2023 RxDC Reporting Instructions Released

The Centers for Medicare and Medicaid Services (“CMS”) recently updated its Prescription Drugs Data Collection (“RxDC”) reporting instructions for 2023 data. There are some noticeable differences. As previously reported, group health plan sponsors (typically employers) are required to submit information to CMS on prescription drugs and health care spending on an annual basis (“RxDC reporting”). The first reporting deadline for calendar years 2020 and 2021 was December 27, 2022 (extended to January 31, 2023). The next deadline for reporting on calendar year 2023 is June 1, 2024, which, despite being a Saturday, is a firm date. It should be noted that carriers, pharmacy benefit managers (“PBMs”), and third-party administrators (“TPAs”)… Read More

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What 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.

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What 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.

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Small 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

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Medicaid 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

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What is Small Business Health Options Program (SHOP)?

The Small Business Health Options Program (SHOP) helps small business owners provide medical and/or dental insurance to their employees. Some smaller employers qualify for tax credits if they enroll in SHOP insurance. A small business can offer SHOP health and/or dental insurance to their employees if they: Small business owners can use an agent or broker to enroll in SHOP insurance, or work with their insurance company. There’s no limited enrollment period for SHOP, so they can apply, pick plans, and enroll employees any time of year. Interested in SHOP for your small business? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.

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Get connected with the IBX Smartphone App

Download the free IBX app for your iPhone or Android to help you make the most of your Independence Blue Cross health plan. With new and improved features, the IBX app gives you easy access to your health care coverage 24/7, wherever you are. As always contact your Total Benefit Solutions, Inc health insurance professionals if you have any questions about this bulletin. Click here to 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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Inflation Reduction Act: Capping Medicare Part D Out-of-Pocket Spending and Other Part D Benefit Changes

Changes would lower beneficiary spending, reduce Medicare’s liability for high drug costs, and increase Part D plan and manufacturer liability for high drug costs. Beneficiaries: Eliminates 5% coinsurance for catastrophic coverage in 2024 Caps out-of-pocket drug spending at $2,000 beginning in 2025 Allows spreading out of out-of-pocket costs over the year Limits premium growth to no more than 6% per year for 2024-2030 Medicare: Lowers share of costs above the out-of-pocket spending cap (“reinsurance”) Part D Plans: Increases share of costs above the out-of-pocket spending cap Modifies share of costs below the out-of-pocket spending cap Drug Companies: Requires a price discount on brand-name drugs above the out-of-pocket spending cap Modifies… 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 is copayment?

A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible. Let’s say your health insurance plan’s allowable cost for a doctor’s office visit is $100. Your copayment for a doctor visit is $20. If you’ve paid your deductible: You pay $20, usually at the time of the visit. If you haven’t met your deductible: You pay $100, the full allowable amount for the visit Copayments (sometimes called “copays”) can vary for different services within the same plan, like drugs, lab tests. and visits to specialists. Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have… Read More

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Premium Formulary Adoption Swells Among Large Group Clients

The Premium formulary is an option for large group clients wanting access to a formulary that manages traditional, non-specialty drug costs without compromising clinical outcomes. In many cases it saved early adopters nearly 10% per member per month on their plan’s traditional drug spend. Overall, members saved on drug costs without rigorous additional step therapies, prior authorizations, or other invasive utilization management strategies. Members transitioning to the Premium formulary will receive communications about the change, potential disruptions to their drug therapies, and clinically appropriate and cost-effective alternatives. Blue KC will continue to make quarterly updates to the Premium formulary and will send subsequent member communications about those changes and appropriate… Read More

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Alternative Funding Yields Big Savings

The Issue A firm we had worked with for several years had expressed a concern that the cost of their employee benefits package was threatening the financial stability of their firm. With a little over 150 employees, their annual benefits cost was exceeding $1.3 million and increasing at a rate of 8-15% each year. Even more concerning was that the benefits cost represented 32% of the company’s operating revenue. They had contemplated making plan changes including an increase in deductibles, copays and co-insurance limits, but they cared about the well-being of their employees and felt compelled to keep a competitive level of benefits. Our Solution We took the approach that… Read More

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Health Insurance Nondiscrimination Rules Small Business Owners Need to Know

Group health plans and tax-favored accounts—including health savings accounts (HSAs), health flexible spending arrangements (health FSAs), and health reimbursement arrangements (HRAs)—are subject to numerous nondiscrimination provisions under federal law. The most common nondiscrimination provisions are described. Please download the entire bulletin for details. As always please contact your Total Benefit Solutions, Inc group account manager at (215)355-2121 with any questions or concerns. This bulletin covers the following topics: Overview General Rules Section 125 Nondiscrimination Rules for Cafeteria Plans Section 105 Nondiscrimination Rules for Self-Insured Plans HIPAA Nondiscrimination Rules Nondiscrimination Rules Related to Medicare-Eligible Individuals Other Nondiscrimination Rules Additional Information

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Turning 26: Your Guide to Health Insurance

Thanks to the Affordable Care Act (ACA), many young people choose to stay on their parent’s health insurance for as long as possible, and with good reason. The historic healthcare law, also known as Obamacare, allows young adults to stay on their parent’s health plan until they turn 26, no matter what. Download our free easy to read guide to getting your own health insurance here. Contact your health insurance experts at Total Benefit Solutions Inc with any additional questions (215)355-2121

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Aetna Client Series: Reimagining Workforce Strategies Webinar

Reimagining Workforce Strategies Thursday, June 23 at 2 PM ET Our next Aetna Client Series webinar is on Thursday, June 23 at 2 PM ET featuring: Tanya Taupier, SVP and Senior HRBP – HCB, Aetna and Jannine Zucker, Principal, Deloitte Consulting. This webinar is specifically designed for Aetna clients to hear about relevant thought leadership content. The topic of this webinar will be: Reimagining workforce strategies. Please share this invitation with your clients and join them to learn more about workforce strategies for success. Many organizations are struggling with an urgent talent crisis: The Great Resignation. As businesses search for ways to attract – and retain – talent. They have an opportunity to refocus their thinking on how and… Read More

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Philadelphia Passes New COVID-19 Paid Leave Law

Philadelphia has enacted a new law that requires employers to provide paid time off for COVID-19 purposes. The ordinance, which took effect March 9, 2022, applies to employers with at least 25 employees. Covered EmployeesThe ordinance covers employees who: Work in Philadelphia; Normally work in Philadelphia but currently telework from any other location as a result of COVID-19; or Work from multiple locations or from mobile locations, provided that 51% or more of their time is in Philadelphia. There is no waiting period or accrual requirement for leave. Permitted Purposes for COVID-19 LeaveLeave must be allowed for specified COVID-19 reasons relating to an employee’s (or their family members’) exposure to, symptoms of or diagnosis with COVID-19. Leave… Read More

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How does level funding health insurance work?

Level funding (also called alternate funding) is a group health insurance product available to employers. It behaves just like a fully-insured product, and allows some groups to get coverage at more competitive rates than traditional fully insured ACA plans. How does level funding work? An employer pays a set monthly cost into an account, like a ” premium”. This “premium” money is then used to pay claims for employee health care. If there’s any money left in the account at the end of the plan year, it goes back to the employer. If employee claims spending exceeds the funds in the account, the health insurer covers the difference. If there are any large… Read More

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Health Plan PCORI Fees Are Due July 31

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Court Strikes Down Association Health Plan Rules

On March 28th, 2019, a Federal District Court in the District of Columbia struck down significant portions of the Department of Labor’s (DOL’s) Association Health Plan (AHP) Final Rule. Specifically, the Court found the DOL “failed to reasonably interpret” ERISA when issuing these rules: • expanding the definition of “employers” to include disparate groups of employers with no other commonality of interest other than geographic location; and • bringing working owners without employees within ERISA’s framework. This ruling effectively eliminates the expansion of AHPs to certain employers and working owners who do not meet the original parameters to be a part of an AHP. Click below to download the complete… Read More

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Medicare Won’t Cover This Key Expense…

Dental costs can take a huge bite out of seniors’ finances, even if they have Medicare. And many Seniors have to tap into their Retirement Funds to cover treatment.

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The Future of Employee Benefit Offerings: Student Debt Repayment Assistance

When looking for a job, the benefits offered to an Employee are definitely a big factor in consideration of accepting an offer of employment. Most people are willing to choose a company with a slight pay decrease if the benefit package compensates for the lost wages. With unemployment the lowest it has been since 2000 in the United States, attracting new talent isn’t as easy as it used to be and Employers are looking for ways to snatch up qualified applicants. When you think of benefit packages, you usually think of the basics: Health Insurance (with possibly an HSA, HRA, or FSA included), Dental and Vision coverage. “Good” benefit packages… Read More

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