Every year, insurance carriers are required to meet specific Medical Loss Ratio (MLR) thresholds, ensuring that a significant portion of collected premiums goes toward medical care and improving healthcare quality. For the large group market, this threshold stands at 85 cents for every premium dollar collected, while in the small group market, it’s 80 cents. If these thresholds are not met, employers are in for a timely financial boost, in the form of premium credits or checks. MLR Rebate Deadline: September 30, 2023 The clock is ticking. If your insurance carrier falls short of the MLR threshold, they are obligated to distribute MLR checks to employers by September 30, 2023.… Read More
Continue ReadingWhat are the preferred plans for insured employees?
Preferred Provider Organization plans remain the most common plan type. Nearly half (49%) of insured employees enrolled in a PPO in 2022. That compares to 29% enrolled in an HDHP, 12% enrolled in an HMO, nine percent in a Point-of-Service (POS) plan, and one percent in a conventional (indemnity) plan. If you have any questions or concerns about this bulletin, please contact your Total Benefit Solutions Inc health insurance account manager at (215) 355-2121
Continue ReadingHow much do employees contribute towards their insurance expenses?
Average Contributions Most employees do make a contribution toward their insurance costs. Covered workers, on average, contribute 17% of the premium for single coverage and 28% of the premium for family coverage. These numbers are similar to those reported by KFF in its EHBS in 2021. The average contribution for workers at small firms is $7,556, which is more than a third higher than the average for those at large firms ($5,580). Workers at private, for-profit firms contribute a higher percentage of the premium versus those at public firms, regardless of coverage type. A fortunate one-third of employees (33%) at small firms are enrolled in coverage where the employer pays… Read More
Continue Reading10 Things to Know About Medicaid Managed Care
Managed care is the dominant delivery system for Medicaid enrollees. With 72% of Medicaid beneficiaries enrolled in comprehensive managed care organizations (MCOs) nationally, plans have played a key role in responding to the COVID-19 pandemic and are expected to work with states in conducting outreach and providing support to enrollees during the unwinding of the continuous enrollment requirement. While managed care is the dominant Medicaid delivery system, states decide which populations and services to include in managed care arrangements which leads to considerable variation across states. Additionally, while we can track state requirements for Medicaid managed care plans, plans have flexibility in certain areas including in setting provider payment rates… Read More
Continue ReadingWhat is cost sharing reduction (CSR)?
A discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. In the Health Insurance Marketplace®, cost-sharing reductions are often called “extra savings.” If you qualify, you must enroll in a plan in the Silver category to get the extra savings. Have any questions regarding this notice? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.
Continue ReadingACA special enrollment period opens soon for people losing Medicaid coverage
The Centers for Medicare and Medicaid Services (CMS) will open an ACA special enrollment period (SEP) for people losing Medicaid coverage due to the end of the COVID-19 public health emergency (PHE). The PHE ends May 11. The ACA SEP aims to maintain continuity of coverage as people transition from Medicaid into a Marketplace-qualified health plan. It runs March 31 to July 31, 2023. Have any questions regarding this notice? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.
Continue ReadingThe End of COVID-19 Public Health Emergency: How will telemedicine be affected?
On Jan. 30, 2023, the Biden Administration announce it will end the public health emergency (and national emergency) declarations on May 11, 2023. Telemedicine What’s changing: Some flexibilities associated with providing health care via telehealth during the public health emergency will end. What’s the same: Expanded telehealth for Medicare beneficiaries was once tied to the public health emergency but, due to recent legislation, will remain unchanged through December 31, 2024. Most private insurers already covered telemedicine before the pandemic. In Medicaid, states have broad authority to cover telehealth without federal approval. Most states have made, or plan to make, some Medicaid telehealth flexibilities permanent. Have any questions regarding this notice?… Read More
Continue ReadingWhat is an agent and broker?
A trained insurance professional who can help you enroll in a health insurance plan. Agents may work or a single health insurance company; brokers may represent several companies. You won’t pay anything additional if you enroll with an agent or broker. As always, don’t hesitate to contact your Total Benefit Solutions health insurance specialists with any questions or concerns today at (215)355-2121.
Continue ReadingThe End of COVID-19 Public Health Emergency: How will COVID treatments be affected?
On Jan. 30, 2023, the Biden Administration announced it will end the public health emergency (and national emergency) declarations on May 11, 2023. COVID Treatment What’s changing: People with public coverage may start to face new cost-sharing for pharmaceutical COVID treatments (unless those doses were purchased by the federal government). Medicare beneficiaries may fact cost-sharing requirements for certain COVID pharmaceutical treatments after May 11. Medicaid and CHIP programs will continue to cover all pharmaceutical treatments with no-cost sharing through September 2024. After that date, these treatments will continue to be covered; however, states may impose utilization limits and nominal cost-sharing. What’s the same: Any pharmaceutical treatment doses (e.g., Paxlovid) purchased… Read More
Continue ReadingWhat is a bronze health plan?
One of 4 plan categories (also known as “metal levels”) in the Health Insurance Marketplace®. Bronze plans usually have the lowest monthly premiums but the highest costs when you get care. They can be a good choice if you usually use few medical services and mostly want protection from very high costs if you get seriously sick or injured. Note: Bronze plan deductibles can be very high. This means you could have to pay thousands of dollars of health care costs yourself before your plan starts to pay its share. All health plans in all categories provide free preventive services, and some plans offer other services at low or no… Read More
Continue ReadingNotice: White House announces COVID-19 PHE and National Emergency will be allowed to expire
On January 30, 2023, the White House announced its plan to allow the COVID-19 Public Health Emergency (PHE) and National Emergency periods to expire on May 11, 2023. We have provided example scenarios in the Compliance Alert that demonstrate the impact of the national emergency period expiration. We encourage you to review each example to determine the impact on your specific plan(s). Although we encourage you to review the entire Compliance Alert, we have provided a summary of the content for your review: Public Health Emergency During the PHE, group health plans are required to cover the cost of COVID-19 tests and testing-related services without cost-sharing or prior authorization or… Read More
Continue ReadingWhat is the tax filing requirement?
The minimum amount (or threshold) of income requiring you to file a federal tax return. 2022 filing requirements for most taxpayers: Gross income of at least $12,950 (individuals) or $25,900 (married filing jointly). Different thresholds apply for dependents, people 65 and older, and those who use other tax filing statuses (like married filing separately). Have any questions regarding this notice? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.
Continue ReadingDo HSA’s, FSA’s, or HRA’s carryover or rollover?
Health Savings Account (HSA): All funds belong to the employee. Unused balances roll over into the next year. Funds do not expire from year-to-year. Rollover funds do not count towards the contribution limit. Health Flexible Spending Account (FSA): Amounts must be incurred by the end of the plan year and do not usually carry over unless an employer allows up to $610 to carry over into the next year. Amounts that roll do not affect the maximum election that can be made for the plan year. Otherwise, employers may adopt a 2 and half month grace period that allows participants to access unused amounts remaining in their accounts. Health Reimbursement… Read More
Continue ReadingSmall Group – Form 1095-B: Who receives it and why
Form 1095-B is a health insurance tax form used to report certain information to the IRS and taxpayers about individuals who are covered by Minimum Essential Coverage (MEC). What are the IRS reporting requirements? The ACA requires individuals to obtain and report that they had MEC or otherwise qualify for an exemption from the requirement. However, there is no longer an individual tax penalty following the 2017 Tax Cuts and Jobs Act. Individuals may need Form 1095-B to demonstrate MEC for nontax-related purposes. The ACA also requires certain employers to offer all full-time employees and their dependents MEC to meet affordability and minimum value standards. This is known as the… Read More
Continue ReadingThe End of the COVID-19 Public Health Emergency: How will at-home COVID tests be affected?
On Jan. 30, 2023, the Biden Administration announced it will end the public health emergency (and national emergency) declarations on May 11, 2023. At-home COVID tests What’s changing: At-home (or over-the counter) tests may become more costly for people with insurance. After May 11, 2023, people with traditional Medicare will no longer receive free, at-home tests. Those with private insurance and Medicare Advantage (private Medicare plans) no longer will be guaranteed free at-home tests, but some insurers may continue to voluntarily cover them. For those on Medicaid, at-home tests will be covered at no-cost through September 2024. After that date, home test coverage will vary by state. A temporary Medicaid… Read More
Continue ReadingUHC: Short Term Medical no longer offered in DE & SD, starting February 17, 2023
Effective February 17, 2023, the United Healthcare-branded Short Term Medical product, underwritten by Golden Rule Insurance Company will no longer be available for new sales in Delaware and South Dakota. View the updated product availability grid. This change does not affect existing business of this product in these states. Current customers can keep their coverage until the plan’s term date if they continue plan payments and meet the eligibility requirements of their plan. As always, don’t hesitate to contact your Total Benefit Solutions health insurance specialists with any questions or concerns today at (215)355-2121.
Continue ReadingMedicaid Redetermination
Pennsylvania resumed their redetermination process for current Medicaid members February 1, 2023. The Families First Coronavirus Response Act (FFCRA) provided states with additional Medicaid funding. To receive additional funding, a state was required to pause all Medicaid disenrollment. The pause on Medicaid disenrollment is now ending and states will resume Medicaid redeterminations of eligibility and disenrollment of those determined to be ineligible for Medicaid coverage. Loss of eligibility for Medicaid is a Qualifying Event for Special Enrollment on the Marketplace. Many of these individuals could be eligible for financial assistance on the Marketplace and will need enrollment assistance from a broker. Visit the Medicaid Redetermination Resource Center for important updates… Read More
Continue ReadingAir Ambulance Reporting Update
As previously reported, group health plans will be required to submit information related to air ambulance claims to the Department of Health and Human Services (“HHS”). In a September 2021 proposed rule, the regulators expected that rulemaking would be finalized during 2021, and that plans and carriers would be required to submit the data for calendar year 2022 by March 31, 2023, and the data for calendar year 2023 by March 31, 2024. However, under the statute, the reporting is not due until regulations are final, and the proposed rule has not been finalized. As a result, absent further guidance, there should be no reporting requirement in 2023. HHS has… Read More
Continue ReadingThe End of the COVID-19 Public Health Emergency: How will vaccines be affected?
On Jan. 30, 2023, the Biden Administration announced it will end the public health emergency (and national emergency) declarations on May 11, 2023. Vaccines What’s changing: Nothing. The availability, access, and costs of COVID-19 vaccines, including boosters, are determined by the supply of federally purchased vaccines, not the public health emergency. What’s the same: As long as federally purchased vaccines last, COVID-19 vaccines will remain free to all people, regardless of insurance coverage. Providers of federally purchased vaccines are not allowed to charge patients or deny vaccines based on the recipient’s coverage or network status. Although a federal rule temporarily required private insurers to reimburse out-of-network providers for vaccine administration… Read More
Continue ReadingStay Up to Date on the Affordability of Employer Coverage and the Family Glitch with These Resources
beginning on January 1, 2023, the new rule on affordability of employer coverage for the family members of employees went into place and changed how affordability is calculated for employees’ family members. To assist employers in understanding this rule change, the Centers for Medicare & Medicaid Services (CMS) created a resource outlining the most important takeaways for employers. Employers can use this resource to understand the family glitch and how it affects them and their employees. You can view this resource here. Have any questions regarding this notice? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.
Continue ReadingDo FSA’s and HRA’s have Reimbursable Expenses?
Health Flexible Spending Account (FSA) Health Reimbursement Arrangement (HRA) As always, don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.
Continue ReadingDoes a Health Savings Account (HSA) have Reimbursable Expenses?
Employees can use the HSA to pay for Code §213(d) medical expenses, expenses such as expenditures for medical care, to the extent that such amounts are not reimbursed by insurance or any other source. Medicines and drugs (other than insulin) can be qualified medical expenses only if they are prescribed. Under the CARES Act, employers can also allow for reimbursement of OTC drugs. With certain exceptions, qualified medical expenses do not include payments for health insurance premiums or coverage contributions toward self-funded health coverage. However, the expense for coverage under any of the following will be an HSA-qualified medical expenses: HSA funds may not be used to pay insurance premiums… Read More
Continue ReadingDOL Penalties Increase for 2023
The Department of Labor (“DOL”) has published the annual adjustments for 2023 that increase certain penalties applicable to employee benefit plans. As always, please contact your Total Benefit Solutions health insurance specialists with any questions or concerns today at (215)355-2121.
Continue ReadingPennie: 1095-A Tax Form Available for Customers
The 1095-A tax form has been delivered to Pennie customers for their 2022 tax returns. The 2022 1095-A Form: Health Insurance Marketplace Statement has been delivered to customers’ Pennie Secure inboxes. Important: The 1095-A reflects a Pennie customer’s 2022 enrollment information. Click here to learn more about 1095-A forms. Have any questions regarding your Pennie account or the 1095-A tax form? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.
Continue ReadingWhat is vision coverage?
A health benefit that at least partially covers vision care, like eye exams and glasses. All the plans in the Health Insurance Marketplace include vision coverage for children. Only some plans include vision coverage for adults. If adult vision coverage is important to you, check the details of any plan you’re considering. If your plan doesn’t include adult vision coverage, you can buy a “stand-alone” vision plan to reduce your vision care expenses. The Marketplace doesn’t offer stand-alone vision plans. To shop for stand-alone vision plans, contact an insurance agent or broker, or search for plans online. You can also contact your state’s Department of Insurance. As always, don’t hesitate… Read More
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