Read More

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A new group health insurance offering for small businesses. Introducing CIGNA + Oscar

We’ve partnered with Cigna + Oscar to deliver small business health insurance that brings together Cigna’s most popular provider networks and Oscar’s tech-driven approach to customer service and care navigation. Cigna + Oscar plans are available in the Philadelphia 5 county area beginning with effective dates starting January 1 2023. Your Total Benefit Solutions, Inc health insurance specialists are available to help you quote and compare plans. Call us today to get your quote and compare these newest plans to your current renewal. You might be surprised at the competitive cost and plan designs! (215)355-2121

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Part D Senior Savings Model: Will step therapy apply with insulin drugs?

Step therapy is when a Part D plan requires enrollees to first try certain drugs to treat a medical condition before the plan will cover another drug for that condition. The Model doesn’t change Part D sponsors’ formulary requirements. Enrollees can find out if the insulin or insulins they use have any additional step therapy requirements or limits by looking at the Part D plan’s formulary. Have any questions regarding this notice? Please contact your Total Benefit Solutions Medicare health insurance specialists at (215)355-2121.

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Can consumers who qualify for COBRA continuation coverage opt out of it and get coverage through the Marketplace instead?

Consumers who qualify for COBRA coverage can opt out of it and enroll in Marketplace coverage. However, voluntarily terminating COBRA continuation coverage does not make a consumer eligible for a Special Enrollment Period (SEP) based on loss of the COBRA continuation coverage. Note that all qualified enrollees eligible for COBRA continuation coverage can get the Marketplace subsidy, not just the employee who qualifies for the COBRA benefit, as long as they are not actually enrolled in the COBRA continuation coverage. Please contact your trusted Total Benefit Solutions health insurance specialists with any questions or concerns at (215)355-2121.

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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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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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Health Insurer Ordered to Stop Selling in Washington

Medova Healthcare, which sold illegal insurance plans through chambers of commerce, has agreed to stop selling in Washington, according to the Office of the Insurance Commissioner. The company also agreed to a $310,000 suspended fine, according to the OIC. It operated in 38 states including Washington and served 35,000 employees nationwide. Medova sold health insurance plans to almost 140 small businesses in the state, covering 1,487 employees, through chambers of commerce. One of them mentioned in the OIC investigation was the Lakewood Chamber of Commerce. The chamber did not respond to inquiries. The health plans were marketed to small businesses as traditional insurance plans, but they were self-funded Employment Retirement… Read More

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Prescription Drug Provisions in the Inflation Reduction Act

For the first time, requires the federal government to negotiate prices for some top-selling drugs covered under Medicare Requires drug companies to pay rebates if prices rise faster than inflation for drugs used by Medicare beneficiaries Eliminates 5% coinsurance for catastrophic coverage in Medicare Part D in 2024, adds a $2,000 cap on Part D out-of-pocket spending in 2025, and limits annual increases in Part D premiums for 2024-2030 Limits monthly cost sharing for insulin products to $35 for people with Medicare Expands eligibility for Medicare Part D Low-Income Subsidy full benefits Eliminates cost sharing for adult vaccines covered under Medicare Part D and improves access to adult vaccines under… Read More

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Open Enrollment Tips!

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

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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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What is an Out-of-Pocket Maximum/Limit?

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs covered benefits. The out-of-pocket limit doesn’t include: Your monthly premiums Anything you spend for services your plan doesn’t cover Out-of-network care and services Costs above the allowed amount for a service that a provider may charge The out-of-pocket limit for Marketplace plans varies, but can’t go over a set amount each year. For the 2022 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,700 for an individual and $17,400… Read More

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The Employer Shared Responsibility Provision Estimator

The Taxpayer Advocate Service developed the Employer Shared Responsibility Provision (ESRP) Estimator to help employers understand how the provision works and learns how the provision may apply to them. The provision applies to applicable large employers – generally, that means employers that had an average of at least 50 full-time employees (including full-time equivalent employees-FTEs), during the preceding calendar year. If you are an employer, you can use the estimator to determine: The number of your full-time employees, including FTEs, Whether you might be an applicable large employers, and If you are an applicable large employer, an estimate of the maximum amount of the potential liability for the employer shared… 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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When is the Part D Senior Saving Model expected to end? How many years is the model?

Since CMS is testing the Part D Senior Savings Model to lower costs and improve health care quality, it has a set period for when it’s available. Part D plans participating in the Model first became available on January 1, 2021. The Model extends until December 31, 2025, but the plans participating in the Model may change each year. Please contact your Total Benefit Solutions Medicare health insurance specialists at (215)355-2121, if you have any questions or concerns.

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Medigap Open Enrollment Period

Most beneficiaries get ONE Medigap Open Enrollment Period. The Medigap Open Enrollment Period cannot be changed or repeated. Under 65 Medicare beneficiaries get another Medigap Open Enrollment Period when they turn 65. As always, please contact your Total Benefit Solutions, Inc health insurance specialists with any questions or concerns at (215)355-2121.

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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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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 a Medicare Coverage Gap?

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again. As always, please contact your Total Benefit Solutions Medicare health insurance specialists today at (215)355-2121.

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Guaranteed Issue Rights

Guaranteed Issue (GI) rights are rights the beneficiary has in certain situations when insurance companies must offer certain Medigap policies. There are ONLY 7 situations where Guaranteed Issue Rights apply. Two of the most common are: Beneficiary is in a Medicare Advantage Plan, and the plan is leaving Medicare or stops giving care in their area, or the beneficiary moves out of the Medicare Advantage plan’s service area. Beneficiary has Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending. Just like with the Medigap Open Enrollment Period, during a Guaranteed Issue: No eligibility… Read More

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