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 MoreContinue Reading
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.Continue Reading
ACA 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 Reading
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.Continue Reading
What 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 MoreContinue Reading
What 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 Reading
Do 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 MoreContinue Reading
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 MoreContinue Reading
The 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 MoreContinue Reading
UHC: 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 Reading
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 MoreContinue Reading
Do 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 Reading
Does 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 MoreContinue Reading
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.Continue Reading
Pennie: 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 Reading
What is a stand-alone dental plan?
A type of dental plan offered through the Marketplace that’s not included as part of a health plan. You may want this if the health coverage you choose doesn’t include dental, or if you want different dental coverage. As always, please contact your Total Benefit Solutions health insurance specialists with any questions or concerns today at (215)355-2121.Continue Reading
What is a Preferred Provider Organization (PPO)?
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost. As always, please contact your Total Benefit Solutions health insurance specialists with any questions today at (215)355-2121.Continue Reading
What is Medicaid?
Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels. Whether you qualify for Medicaid coverage depends partly on whether your state has expanded its program. Medicaid benefits, and program names, vary somewhat between states. You can apply anytime. If you qualify, your coverage can begin immediately, any time of year. As always, please contact your Total Benefit Solutions health insurance specialists with any questions today at (215)355-2121.Continue Reading
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 MoreContinue Reading
What is a Health Reimbursement Arrangement (HRA)?
Health Reimbursement Arrangements (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the arrangement. Health Reimbursement Arrangements are sometimes called Health Reimbursement Accounts. As always, please contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.Continue Reading
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 MoreContinue Reading
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.Continue Reading
Inflation Reduction Act: Requires Drug Manufacturers to Pay Rebates for Drug Price Increases Above Inflation
Requires drug manufacturers to pay a rebate if drug prices increase faster than the rate of inflation (CPI-U) for: Single-source drugs and biologicals covered under Medicare Part B All covered drugs under Medicare Part D except those where average annual cost is <$100 2021 is the base year for measuring cumulative price changes relative to inflation The rebate amount is based on units sold in Medicare multiplied by the amount that a drug’s price in a give year exceeds the inflation-adjusted price Price changes are measured based on the average sales price (for Part B drugs) or the average manufacturer price (for Part D); these measures include prices charged in… Read MoreContinue Reading
Part D Senior Savings Model: Will there be a plan with higher premiums for insulin at a lower cost?
The Part D Senior Savings Model allows drug manufacturers to offer their discounts in the coverage gap, even when a Part D plan enhances cost sharing. This allows plans to offer a fixed, consistent cost sharing on insulin. This structure is estimated to save enrollees who take insulin $446 in annual out-of-pocket costs. Part D sponsor plan premiums vary and beneficiaries should find a Part D plan that provides coverage they want at the lowest total annual cost, premiums and out-of-pocket costs combined. As always, please contact your Total Benefit Solutions Medicare health insurance specialists at (215)355-2121 with any questions or concerns.Continue Reading
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 MoreContinue Reading