Discover effective strategies to seamlessly incorporate financial wellness into your comprehensive employee benefits program.
Learn how to enhance your employees’ financial literacy and capabilities by leveraging a combination of digital tools and personalized human support.
Gain insights into tangible outcomes and actionable strategies to foster meaningful engagement among your employees on their financial well-being journey.
Discover the transformative advantages of integrating financial wellness into your employee benefits package. Tackling financial stress among employees has a ripple effect, enhancing workplace culture, engagement, productivity, and the overall success of your organization.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
Recently, UHC/Oxford and Mt Sinai Health System had split effective January 1, 2024. Since that time there have been a state-required cooling-off period and ongoing talks on resolution but that has not yielded a positive outcome yet. The Mount Sinai Hospital, Mount Sinai Queens, and their related hospital outpatient locations will remain in-network for all patients until at least Friday, March 1.
According to UnitedHealthcare/Oxford:
People enrolled in UnitedHealthcare fully insured commercial plans have continued network access to all of Mount Sinai’s hospitals through Feb. 29, 2024, due to New York cooling-off requirements.
Unless they obtain admitting privileges to another in-network hospital, the majority of Mount Sinai’s physicians will no longer participate in our network for employer-sponsored and individual plans, including the Oxford Health Plan, effective March 22, 2024.
This negotiation only impacts our relationship with Mount Sinai for employer-sponsored and individual commercial plans, including Oxford. All other active contracts, including Medicare Advantage and the Empire Plan, remain in place with no change.
The two organizations had a three-year agreement that took effect on Jan. 1, 2022, which was canceled before it was supposed to expire amid a dispute over payment rates. Both institutions are blaming one another for the standoff.
Mount Sinai claims UnitedHealthcare compensates it an average of 30% less for care than other health systems in New York. The insurer pays New York-Presbyterian $25,911 for a normal vaginal birth, and Mount Sinai $15,989, Mount Sinai said.
“Mount Sinai must be paid fairly,” spokeswoman Lucia Lee said in a statement. “As Mount Sinai costs substantially less than our peers, UHC/Oxford will actually end up paying more for patients to get care at other systems in New York. This cost — estimated to be at least $140 million more over the course of a year — will be passed on to employers and patients.”
UnitedHealthcare says Mount Sinai sought “outlandish price hikes” that would increase costs for services an average of 50% over three years or $600 million — an estimate disputed by Mount Sinai. For example, a regular, outpatient colonoscopy at South Nassau costs about $6,000 and would be about $8,700 in three years under Mount Sinai’s proposal, according to UnitedHealthcare.
Mt Sinai Hospitals & Health System
Facility Name
County
Mount Sinai Beth Israel
NYC
The Mount Sinai Hospital
NYC
Mount Sinai Morningside
NYC
The Mount Sinai West
NYC
Mount Sinai-Union Square
NYC
Mount Sinai Kravis Children’s Hospital
NYC
Mount Sinai-Behavioral Health Center (MSBHC)
NYC
Blavatnik Center, Medical Center
NYC
New York Eye and Ear Infirmary of Mount Sinai
NYC
Mount Sinai Brooklyn
Brooklyn
Mount Sinai Queens
Queens
Mount Sinai South Nassau
Long Island
Neighboring Hospitals
Bellevue Hospital Center
NYC
New York Presbyterian Queens
Queens
Elmhurst Hospital Center
Queens
New York Presbyterian Weill Cornell
NYC
Flushing Hospital Medical Center
Queens
North Shore University Hospital Manhasset
Long Island
Lenox Hill Hospital
NYC
NYU Langone Hospital Brooklyn
Brooklyn
Long Island Jewish Medical Center
Brooklyn
NYU Langone Hospital Long Island
Long Island
Maimonides Medical Center
Brooklyn
St. Francis Hospital
Long Island
Mercy Medical Center
Long Island
St. Johns Episcopal Hospital
Queens
New York Presbyterian Columbia
NYC
St. Joseph Hospital
Queens
New York Presbyterian Lower Manhattan Hospital
NYC
Wyckoff Heights Medical Center
Brooklyn
Both sides need each other as both are market leaders in their fields. It is our hope and most of our clients that they get this resolved soon. In the meantime, please bookmark our site for the latest updates. And do reach out to us and learn the steps that you can take to smoothen this temporary roadblock.
We already love Professional Employer Organizations (PEO)– our clients do too. Today we’re counting down our top 5 reasons why we love PEO:
1. National Capabilities: It ensures your compliance with local and federal laws, even if your business has locations in different states. Access to a national provider healthcare plan, not single state carriers
2. Liability Protections: Some liability moves to the PEO service instead of your company.
3. It saves you money on HR staff. Being part of a PEO gives you a clear-cut idea of what your costs are going to be a year in and year out. The PEOs work tirelessly to keep their insurance renewals down, so their clients won’t leave. Every year they work with the insurance carriers to introduce new plans and ways to reduce the costs of insurance to their clients. This gives you the ability to forecast and know precisely what your costs will be.
4. Technologies: Online HR resources for self-service issues Ability for employees to make personal changes on their own, online. Ability to track PTO (paid-time off).
5. One Vendor: It streamlines HR tasks like payroll, taxes, employee benefits, worker’s compensation, 401K, and HR administrative tasks.
Our PEO Quoting Tool ensures that we have first-hand insight as to what the small business owner needs to be successful. Click below for a quote.
Recent headlines announced a new regulatory view from the federal government regarding the ability of US consumers to obtain drugs from other countries. In particular, the Federal Drug Administration (FDA) approved an application from the State of Florida to obtain some specified prescription pharmaceuticals directly from Canadian sources for some of its state-funded programs and expanding to its Medicaid population. The move was hailed by many as a necessary first step in controlling prescription drug prices. How it will be implemented and whether the option benefits employer plans are still not clear.
Background
The US is typically described, as it is in thisRand study, as having higher costs for brand-name prescription drugs than other countries. There are reasons for that, including price controls in other countries that artificially restrict prices for brand-name drugs in those countries. Ironically, the Rand study also notes that prices for generic drugs are typically lower in the US than in those other countries. Nevertheless, for decades, many observers have advocated the ability of US-based individuals and plans, including employer-sponsored health plans, to import brand-name drugs from those other countries with the hope of driving down the costs of prescription drugs that are used by US citizens.
Congress hasinvestigatedthe effects. The potential impact has traditionally been seen asambiguous, as it is not clear how the Canadian or other governments would react or whether the consumer can be adequately assured, in the absence of FDA approval, of actually obtaining the same or the equivalent of the FDA-approved pharmaceutical. Recenthistoryhas seen those pressures increase, and the FDA may be more inclined to permit more importation of drugs than in previous years. Ironically, perhaps, there has been amove in the marketthat should make generic drugs less expensive (as they have been increasingly costly in recent years as well).
With the approval of the Florida application to import brand name prescription drugs for some of the Florida-run plans, many employers will ask if that avenue will be available for employer plans as well.
Employers are being contacted by various vendors who claim to help employer plans reduce prescription drug costs by importing the drugs from Canada. If there is no enforcement, the question is whether the employer plan should go ahead and pursue that option. There is no “right” answer, but there are various factors that employers should consider before they sign on.
Will importation result in real cost savings, and are these medications the major cost drivers for the employer’s group health plan? Will drug manufacturers react by increasing prices to US importers? There is certainly no reason to believe that the medications will be sold in the US at lower prices. Perhaps that will be true, but some news reports have noted thatCanadian authorities are not keen on making limited drugs widely available to US patients.
There is no specified pathway for employer plans to gain access to the prescription drugs and the savings, if any, that the states can negotiate. It is entirely possible, given thestatements from the Canadian authorities, that limited volumes, if any, of the drugs will be available given the concern of the Canadian government for the health of their citizens.
It is also unclear whether expanding the program to other countries will assist with the volume of drugs available for import to the US. The pharmaceutical industry (which has its own point of view, of course)has provided information for yearsthat it is just not possible for the FDA to know that drugs imported from other countries are safe and effective. TheFDA itselfhas noted that it cannot vouch for the safety of drugs from other countries. So, employers will need to take additional steps to ensure the safety of the drugs if they seek to use that route.
Conclusion
Employers have been seeking importation as a silver bullet to lower prescription drug costs for their plans. Given the prescription drug inflation of the last few years and the unsustainable costs, employers are desperate for some relief. The final verdict on whether this approach will effectively address medical costs remains uncertain.
Interested in learning more? World Payroll or our PEO Partners can assist with the E-Verify process. Please email info@medialsolutionscorp.com or call us at 855-667-4621.
Please Note: While the information within this alert may concern certain employment laws and regulations to be aware of, it is provided solely as general guidance so that you maintain compliance. It is not the equivalent of legal advice, nor does it serve as a substitute for the advice of an attorney, if applicable.
It’s no secret that people are using diabetes medication off-label for weight loss—with or without insurance coverage.
But with the increasing demand and the positive benefits of reducing obesity in the workplace, more employees are demanding their employers’ health plans cover the expense of the medication.
Join this webinar to discover why 43% of employers plan to cover weight loss drugs in 2024—nearly double from 2023—and how doing so can impact your business.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
Healthcare is constantly evolving, shaping how people view their health and well-being. The complexities of managing rising healthcare costs, the continuous evolution of the modern workplace, and a heightened focus on employee wellbeing highlight the necessity for a broader perspective on the concept of “workplace wellbeing.”
To be successful, organizations must construct a future that works for everyone, including individuals, the workforce, and the organization.
How will employers invest in workplace well-being?
According to aGreat Place to Workand Johns Hopkins survey in 2023, employee well-being is a key predictor of employee retention and referrals. It identifies that:
Promoting employee well-being requires consistent listening and regular communication with employees.
Employees who experience high levels of well-being in the workplace are three times more likely to stay with their employer.
Employees who experience high levels of well-being in the workplace are three times more likely to recommend their employer to others.
It’s safe to say that providing a culture of health and well-being within your organization significantly impacts more than just healthcare costs and physical health.
Think about every aspect of your life where support is needed—and how everyone’s list differs. Wellbeing at work should be addressed by supporting the “whole person.” This means employers should support not only physical health but also the following:
Mental health
Digital wellbeing
A work-life balance
Financial wellbeing
Family support services
Although this list is not exhaustive, it highlights the complex and interdependent nature of workplace wellbeing needs.
5 trends that will shape the future of employee wellbeing:
Mental Health and Emotional Wellbeing:
Emotional wellbeing has taken center stage in the post-pandemic years. One positive outcome of the pandemic is the awareness and need for greater mental health resources and the de-stigmatization of mental health in the workplace. According to aGallup poll, 19% of U.S. workers rate their mental health as fair or poor.
Here are some of the things that are being implemented as they relate to mental wellbeing at work:
“Safe Space” communities:Employees can access mental health resources and learn to support others while sharing personal stories.
Manager’s Training:Leaders can access training to learn how to be effective listeners, identify, and respond swiftly to the mental health needs of their teams. These training courses also help inform company policy needs and provide a framework to be developed within all areas of the organization.
Mindfulness Resources:Incorporating relaxation solutions into the workplace with on-the-go apps, online platforms, calm spaces, or meditation rooms involves integrating mindfulness tools into communication platforms.
The Continued Rise of Technology – Driven Solutions
The intersection of convenience, privacy, and adaptability is crucial for digital wellbeing tools. Integrating technology into employee wellbeing programs not only improves accessibility and convenience but also enhances data collection and analysis, which helps organizations gain insight into health trends and potential interventions. Finding a way to tie these different technology systems together will be instrumental when it comes to the interconnectedness of data and programs.
Some solutions are determined to stick around, and ones that you might consider include:
Personalized Wellness Platforms: Artificial Intelligence (AI) is inspired to adapt to individual preferences and circumstances with constantly evolving algorithms that adjust real-time recommendations based on new user data, behavioral patterns, personalized content, and customized plans.
Telehealth Solutions: With multi-modal consultation formats and interactive platforms, integrated health allows individual solutions to be consolidated into more holistic platforms, bringing together everything someone needs in one place.
Wearable Technology: Fitness trackers and smartwatches are being used to monitor physical activity, sleep patterns, and overall health. Wearables that adapt their tracking based on user lifestyle algorithms will be instrumental in personalization and customization.
Flexibility and Work/Life Balance:
The COVID-19 pandemic forced organizations to adopt remote work arrangements on an unprecedented scale. Whether your office now promotes a worksite that is hybrid, in-office, or remote, having flexible work arrangements helps accommodate employees, enhance work-life balance, and make companies more attractive.
Develop strategies to support employees wherever they are:
Virtual Wellness and Fitness Classes:Allow employees to participate in their health and wellbeing wherever they are.
Telehealth Visits:Offers flexibility to talk with a doctor from the comfort of their home.
Virtual Team-building Activities:Allow employees to connect even though they are not physically together.
Invest in Technology Tools:Facilitating seamless collaboration among remote and in-office teams or multiple locations.
Financial Wellbeing
A recentstudy by PwCfound that57%of employees say finances are the top cause of stress in their lives. When people have money worries, it impacts morale and productivity, not to mention overall physical and mental health. Businesses have a responsibility to help their employees by investing in financial wellbeing, education, and resources, but also to help retain top talent in this ever-changing job market.
Here are some services to consider offering:
Financial Wellness Coaching:Such as one-on-one coaching, workshops, webinars, and online tools
Financial Education:Literacy opportunities on topics such as budgeting, saving, investing, debt management, and overall financial planning.
Financial Wellness Benefits:Such as tuition reimbursement, employer-sponsored retirement plans, or home-buying assistance programs.
Family Support Services:
Balancing the roles of parent, caregiver, and employee can feel like juggling two full-time jobs. Having a supportive employer makes all the difference.Caregiver responsibilitiesfor both children and aging parents put a strain on mental and physical health. Having programs and support for a range of needs helps employees feel supported.
How do you invest in caregivers?
Financial support, such as childcare subsidies or discounts for daycare centers
Flex spending accounts for dependent care expenses
Backup care services
Eldercare resources
Caregiver leave/paid time off
Maternity and paternity leave
Mental health benefits for caregivers
Return to work programs
Wellbeing investments in the workplace are retention boosters and help secure top talent. According to anotherGallup poll, 63% of workers say that having work-life balance and better personal wellbeing opportunities is very important when considering a new job. Organizations should look to provide more inclusive, equitable benefits and wellbeing programs across their workforce. In the future, organizations will intensify their focus on human-centric wellbeing, aiming to enhance the employee experience and drive concrete business results by evolving from the appearance of personalization to genuine personalization.
The wellness landscape is changing daily. Employers should research the options by seeking guidance with a PEO. We have multiple wellness programs and initiatives that can be implemented and offer comprehensive ACA compliance/reporting services to clients.
All businesses today are aware that a healthy workforce translates to a happier and more productive employee. Nearly a quarter of participants in SHRM’s latest benefits survey plan to increase their Health & Wellness benefits, whose percentage was higher than other categories such as professional and career development, flexible work schedules, retirement and family-friendly policies. One unusual offering, workstations that allow people to stand, soared to 44% from just 13% in 2013 when the data was first tracked.
Helping your employees strive towards physical, emotional, mental, and even spiritual well-being can lead to increased productivity and employee longevity. But how can you offer wellness programs that your employees will actually use and find beneficial? There’s no one size fits all solution, and the best way to get started is to invite employee input. Need some inspiration? Here are 5 employee wellness programs that might be the right fit for your company this coming year:
1. Online Wellness/Health Screening
Did you know many health nurses today pay their employees to take an online health risk assessment? Covered members receive a lump sum benefit payment once a year if they complete certain health-related activities (i.e. routine screenings, programs like smoking cessation and weight reduction, and more). Payment options range from $50 to $150. Empire Blue Cross, for example, pays up to $300 for this including a smoking cessation online questionnaire and flu vaccination.
2. Gym Reimbursements
You might not be able to build a gym at the office, but that doesn’t mean you can’t take advantage of your neighborhood businesses. Did you know most healthcare compare today to offer up to $400 annual gym reimbursement? Most include a $200 spousal gym reimbursement as well.
3. Start a Walking Group
This solution is easy, free, and can be employee-driven. Failing to take breaks leads to burnout and eventually employee resentment. Encourage employees to take frequent breaks, but not just to the break room for more artificial lighting and a caffeine boost. Rally eager employees to lead morning, lunch, and/or after-work walking groups. The fresh air is energizing, boosts creativity, and helps feed social wellness needs, too.
4. Create a Healthy Challenge That Isn’t Based on Numbers
Although some businesses have success with Biggest Loser-style in-office challenges, it can also trigger disordered eating. Instead of focusing on numbers, focus on more subjective goals—like how many consecutive days fresh, local fresh vegetables can be part of a lunch. Kicking off these challenges with a brief intro to the importance of a healthy diet for life can help employees re-think their choices.
5. Seek Help from Outside Resources
There are several organizations that employers can turn to for information, research, and guidance on wellness programs. Below are just a few for you to explore for helpful ideas on how to develop a culture of health in your organization.
HERO is a national non-profit dedicated to identifying and sharing best practices in the field of workplace health and well-being (HWB). Their mission is to improve the health and well-being of workers, their spouses, dependents, and retirees. Check out the wealth of information on their site, including research studies and a blog.
The Health Project is a tax-exempt not-for-profit corporation formed to bring about critical attitudinal and behavioral changes in addressing the health and well-being of Americans. The Health Project focuses on improving personal healthcare practices and supporting population health by reaching adults where they spend most of their waking hours: at work. Many organizations have adopted health promotion (wellness) programs that encourage good health habits and an improved understanding of how individual workers and their families can more effectively use health services.
Harvard Health Newsletters are free newsletters targeted to individuals with the purpose of providing educational information to help them invest in their own health or the health of their families.
CLICK HERE
Contact us to learn more about how health and wellness benefits can help you attract and retain your top talent.
About this Session: Pharmacy represents 25%+ of employer’s healthcare spend annually, and the total health spend is expected to rise by 10% next year. Don’t let drug costs and coverage eat away your budget and take away from your profits.This session will help you learn ways to leverage your data and workforce needs, gain knowledge about pharmaceutical trends and alternate solutions and ways to drive your employees to other options when feasible.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
Great news, during FOE groups will not be subject to any enrollment participation requirements!
FOE will run from 11/15 through 12/15. See below for submission timelines:
12/1 effective date groups must be entered by 11/24
1/1 effective date groups must be entered by 12/15
A little-known requirement but most important under the Affordable Care Act (ACA) is that Health Insurers must waive their minimum employer-contribution and employee-participation rules once a year. ACA requires a one-month Special Open Enrollment Window for January 1st coverage.
The special open enrollment period occurs November 15th through December 15th of each year, allowing eligible small group employers to enroll for coverage effective January 1st of the following year.
Background
The ACA has a section in it called the “guaranteed issuance of coverage in the individual and group market.” It stipulates that “each health insurer that offers health insurance coverage in the individual or group market in the state must accept every employer and individual in the state that applies for such coverage.” The section also states that this guaranteed issuance of coverage can only be offered during (special) open enrollment periods and that plans can only be offered to applicants that live in, work in, or reside in the plan’s service area(s).
Participation and Contribution Requirements
In many states (including California and Nevada), carriers can decline to issue group health coverage if fewer than 70% of employees elect to enroll in coverage. Some carriers may have even tighter participation requirements.
Generally speaking, employees with other coverage (Medicare, other group coverage, individual coverage through the Exchange, etc.) are removed from the participation requirement calculation – though it varies by insurance carrier.
Furthermore, employer contribution rules require employers to contribute a certain percentage of premium costs for all employees in order to attain group health coverage. Some businesses struggle to meet these contribution requirements for a variety of financial reasons.
Problem Solved: Special Open Enrollment Period
Many employers want to offer coverage to their employees but are denied because they struggle to meet participation and/or contribution requirements. Employers cannot force employees to enroll in coverage unless the employer pays for 100% of the employees’ premiums, which many employers cannot afford. Even with moderate to generous employer contributions, many employers still find young and lower-income employees waiving coverage.
The U.S. Department of Health & Human Services provides final guidance on this in regulation 147.104(b)(1): “In the case of health insurance coverage offered in the small group market, a health insurance issuer may limit the availability of coverage to an annual enrollment period that begins November 15 and extends through December 15 of each year in the case of a plan sponsor that is unable to comply with a material plan provision relating to employer contribution or group participation rules.”
If your employer groups are struggling with participation and/or contribution, the Special Open Enrollment Window is the time to enroll them in coverage.
With the right information and knowledge, you can take control of your plan design and help drive down employee plan spend. This can significantly reduce wasted healthcare dollars. During this session, we will look at leveraging your population health data to drive the best-suited plan design with the right incentives for your employees. Next, we will discuss how to provide them with the information they need, leverage incentives, make the service selections they need, and help drive down your costs.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
This Compliance Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.
In preparation for open enrollment, Employers should review their plan documents in light of changes for the plan year beginning Jan 1, 2024. Below is an Employer 2024 Open Enrollment Checklist including some administrative items to prepare for in 2024.
Change has been constant for employer plans in the last few years. Unfortunately, 2023 was no exception. As they prepare for 2024 open enrollment, employers must incorporate new requirements affecting the design and administration of their health plans for plan years beginning on or after Jan. 1, 2024. Those changes include items that are adjusted for cost of living changes each year, – e.g., the cost-sharing limits for high deductible health plans (HDHPs), contribution limits to health savings accounts (HSAs), as well as new requirements due to legislative and regulatory updates, such as the expiration of COVID-19 mandates, to name a few.
Employers should ensure their health plan is updated and communicate benefit changes to participants through an updated summary plan description (SPD) or a summary of material modifications (SMM) for the 2024 plan year.
As a general best practice, employers should confirm that their open enrollment materials contain certain required participant notices and consider including some periodic notices, such as the Medicare Part D creditable/non-creditable coverage notice, in their open enrollment materials.
PLAN DESIGN CHANGES
ACA Mandates
Affordability Requirements
Under the ACA’s employer shared responsibility rules (the “pay or play” rules), applicable large employers (ALEs) (those with 50 or more full-time employees or the equivalent) are required to offer affordable, minimum value health coverage to their full-time employees (and dependent children) or risk paying a penalty.
Under the ACA, an ALE’s health coverage is considered affordable if the employee’s required contribution to the plan does not exceed 9.5% of the employee’s household income for the taxable year (as adjusted each year). The adjusted percentage is 9.12% for 2023.
The affordability percentage for plan years that begin on or after Jan. 1, 2024, will be 8.39%. That is another reduction demonstrating the need for ALEs to monitor the affordability percentage each year so they can confirm that at least one of the health plans offered to full-time employees satisfies the ACA’s affordability standard (typically by the use of one of the optional safe harbors – federal poverty level, W-2 or rate of pay).
Out-of-pocket Maximum
Under the ACA, non-grandfathered health plans (which apply to almost all employer plans) are subject to limits on cost sharing for essential health benefits. Confirm that out-of-pocket maximum limits for your health plan comply with the ACA’s limits for the 2024 plan year.
Plan years beginning on or after Jan. 1, 2024:
$9,450for self-only coverage
$18,900for family coverage
Note, the out-of-pocket maximum limits for HDHPs compatible with HSAs must be lower than the ACA’s limits. For the 2024 plan year, the out-of-pocket maximum limits for HDHPs are $8,050 for self-only coverage and $16,100 for family coverage.
Preventive Care Benefits
The ACA requires non-grandfathered health plans to cover certain preventive health services without imposing cost-sharing requirements (e.g., deductibles, copayments, or coinsurance) when in-network healthcare providers supply the services. The preventive care services covered by the requirements are based on the following:
Evidence-based items or services that have a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF).
Immunizations for routine use in children, adolescents, and adults that are currently recommended by the Centers for Disease Control and Prevention.
Evidence-informed preventive care and screenings are included in the Health Resources and Services Administration (HRSA) guidelines for infants, children, and adolescents.
Evidence-informed preventive care and screenings are included in HRSA-supported guidelines for women.
There needs to be some clarity. An ongoing court case has raised some uncertainty about using the USPSTF recommendations. However, guidance from federal agencies will permit employers to use those factors without the risk of penalties for the time being. Therefore, employers should monitor future developments regarding the ACA’s preventive care mandate, which is expected by the end of 2023.
Coverage For COVID-19 Vaccines, Testing And Treatment
Because the COVID-19 public health emergency has ended (seeAlert here), health plans are no longer required to cover COVID-19 diagnostic tests and related services without cost sharing or other medical management requirements. Health plans are still required to cover recommended preventive services (under the ACA requirements), including COVID-19 immunizations, without cost sharing, but this coverage requirement can now be limited to in-network providers.
For plan years ending after Dec. 31, 2024, an HSA-compatible HDHP is no longer permitted to provide COVID-19 testing and treatment benefits without a deductible (or with a deductible below the minimum deductible for an HDHP). Therefore, employers should
Determine whether health plans will impose cost-sharing requirements, prior authorization, or other medical management requirements on COVID-19 testing for the upcoming plan year.
Determine whether health plans will continue covering COVID-19 immunizations without cost sharing from all healthcare providers or whether this first-dollar coverage will be limited to in-network providers.
Confirm that HDHPs that do not have a calendar year as the plan year will not pay benefits for COVID-19 testing and treatment before the annual minimum deductible has been met for plan years ending after Dec. 31, 2024.
Notify plan participants of any changes for the 2024 plan year regarding COVID-19 testing and vaccines through an updated SPD or SMM.
The IRS issued a memorandum on claims substantiation (see Article here) for health FSAs. The memorandum clarifies that health FSA expenses are not considered properly substantiated if employees self-certify expenses, if the plan uses sampling, if only amounts over a certain level are substantiated, or if charges from favored providers are not substantiated. Employers should, therefore, review the health FSA substantiation procedures to make sure they comply with IRS rules.
If you offer an HDHP to your employees that is compatible with an HSA, you should confirm that the HDHP’s minimum deductible and out-of-pocket maximum comply with the 2020 limits. The IRS limits for HSA contributions and HDHP cost-sharing increase for 2024. The HSA contribution limits will increase effective Jan. 1, 2024, while the HDHP limits will increase effective for plan years beginning on or after Jan. 1, 2024.
Check whether your HDHP’s cost-sharing limits need to be adjusted for the 2024 limits.
If you communicate the HSA contribution limits to employees as part of the enrollment process, these enrollment materials should be updated to reflect the increased limits that apply for 2024.
The following table contains the HDHP and HSA limits for 2024 as compared to 2023. It also includes the catch-up contribution limit that applies to HSA-eligible individuals who are age 55 or older, which is not adjusted for inflation and stays the same from year to year.
Type of Limit
2024
2023
Change
HSA Contribution Limit
Self-only
$4,150
$3,850
Up $300
Family
$8,300
$7,750
Up $550
HSA Catch-up Contributions (not subject to adjustment for inflation)
Age 55 or older
$1,000
$1,000
No change
HDHP Minimum Deductible
Self-only
$1,600
$1,500
Up $100
Family
$3,200
$3,000
Up $200
HDHP Maximum Out-of-pocket Expense Limit (deductibles, copayments and other amounts, but not premiums)
Self-only
$8,050
$7,500
Up $550
Family
$16,100
$15,000
Up $1,100
HDHP Design Option – Telehealth
At the beginning of the COVID-19 pandemic, Congress temporarily relaxed the rules for HDHPs to allow them to provide benefits for telehealth or other remote care services before plan deductibles were met without jeopardizing HSA eligibility. That relaxed rule currently applies for plan years beginning before Jan. 1, 2025.
Determine whether HDHPs will waive the deductible for telehealth services for the plan year beginning in 2024
Communicate plan changes for the upcoming year to participants through an updated SPD or SMM
Mental Health Parity – Required Comparative Analysis For NQTLs
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires parity between a group health plan’s medical/surgical benefits and its mental health or substance use disorder (MH/SUD) benefits. These parity requirements apply to financial requirements and treatment limits for MH/SUD benefits. In addition, any nonquantitative treatment limitations (NQTLs) placed on MH/SUD benefits must comply with MHPAEA’s parity requirements. For example, NQTLs include prior authorization, step therapy protocols, network adequacy, and medical necessity criteria.
MHPAEA requires health plans and issuers to conduct comparative analyses of the NQTLs used for medical/surgical benefits compared to MH/SUD benefits. This analysis must contain a detailed, written, and reasoned explanation of the specific plan terms and practices and include the basis for the plan or issuer’s conclusion that the NQTLs comply with MHPAEA. Plans and issuers must make their comparative analyses available to specific federal agencies or applicable state authorities upon request.
Employers should request that health plan issuers (or third-party administrators) confirm that comparative analyses of NQTLs will be updated, if necessary, for the plan year beginning in 2024 and make the analysis available to the employee.
Open Enrollment Notices
Employers who sponsor group health plans should provide certain benefits notices in connection with their open enrollment periods. Some of these notices must be provided at open enrollment time, such as the Summary of Benefit and Coverage (SBC). Other notices, such as the WHCRA notice, must be distributed annually. Although these annual notices may be provided at different times throughout the year, employers often include them in their open enrollment materials for administrative convenience.
In addition, employers should review their open enrollment materials to confirm that they accurately reflect the terms and cost of coverage. In general, any plan design changes for 2024 should be communicated to plan participants through an updated SPD or an SMM.
Summary Of Benefits And Coverage
The ACA requires health plans and health insurance issuers to provide an SBC to applicants and enrollees each year at open enrollment or renewal. Federal agencies have provided atemplatefor the SBC, which health plans must use.
Note that for self-funded plans, the plan administrator is responsible for providing the SBC. For insured plans, the issuer usually prepares the SBC. If the issuer prepares the SBC, an employer is not required to also prepare an SBC for the health plan, although the employer may need to distribute the SBC prepared by the issuer.
Medicare Part D Notices
Group health plan sponsors must provide a notice of creditable or non-creditable prescription drug coverage to Medicare Part D-eligible individuals covered by, or who apply for, prescription drug coverage under the health plan. The notice alerts the individuals about whether their prescription drug coverage is at least as good as Medicare Part D coverage. The notice generally must be provided at various times that cannot always be anticipated, including when an individual enrolls in the plan and each year before Oct. 15 (when the Medicare annual open enrollment period begins). Therefore, the best practice is to provide it annually at open enrollment, as that will ensure timely compliance. Model notices are available on the Centers for Medicare and Medicaid Services’website.
Annual CHIP Notices
Group health plans covering residents in a state that provides a premium subsidy to low-income children and their families to help pay for employer-sponsored coverage must send an annual Children’s Health Insurance Program (CHIP) notice about the available assistance to all employees in that state. The U.S. Department of Labor (DOL) has provideda model notice.
Initial COBRA Notices
COBRA applies to employers with 20 or more employees who sponsor group health plans. Group health plan administrators must provide an initial COBRA notice to new participants and certain dependents within 90 days after plan coverage begins. The initial COBRA notice may be incorporated into the plan’s SPD. Because the COBRA election-period will not start until this notice is provided, it is helpful to many employers to include a copy in the open enrollment materials as a backup.
Notices Of Patient Protections
Under the ACA, group health plans and issuers that require the designation of a participating primary care provider must permit each participant, beneficiary, and enrollee to designate any available participating primary care provider (including a pediatrician for children). Additionally, plans and issuers that provide obstetrical/gynecological care and require a designation of a participating primary care provider may not require preauthorization or referral for such care. If a health plan requires participants to designate a participating primary care provider, the plan or issuer must provide a notice of these patient protections whenever the SPD or similar description of benefits is provided to a participant. If an employer’s plan is subject to this notice requirement, they should confirm that it is included in the plan’s open enrollment materials. This notice may be included in the plan’s SPD.Model languageis available from the DOL.
Grandfathered Plan Notices
If an employer has a grandfathered plan, they should include information about its grandfathered status in plan materials describing the coverage under the plan, such as SPDs and open enrollment materials. Model language is available from the DOL.
Notices Of HIPAA Special Enrollment Rights
At or before enrollment, an employer’s group health plan must provide each eligible employee with a notice of their special enrollment rights under HIPAA. This notice may be included in the plan’s SPD.
HIPAA Privacy Notices
The HIPAA Privacy Rule requires covered entities (including group health plans and issuers) to provide a Notice of Privacy Practices (or Privacy Notice) to everyone who is the subject of protected health information (PHI). Health plans are required to send the Privacy Notice at certain times, including to new enrollees at the time of enrollment. Also, at least once every three years, health plans must either redistribute the Privacy Notice or notify participants that the Privacy Notice is available and explain how to obtain a copy. Self-insured health plans are required to maintain and provide their own Privacy Notices. However, special rules apply for fully insured plans, where the health insurance issuer, not the plan itself, is primarily responsible for the Privacy Notice.
Special Rules for Fully Insured Plans
The plan sponsor of a fully insured health plan has limited responsibilities with respect to the Privacy Notice, including the following:
If the sponsor of a fully insured plan has access to PHI for plan administrative functions, they are required to maintain a Privacy Notice and to provide the notice upon request.
If the sponsor of a fully insured plan does not have access to PHI for plan administrative functions, they are not required to maintain or provide a Privacy Notice.
A plan sponsor’s access to enrollment information, summary health information, and PHI that is released pursuant to a HIPAA authorization does not qualify as having access to PHI for plan administration purposes.
Model Privacy Notices are available through the Department of Health and Human Services.
WHCRA Notices
Plans and issuers must provide notice of participants’ rights to mastectomy-related benefits under the WHCRA at the time of enrollment and annually. The DOL’s compliance assistance guide includes model language for this disclosure.
SARs
Plan administrators required to file Form 5500 must provide participants with a narrative summary of the information in Form 5500, called a summary annual report (SAR). Amodel noticeis available from the DOL.
Group health plans that are unfunded (that is, benefits are payable from the employer’s general assets and not through an insurance policy or trust) are not subject to the SAR requirement. The plan administrator generally must provide the SAR within nine months of the close of the plan year. If an extension of time to file Form 5500 is obtained, the plan administrator must furnish the SAR within two months after the close of the extension period.
Wellness Program Notices
Group health plans that include wellness programs may be required to provide certain notices regarding the program’s design. As a general rule, these notices should be provided when the wellness program is communicated to employees and before employees provide any health-related information or undergo medical examinations. These notices are required in the following situations:
HIPAA Wellness Program Notice—HIPAA imposes a notice requirement on health-contingent wellness programs offered under group health plans. Health-contingent wellness plans require individuals to satisfy standards related to health factors (e.g., not smoking) to obtain rewards. The notice must disclose the availability of a reasonable alternative standard to qualify for the reward (and, if applicable, the possibility of waiver of the otherwise applicable standard) in all plan materials describing the terms of a health-contingent wellness program. The DOL’scompliance assistance guideincludes a model notice that can be used to satisfy this requirement.
ADA Wellness Program Notice—Employers with 15 or more employees are subject to the Americans with Disabilities Act (ADA). Wellness programs that include health-related questions or medical exams must comply with the ADA’s requirements, including an employee notice requirement. Employers must give participating employees a notice that tells them what information will be collected as part of the wellness program, with whom it will be shared, and for what purpose, as well as the limits on disclosure and the way information will be kept confidential. The U.S. Equal Employment Opportunity Commission (EEOC) has provided asample noticeto help employers comply with this ADA requirement.
ICHRA Notices
Employers may use individual coverage HRAs (ICHRAs) to reimburse their eligible employees for insurance policies purchased in the individual market or Medicare premiums. Employers with ICHRAs must notify eligible participants about the ICHRA and its interaction with the ACA’s premium tax credit. In general, this notice must be provided at least 90 days before the start of each plan year. Employers may provide this notice at open enrollment time if it is at least 90 days before the beginning of the plan year. A model notice is available for employers to use to satisfy this notice requirement.
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Enhance Your Employee Benefits Package. A competitive benefits package is key to keeping and attracting top talent.Assess your current benefits package and consider making necessary adjustments to include options, such as expanded mental health support, for example.
GENERAL HR
Review Employee Records. The fourth quarter is a good time to review your employee records and check record retention guidelines. Don’t forget to dispose of outdated termination and outdated job applications properly. With W2s around the corner, make sure all addresses and information are updated.
Develop and Distribute Your 2024 Calendar. Create and distribute a calendar outlining important dates, vacation time, pay dates, and company-observed holidays for 2024.
Review and Update Employee Handbook. Review your employee handbook to make sure it is up-to-date and addresses areas, such as employment law mandates, new COVID-related policies, guidelines for remote working, privacy policies, compensation and performance reviews, social media policies, attendance, and time-off, break periods, benefits, and procedures for termination, discipline, workplace safety, and emergency procedures.
PLEASE NOTE: This Checklist is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. This information is for general reference purposes only. Because laws, regulations, and filing deadlines are likely to change, please check with the appropriate organizations or government agencies for the latest information and consult your employment attorney and/or benefits advisor regarding your responsibilities. In addition, your business may be exempt from certain requirements and/or be subject to different requirements under the laws of your state. (Updated Sept 3, 2023)
Contact us at (855) 667-4621 or email us at info@medicalsolutionscorp.com
As per NY State Law, Health Insurers are required to send out early notices of rate request filings to groups and subscribers. Despite only 3 months of mature claims data experience for 2023 health insurers’ original requests were noticeably above the average of 22%/individuals and 15.3% for small groups.
State Department of Financial Services officials asserted the rising cost of medical care — including in-patient hospital stays and rapid increases in drug prices — continued to be the main driver of health insurance premium increases. The final approved rates for 2024 would keep health insurers’ profit provisions at 1%, state officials added, noting they sought to limit those returns in light of ongoing inflationary pressures harming consumers. That said, in anticipation of spikes in claims submissions + overall inflation, a larger-than-average increase is needed. This is in addition to increases in pricing by hospitals, consolidated IPA groups, and pharmaceuticals.
Rate Factors
The state noted that the premiums increase main drivers are medications. “Rising medical costs and inflation continue to put upward pressure on premiums,” said Superintendent Harris. “With our rate actions announced today, we continue to prioritize the financial well-being of consumers while ensuring that New Yorkers have access to a robust, stable health insurance market.” Also, DFS, recognizing the continued uncertainty of the pandemic’s effect on consumers’ healthcare costs and the economy, held insurers’ profit provisions to a low 1%.
Health Insurers
Oxford/Unitedhealthcare, notably, got only a 4.7% rate increase approval for next year. This is a sharp reduction from the original 15.5% request in part to disagreed anticipated costs, held reserves, overall market pricing, and reinsurance gained from ACA’s Risk Corridor. See more info here, https://medicalsolutionscorp.com/risk-adjustment-reinsurance-and-risk-corridors/.
Small Group Market
Almost 800,000 New Yorkers are enrolled in small group plans, which cover employers with up to 100 employees. Insurers requested an average rate increase of 15.3% in the small group market, which DFS cut by 52% to 7.4% for 2024, saving small businesses $607 million. A number of small businesses also will be eligible for tax credits that may lower those premium costs even further, such as the Small Business Health Care Tax Credit.
DFS SMALL GROUP MARKET RATE ACTIONS
*Indicates the Company will offer products on the NY State of Health Marketplace in 2024.
PEO Alternatives to Small Group
Before you consider renewing automatically, you should first find out what is a PEO so that you can know exactly what to expect from it. PEOs are large-group markets underwritten. With the right PEO, you will be able to manage your business’s demand for growth and your employees as well.
Clients on average save 15-40% off the small group market. If you are looking for a complete insurance solution for your business, go to our website and check out our business insurance solutions. Contact us for more information today.
Learn how a PEO can make a difference for your group. For more information on how Employer-Sponsored Insurance and a PEO can make a difference for your small business please contact us at info@medicalsolutionscorp.com or 855-667-4621.
About this Session: Engaging your workforce and captivating them: How do you achieve this? During this session we discuss how to deploy engaging tactics with the right balance of frequency and educational impacts across a multi-generational workforce to engage your employees when it matters most..
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
About this Session: Employers have become accustomed to just accepting carrier data, ludicrous assumptions, and flawed methodology in the underwriting process. This is understandable since the fully insured renewal proposal can be hard to decipher. We will help you decode what seems undecodable and give you the tools and knowledge to understand your renewal — sharing an actual case study. This will help put you in the driver’s seat to ask the right questions, challenge carrier assumptions that do not align with your plan analytics and give you more leverage for negotiating your renewal to save money.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
“This year’s rankings represent an expanded universe, with three new countries on the list—Colombia, Saudi Arabia, and the United Arab Emirates—bringing the total to over 2,300 hospitals in 28 countries. And the results show a remarkable cross-section of excellence across the world: Twenty-one countries are represented in the global top 150. The U.S. leads with 29 hospitals, followed by Germany with 16; Italy and France with 10 each; and South Korea with eight. Overall, there were 13 new hospitals in this year’s top 100. Among the biggest movers from last year’s rankings were No. 8 Northwestern Memorial Hospital (28 in 2022); No. 40 Seoul’s Samsung Medical Center (73) and No. 11 New York’s NYU Langone Hospitals (59).”
Top 10 Internationally:
1Mayo Clinic Rochester- United States 2Cleveland Clinic- United States 3Massachusetts General Hospital- United States 4The Johns Hopkins Hospital- United States 5Toronto General – University Health Network- Canada 6Karolinska Universitetssjukhuset- Sweden 7Charité – Universitätsmedizin- BerlinGermany 8AP-HP – Hôpital Universitaire Pitié Salpêtrière- France 9Singapore General Hospital- Singapore 10UCLA Health – Ronald Reagan Medical Center- United States
Top 20 Nationally:
1Mayo Clinic – Rochester 2ClevelandClinic 3MassachusettsGeneral Hospital 4TheJohns Hopkins Hospital 5UCLAHealth – Ronald Reagan Medical Center 6 Stanford Health Care – Stanford Hospital 7BrighamAnd Women’s Hospital 8NorthwesternMemorial Hospital 9TheMount Sinai Hospital 10New York-Presbyterian Hospital-Columbia and Cornell
11. University of Michigan Hospitals – Michigan Medicine 12 Cedars-Sinai Medical Center 13. UCSF Medical Center 14. Duke University Hospital 15. Hospital of the University of Pennsylvania – Penn Presbyterian 16. NYU Langone Hospitals 17. Mayo Clinic – Jacksonville 18. Russh University Medical Center 19. Mayo Clinic – Phoenix 20. Houston Methodist Hospital
Top 10 NY/NJ Metro Hospitals:
9
The Mount Sinai Hospital
83.98%
New York
NY
10
New York-Presbyterian Hospital-Columbia and Cornell
83.94%
New York
NY
16
NYU Langone Hospitals
81.23%
New York
NY
46
Morristown Medical Center
70.66%
Morristown
NJ
57
Hackensack University Medical Center
69.52%
Hackensack
NJ
117
Strong Memorial Hospital – University of Rochester
65.36%
Rochester
NY
121
Valley Hospital
65.30%
Ridgewood
NJ
130
North Shore University Hospital
65.21%
Manhasset
NY
148
Saratoga Hospital
64.71%
Saratoga Springs
NY
167
Overlook Medical Center
64.42%
Summit
NJ
Top 3 CT Hospitals:
35YaleNew Haven Hospital 158 St. Francis Hospital& Medical Center 201Griffin Hospital
Top 10 PA Hospitals:
15
Hospital of the University of Pennsylvania – Penn Presbyterian
Philadelphia
PA
54
Jefferson Health – Thomas Jefferson University Hospitals
Philadelphia
PA
58
UPMC Presbyterian & Shadyside
Pittsburgh
PA
64
Penn State Health – Milton S. Hershey Medical Center
Hershey
PA
76
Penn Medicine Chester County Hospital
West Chester
PA
103
Reading Hospital
Reading
PA
116
St. Luke’s Hospital Bethlehem
Bethlehem
PA
122
Doylestown Hospital
Doylestown
PA
153
Lancaster General Hospital
Lancaster
PA
168
Main Line Health – Lankenau Medical Center
Wynnewood
PA
Top 10 FL Hospitals:
17
Mayo Clinic – Jacksonville
Jacksonville
FL
45
Cleveland Clinic – Florida
Weston
FL
84
Tampa General Hospital
Tampa
FL
146
Sarasota Memorial Hospital
Sarasota
FL
149
St. Joseph’s Hospital – BayCare
Tampa
FL
172
Baptist Health Baptist Hospital
Miami
FL
176
Morton Plant Hospital
Clearwater
FL
179
Baptist Medical Center – Beaches
Jacksonville Beach
FL
183
Adventhealth Orlando
Orlando
FL
215
Cape Canaveral Hospital
Cocoa Beach
FL
NOTE: For patients and their physicians, these rankings and ratings should be seen as just a starting point. While this is helpful information to have, benefit plan participants should also research quality hospitals using transparency tools if these services are available through the health plan or benefits package. For a customized review of your commercial sponsored plan using latest tools and third part-tools please contact us today.
About this Session: The healthcare landscape continues to change quickly and significantly. Why, then, are many of the health plans being offered today designed years ago? Changes made to plans are often limited to cost-shifting, which can help control costs, but do not provide solutions to improving health outcomes and can put an undue burden on your employees. In this session, we will go over some of the new and innovative options and demonstrate a different approach to designing a health plan. We will introduce care and value initiatives that can reduce cost and improve overall population health and provide 10 tips to take back control of your health plan.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
Discover the latest employee benefit marketplace trends, explore their impact on costs and member experience, and delve into healthcare utilization patterns, medical inflation drivers, and the response from the medical insurer marketplace.
Each month our team covers hot topics to help simplify them and educate you on the latest trends, issues, and innovations
About this Session: Employee benefit marketplace trends can positively or negatively impact costs and member experience. We’ll take a deep dive into current healthcare utilization patterns, medical inflation drivers, and the medical insurer marketplace’s response. With a thorough understanding of the current state of the market, you will be able to see how the benefits program of the future can provide opportunities along with challenges — and help you plan now.
During this session, we will also introduce some of the disrupters making waves in mainstream benefits strategies from the “Insuretech” marketplace and the health outcomes and the financial impacts of those programs.
Accreditation: By attending this webinar, you will receive 1 hour (General) recertification credit hour through the HR Certification Institute® (HRCI) and 1 hour credit through SHRM.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
Education and information to help keep you up-to-date and informed
Each month our Employee Benefits team covers trending, top–of–mind topics relevant to the world of benefits. These subject matter experts leverage their extensive experience, data, and research, and then simplify and summarize these topics to educate and help leaders drive their businesses forward.
Don’t Let Employee Leaves Keep You Guessing. What Can You Do and What are the Best Practices?
We know business owners and executives are challenged with controlling costs while meeting the company’s changing physical, emotional, and financial needs. The employee benefits landscape also continues to change, and so do compliance rules and regulations. How do you stay on top of it?
Meet our Speaker
Jay Kirschbaum,Director of Employee Benefits Compliance
Jay has more than 30 years of experience as a tax attorney specializing in employee benefits and the application of a broad range of compensation and employer-sponsored benefits programs. His experience combines a high level of technical expertise with creative and practical business-oriented solutions. (Click Home icon to view full bio).
Meet our Speaker
Mike Barton. Chief Growth Officer Employee Benefits
Mike has more than 30 years of insurance industry experience, with a proven-track record in business development and multi-channel distribution. He oversees all aspects of sales and plays a pivotal role in the development of new business, market cultivation, and product development, as well as our long-term growth goals. (Click Home icon to view full bio).
Meet our Speaker
David Stoddard. Director of Analytics and Actuarial Services
David has over 10 years of experience in the health care industry as a lead health benefits actuary performing high impact actuarial consulting for large multi-state employers in a variety of industries. He creates new, scalable, data-driven solutions for clients including financial and contractual analysis, claims utilization and modeling, renewal projection, and premium rate analysis and modeling. (Click Home icon to view full bio).
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
Employee benefit marketplace trends can positively or negatively impact costs and member experience.We’ll take a deep dive into current healthcare utilization patterns, medical inflation drivers, and the medical insurer marketplace’s response. With a thorough understanding of the current state of the market, you will be able to see how the benefits program of the future can provide opportunities along with challenges —and help you plan now.
During this session, we will also introduce some of the disrupters making waves in mainstream benefits strategies from the “Insuretech” marketplace and the health outcomes and the financial impacts of those programs.
Accreditation: By attending this webinar, you will receive 1 hour (General) recertification credit hour through the HR Certification Institute® (HRCI) and 1 hour credit through SHRM.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
Effective July 1, 2023, private employers operating in Florida with 25 or more employees must use E-Verify during their onboarding process. Previously, the E-Verify requirement only applied to public employers, contractors, and subcontractors, while private employers were required to either comply with Form I-9 requirements or use E-Verify.
What is E-Verify?
E-Verify is a digital employment eligibility tool that verifies if the newly hired employee is authorized to work in the United States.
To Whom Does This Law Apply?
This requirement applies to Florida private employers with 25 or more employees. Employers with less than 25 employees are encouraged to use E-Verify but are not required to do so. Employers are not required to utilize E-Verify on independent contractors since they are not considered employees.
Moving Forward: What Are Employers Required to Do?
Florida private employers should update their onboarding process, if necessary, to incorporate the new E-Verify requirement in conjunction with Form I-9 in anticipation of the July 1, 2023, deadline. Employers must verify employment eligibility within three business days of the new hire’s start date.
Record-Keeping Requirements and Certification
Employers must maintain a copy of the documentation provided for Form I-9 and E-Verify and any official verification for three years after the employee’s start date.
Penalties
Beginning July 1, 2024, if the Florida Department of Economic Opportunity (DEO) finds that an employer has knowingly hired someone who is not authorized and did not verify the employee’s employment eligibility, the DEO can impose civil penalties on the employer, including the repayment of any economic development incentive and the DEO will put the employer on probation for one year, requiring the employer to demonstrate compliance every quarter. In addition, if another violation occurs within 24 months, the DEO is authorized to suspend or revoke all Florida-issued licenses.
Additionally, if the DEO finds that an employer failed to use the E-Verify system, it will notify the employer and give them 30 days to rectify the non-compliance. If the DEO finds that the employer has not used the E-Verify system 3 times within a 24-month period, the DEO can fine the employer $1,000 per day until the employer provides proof that it has rectified the non-compliance.
Interested in learning more? World Payroll or our PEO Partners can assist with the E-Verify process. Please email info@medialsolutionscorp.com or call us at 855-667-4621.
Please Note: While the information within this alert may concern certain employment laws and regulations to be aware of, it is provided solely as general guidance so that you maintain compliance. It is not the equivalent of legal advice, nor does it serve as a substitute for the advice of an attorney, if applicable.
About this Session: This can put you in the “driver’s seat,” allowing you to make thoughtful decisions that can expand your medical plan options, which can help put a significant amount of your employee benefits cost back into your and your employees’ pockets! Get your “geek-on” during this session as we assess the fundamentals of funding strategies, review fully insured, self-funded, and captive medical plan options and outline your potential opportunities.
Accreditation: By attending this webinar, you will receive 1 hour (General) recertification credit hour through the HR Certification Institute® (HRCI) and 1 hour credit through SHRM.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
The IRS, yesterday, released the 2024 Health Savings Account (HSA) inflation adjustments. To be eligible to make HSA contributions, an individual must be covered under a high-deductible health plan (HDHP) and meet certain other eligibility requirements.
New HSA 2024 limits are as follows:
2024
2023
HSA Annual Contribution Limit
$4,150; $8,300
$3,850 – Single; $7,750 – Family
HDHP Minimum Annual Deductible
$1,600; $3,200
$1,500 – Single; $3,000 – Family
HDHP Out-of-Pocket Maximum
$8,050; $16,100
$7,500 – Single; $15,000 – Family
Age 55+ Catch-Up Provision
$1,000; $2,000
$1,000- Single; $2,000 – Husband/Wife
Age 55 Catch-Up Contribution
As in 401k and IRA contributions, you are allowed to contribute extra if you are above a certain age. If you are age 55 or older by the end of the year, you can contribute an additional $1,000 to your HSA. If you are married, and both of you are age 55, each of you can contribute an additional $1,000. A savvy strategy for high-income earners is to invest the money in your HSA for the long haul. Once you’re 65, you can take out tax-free distributions to cover Medicare premiums. If you withdraw money at that point for non-medical uses, you pay the same tax as you would on withdrawals from a pretax 401(k). But you can also take money out tax-free to reimburse yourself for prior years’ out-of-pocket medical expenses if you have the old receipts.
COVId-19 Update:
You can even use an HSA to save on a typical trip to the CVS. Thanks to a tax relief provision tucked in the last Covid-19 stimulus package, you can use the money you stash in an HSA or FSA (more on those later) for over-the-counter medications like Tylenol or Flonase as well as menstrual products like tampons and pads. That reverses Obamacare restrictions on OTC meds requiring a doctor’s prescription for them to be eligible for reimbursement.
HSA/HDHP Market Growth
HSA holders own the assets in the accounts and can build up substantial sums over time. Enrollment in HSA-compatible insurance plans has increased to 10 million earlier this year, from 1 million in March 2005, according to, America’s Health Insurance Plans (AHIP), a trade group.
HSAs were authorized starting in January 2004. Since then, AHIP has conducted a periodic census of health plans participating in the HSA/HDHP market.
The number of people with HSA/HDHP coverage rose to more than 11.4 in January 2011, up from 10.0 million in January 2010, 8.0 million in January 2009, and 6.1 million in January 2008.
30 percent of individuals covered by an HSA plan were in the small-group market, 50 percent were in the large-group market, and the remaining 20 percent were in the individual market.
14% of all workers in the private sector have access to a Health Savings Account acc. to the Bureau of Labor Statistics.
States with the highest levels of HSA/HDHP enrollment were California, Ohio, Florida, Texas, Illinois, and Minnesota.
HSA Advantages:
Opportunity to build savings – Unused money stays in your account from year to year and earns tax-free interest. The HSA also gives you an investment opportunity.
Tax-free contributions and earnings – You don’t pay taxes on contributions or earnings.
Tax-Free Money allowed for non-traditional Medical coverage– As per IRS Publication 502, unused money can be used for dental, vision, Lasik eye surgery, acupuncture, yoga, infertility, etc. Popular Examples
Portability – The funds belong to you, so you keep the funds if you change jobs or retire.
Our overall experience with HSAs has been positive when employer funding is at a minimum 50% using either the HSA or an HRA (Health Reimbursement Account-employer keeps unspent money). Traditional plans’ trend of higher copays and new in-network deductibles has also led to the popularity of an HSA.
Next Steps
Plan sponsors should update payroll and plan administration systems for the 2023 cost-of-living adjustments and should incorporate the new limits in relevant participant communications, such as open enrollment and communication materials, plan documents, and summary plan descriptions.
Is your HSA compliant? Which pre-tax qualified HSA, FSA, HRA spending card is right for you? Please contact our team at Millennium Medical Solutions Corp (855)667-4621 for immediate answers. Stay tuned for updates as more information gets released. Sign up for the latest news updates.
About this Session: There is no shortage of third-party vendors trying to partner with you. Selecting the right vendor that can make the right impact within your organization is imperative. During this session, we will discuss how you can implement successful, flexible, and fluid solutions that work together to drive clinical performance and have positive outcomes on the health of your employees.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
On January 30, 2023, the federal government announced that the two national emergencies addressing COVID-19, the public health emergency (PHE) and the national emergency, will end on May 11, 2023.
Starting May 12, 2023, health plans and group plan sponsors will no longer be subject to federal requirements for coverage of COVID-19 testing, vaccinations and treatments. Therefore, there may be changes you should be aware of regarding your health insurance plan and COVID-19.
Below are links to communications by carrier on how they will handle COVID-19 coverage when the public health emergency ends.
Additional resources on the ending of the COVID-19 emergency periods are available on the Department of Labor’s Response to COVID-19 website.
We will communicate additional information as it becomes available. Sign up for the newsletter or for updates email us directly at info@mediclaolsutionscorp.com.
PLEASE NOTE: This information is for general reference purposes only. Because laws, regulations, and filing deadlines are likely to change, please check with the appropriate organizations or government agencies for the latest information and consult your employment attorney and/or benefits advisor regarding your responsibilities. In addition, your business may be exempt from certain requirements and/or be subject to different requirements under the laws of your state.
Contact us at (855) 667-4621 or email us at info@medicalsolutionscorp.com
About this Session: The number of leave options available to employees is at an all-time high. Administering these and staying compliant with their requirements while also reducing the impact on your business can be tricky. As you continue to face this growing challenge, we will discuss:
Education and information to help keep you up-to-date and informed
Each month our Employee Benefits team covers trending, top–of–mind topics relevant to the world of benefits. These subject matter experts leverage their extensive experience, data, and research, and then simplify and summarize these topics to educate and help leaders drive their businesses forward.
Don’t Let Employee Leaves Keep You Guessing. What Can You Do and What are the Best Practices?
The number of leave options available to employees is at an all–time high. Administering these and staying compliant with their requirements while also reducing the impact on your business can be tricky. As you continue to face this growing challenge, we will discuss best practices, and tips to help you manage and administer these leaves, and what to do next.
Meet our Speaker
Ryan Nelson, CLMS. Senior Absence Practice Leader Guardian Life. Sr. Absence Management Solutions Practice Leader with years of experience in helping employers navigate the complexities of the evolving Disability, Leave, and ADAAA landscapes.
Meet our Speaker
Jennifer Barton. Head of Employee Benefits. Jennifer is responsible for the growth —both organic and through acquisitions —and profitability of our employee benefits practice. This includes carrier relationships and strategic partners, client engagement strategy, practice resources, and overall strategic direction. Before joining World, she served in several senior executive roles, including COO of the Human Capital Practice for North America, within Willis Towers Watson.
Join us for an insightful discussion on strategically weaving financial well-being into your employee benefits strategy. Uncover how this approach not only nurtures individual well-being but also plays a pivotal role in cultivating a thriving and harmonious workplace.
Why We Love PEO This Valentine’s Day. Today we’re counting down our top 5 reasons why we love PEO. National Capabilities, Liability Protections, Technologies, One Vendor and PEO saves you money on HR staff. Try Our PEO Quoting Tool today.
Artificial intelligence can help spot early signs of cancer in chest x-rays, according to a new study.
Scientists found that a state-of-the-art AI tool can identify normal and abnormal chest x-rays in a clinical setting.
Scientists said that an AI tool could accurately differentiate between normal and abnormal chest x-rays. (Photo via SWNS)
Chest X-rays are used to diagnose several conditions to do with the heart and lungs.
An abnormal chest X-ray can be an indication of a range of conditions, including cancer and chronic lung diseases.
Scientists say that an AI tool that can accurately differentiate between normal and abnormal chest X-rays would greatly reduce the heavy workload of radiologists.
Study co-author Dr. Louis Lind Plesner said: “There is an exponentially growing demand for medical imaging, especially cross-sectional such as CT and MRI.
“Meanwhile, there is a global shortage of trained radiologists.
“Artificial intelligence has shown great promise, but should always be thoroughly tested before any implementation.”
Dr. Plesner and his colleagues wanted to determine the reliability of using an AI tool that can identify normal and abnormal chest X-rays.
They used a commercially available AI tool to analyze the chest X-rays of 1,529 patients from four hospitals in Denmark.
Chest X-rays were included from emergency department patients, in-hospital patients and outpatients.
The X-rays were classified by the AI tool as either “high-confidence normal” or “not high-confidence normal,” as in normal and abnormal, respectively.
Two board-certified radiologists were used as the reference standard. A third radiologist was used in cases of disagreements.
Of the 429 chest X-rays that were classified as normal, 120 (28 percent) were also classified by the AI tool as normal. Those X-rays – 7.8 percent of the total – could be potentially safely automated by an AI tool.
The AI tool identified abnormal chest X-rays with a 99.1 percent of sensitivity.
Dr. Plesner, from the Department of Radiology at the Herlev and Gentofte Hospital in Copenhagen, said: “The most surprising finding was just how sensitive this AI tool was for all kinds of chest disease.
“In fact, we could not find a single chest X-ray in our database where the algorithm made a major mistake.
“Furthermore, the AI tool had a sensitivity overall better than the clinical board-certified radiologists.”
He said the AI tool performed particularly well at identifying normal X-rays of the outpatient group at a rate of 11.6 percent.
Dr. Plesener said the findings, published in the journal Radiology, suggest that the AI model would perform especially well in outpatient settings with a high prevalence of normal chest X-rays.
He added: “Chest X-rays are one of the most common imaging examinations performed worldwide.
“Even a small percentage of automatization can lead to saved time for radiologists, which they can prioritize on more complex matters.”
The editorial on the topic praised the potential to take care of 7.8% of all the normal readings for the radiologists, one of the key findings of the study, but suggests that as a labor-saving device, more research is needed to ensure radiologists aren’t putting patients at risk for a mere 7.8% reduction in workload.
Effective May 1, 2023 All Commercial Pro and Pro Plus Plans will be discontinued (except the Platinum Pro Plus Plan)
Note: This means an employer renewing 4/1/23 would receive 12 months of coverage as long as they aren’t in a discontinued Gold or Bronze Plan.
The last date of coverage for employers with Gold Plans that were previously discontinued (10/1/22) will be 8/31/23
The last date of coverage for employers with Bronze Plans that were previously discontinued (1/1/23) will be 11/30/23
All other plans except Platinum Plus will be discontinued on renewal beginning 5/1/23. The last possible date of coverage will be 3/30/24
If your group has one of the discontinued HealthFirst plans please contact us at (914) 207-6161 to discuss renewal options.
Learn more about how we have successfully helped navigate SMB for 25+ years. If you have any questions or would like additional information, please contact us at 855-667-4621 or info@medicalsolutionscorp.com.
All businesses today are aware that a healthy workforce translates to a happier and more productive employee. Nearly a quarter of participants in SHRM’s latest benefits survey plan to increase their Health & Wellness benefits, whose percentage was higher than other categories such as professional and career development, flexible work schedules, retirement and family-friendly policies. One unusual offering, workstations that allow people to stand, soared to 44% from just 13% in 2013 when the data was first tracked.
Helping your employees strive towards physical, emotional, mental, and even spiritual well-being can lead to increased productivity and employee longevity. But how can you offer wellness programs that your employees will actually use and find beneficial? There’s no one size fits all solution, and the best way to get started is to invite employee input. Need some inspiration? Here are 5 employee wellness programs that might be the right fit for your company this coming year:
1. Online Wellness/Health Screening
Did you know many health nurses today pay their employees to take an online health risk assessment? Covered members receive a lump sum benefit payment once a year if they complete certain health-related activities (i.e. routine screenings, programs like smoking cessation and weight reduction, and more). Payment options range from $50 to $150. Empire Blue Cross, for example, pays up to $300 for this including a smoking cessation online questionnaire and flu vaccination.
2. Gym Reimbursements
You might not be able to build a gym at the office, but that doesn’t mean you can’t take advantage of your neighborhood businesses. Did you know most healthcare compare today to offer up to $400 annual gym reimbursement? Most include a $200 spousal gym reimbursement as well.
3. Start a Walking Group
This solution is easy, free, and can be employee-driven. Failing to take breaks leads to burnout and eventually employee resentment. Encourage employees to take frequent breaks, but not just to the break room for more artificial lighting and a caffeine boost. Rally eager employees to lead morning, lunch, and/or after-work walking groups. The fresh air is energizing, boosts creativity, and helps feed social wellness needs, too.
4. Create a Healthy Challenge That Isn’t Based on Numbers
Although some businesses have success with Biggest Loser-style in-office challenges, it can also trigger disordered eating. Instead of focusing on numbers, focus on more subjective goals—like how many consecutive days fresh, local fresh vegetables can be part of a lunch. Kicking off these challenges with a brief intro to the importance of a healthy diet for life can help employees re-think their choices.
5. Seek Help from Outside Resources
There are several organizations that employers can turn to for information, research, and guidance on wellness programs. Below are just a few for you to explore for helpful ideas on how to develop a culture of health in your organization.
HERO is a national non-profit dedicated to identifying and sharing best practices in the field of workplace health and well-being (HWB). Their mission is to improve the health and well-being of workers, their spouses, dependents, and retirees. Check out the wealth of information on their site, including research studies and a blog.
The Health Project is a tax-exempt not-for-profit corporation formed to bring about critical attitudinal and behavioral changes in addressing the health and well-being of Americans. The Health Project focuses on improving personal healthcare practices and supporting population health by reaching adults where they spend most of their waking hours: at work. Many organizations have adopted health promotion (wellness) programs that encourage good health habits and an improved understanding of how individual workers and their families can more effectively use health services.
Harvard Health Newsletters are free newsletters targeted to individuals with the purpose of providing educational information to help them invest in their own health or the health of their families.
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Contact us to learn more about how health and wellness benefits can help you attract and retain your top talent.
This Compliance Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.
In preparation for open enrollment, Employers should review their plan documents in light of changes for the plan year beginning Jan 1, 2023. Below is an Employer 2023 Open Enrollment Checklist including some administrative items to prepare for in 2023.
Health plan sponsors should also confirm that their open enrollment materials contain certain required participant notices, when applicable—for example, the summary of benefits and coverage (SBC). There are also some participant notices that must be provided annually or upon initial enrollment. To minimize costs and streamline administration, employers should consider including these notices in their open enrollment materials.
PLAN DESIGN CHANGES
Out-of-pocket Maximum
Effective for plan years beginning on or after Jan. 1, 2014, non-grandfathered health plans are subject to limits on cost-sharing for essential health benefits (EHB). The ACA’s out-of-pocket maximum applies to all non-grandfathered group health plans, including self-insured health plans and insured plans.
$9,100 for self-only coverage and $18,200 for family coverage out-of-pocket maximum.
$7,500 for self-only coverage and $15,000 for family coverage HSA Maximum.
Preventive Care Benefits
The ACA requires non-grandfathered health plans to cover certain preventive health services without imposing cost-sharing requirements (that is, deductibles, copayments or coinsurance) for the services. Health plans are required to adjust their first-dollar coverage of preventive care services based on the latest preventive care recommendations. If you have a non-grandfathered plan, you should confirm that your plan covers the latest recommended preventive care services without imposing any cost-sharing.
The ACA imposes a dollar limit on employees’ salary reduction contributions to a health flexible spending account (FSA) offered under a cafeteria plan. An employer may impose its own dollar limit on employees’ salary reduction contributions to a health FSA, as long as the employer’s limit does not exceed the ACA’s maximum limit in effect for the plan year.
The ACA set the health FSA contribution limit at $2,500. For years after 2013, the dollar limit is indexed for cost-of-living adjustments. For 2023 plan years, the health FSA limit is $3,050. The DFSA Rollover Maximum is $610.
Communicate the health FSA limit to employees as part of the open enrollment process.
If you offer an HDHP to your employees that is compatible with an HSA, you should confirm that the HDHP’s minimum deductible and out-of-pocket maximum comply with the 2020 limits. The IRS limits for HSA contributions and HDHP cost-sharing increase for 2023. The HSA contribution limits will increase effective Jan. 1, 2023, while the HDHP limits will increase effective for plan years beginning on or after Jan. 1, 2023.
Check whether your HDHP’s cost-sharing limits need to be adjusted for the 2023 limits.
If you communicate the HSA contribution limits to employees as part of the enrollment process, these enrollment materials should be updated to reflect the increased limits that apply for 2023.
The following table contains the HDHP and HSA limits for 2023 as compared to 2022. It also includes the catch-up contribution limit that applies to HSA-eligible individuals who are age 55 or older, which is not adjusted for inflation and stays the same from year to year.
Type of Limit
2023
2022
Change
HSA Contribution Limit
Self-only
$3,850
$3,650
Up $50
Family
$7,750
$7,300
Up $100
HSA Catch-up Contributions (not subject to adjustment for inflation)
Age 55 or older
$1,000
$1,000
No change
HDHP Minimum Deductible
Self-only
$1,500
$1,400
No change
Family
$3,000
$2,800
No change
HDHP Maximum Out-of-pocket Expense Limit (deductibles, copayments and other amounts, but not premiums)
Self-only
$7,500
$7,050
Up $50
Family
$15,000
$14,100
Up $100
ACA EMPLOYER MANDATE AND OTHER REQUIREMENTS
Applicable Large Employer Status (ALE)
Under the ACA’s employer penalty rules, applicable large employers (ALEs) that do not offer health coverage to their full-time employees (and dependent children) that is affordable and provides minimum value will be subject to penalties if any full-time employee receives a government subsidy for health coverage through an Exchange.
To qualify as an ALE, an employer must employ, on average, at least 50 full-time employees, including full-time equivalent employees (FTEs), on business days during the preceding calendar year. All employers that employ at least 50 full-time employees, including FTEs, are subject to the ACA’s pay or play rules.
Determine your ALE status for 2023
Calculate the number of full-time employees for all 12 calendar months of 2022. A full-time employee is an employee who is employed on average for at least 30 hours of service per week.
Calculate the number of FTEs for all 12 calendar months of 2022 by calculating the aggregate number of hours of service (but not more than 120 hours of service for any employee) for all employees who were not full-time employees for that month and dividing the total hours of service by 120.
Add the number of full-time employees and FTEs (including fractions) calculated above for all 12 calendar months of 2022.
Add up the monthly numbers from the preceding step and divide the sum by 12. Disregard fractions.
If your result is 50 or more, you are likely an ALE for 2023.
Identify Full-time Employees
All full-time employees must be offered affordable minimum-value coverage. A full-time employee is an employee who was employed on average at least 30 hours of service per week. The final regulations generally treat 130 hours of service in a calendar month as the monthly equivalent of 30 hours of service per week. The IRS has provided two methods for determining full-time employee status—the monthly measurement method and the look-back measurement method.
Determine which method you are going to use to determine full-time status
The monthly measurement method involves a month-to-month analysis where full-time employees are identified based on their hours of service for each month. This method is not based on averaging hours of service over a prior measurement method. Month-to-month measuring may cause practical difficulties for employers, particularly if there are employees with varying hours or employment schedules, and could result in employees moving in and out of employer coverage on a monthly
The look-back measurement method allows an employer to determine full-time status based on average hours worked by an employee in a prior period. This method involves a measurement period for counting/averaging hours of service, an administrative period that allows time for enrollment and disenrollment, and a stability period when coverage may need to be provided, depending on an employee’s average hours of service during the measurement
Audit FTEs for FMLA Compliance
Audit your FTEs to determine if you have reached or exceeded 50 employees and are required to comply with the Family Medical Leave Act (FMLA) in 2022. Employers covered by the FMLA are obligated to provide their employees with certain important FMLA notices, so both employees and the employer have a shared understanding of the terms of the FMLA leave. Note that FMLA compliance requirements are different from ACA compliance.
Offer of Coverage
An ALE may be liable for a penalty under the pay or play rules if it does not offer coverage to “substantially all” (95%) full-time employees (and dependents) and any one of its full-time employees receives a premium tax credit or cost-sharing reduction for coverage purchased through an Exchange. For employees who are offered health coverage that is affordable and provides minimum value are generally not eligible for these Exchange subsidies. The IRS lowered the 2023 employer health plan affordability threshold, or cost-sharing limit, to 9.12% of an employee’s income. The threshold in 2022 was 9.61%.
Offer minimum essential coverage to all full-time employees
Ensure that at least one of those plans provides minimum value (60% actuarial value)
Ensure that the minimum value plan offered is affordable to all full-time employees by ensuring that the employee contribution for the lowest cost single minimum value plan does not exceed 78% of an employee’s earnings based on the employee’s W-2 wages, the employee’s rate of pay, or the federal poverty level for a single individual.
Reporting of Coverage
The ACA requires ALEs to report information to the IRS and to employees regarding employer-sponsored health coverage on Form 1095-C. The IRS will use the information that ALEs report to verify employer-sponsored coverage and to administer the employer-shared responsibility provisions (Code Section 6056).
In addition, the ACA requires every health insurance issuer, sponsor of a self-insured health plan, government agency that administers government-sponsored health insurance programs and any other entity that provides minimum essential coverage (MEC) to file an annual return with the IRS and individuals reporting information for each individual who is provided with this coverage (Code Section 6055).
Determine which reporting requirements apply to you and your health plans
Determine the information you will need for reporting and coordinate internal and external resources to help compile the required data for the 1094-C and 1095-C
ACA Requirement
Deadline
1095 forms delivered to employees
Jan. 31 (extended to March 2)
Paper filing with IRS*
Feb. 28
Electronic filing with IRS
March 31
Comparative Effectiveness Research Fee (PCORI)
Sponsors of self-funded plans and health insurance issuers of fully insured plans are required to pay a fee each year, by July 31st, to fund comparative effectiveness research. Fees will increase to $2.45 per covered life in 2021 and are next due July 31, 2022.
W-2 Reporting
Healthcare Reform requires employers to report the aggregate cost of employer-sponsored group health plan coverage on their employees’ Forms W-2. This reporting requirement was originally effective for the 2011 tax year. However, the IRS later made reporting optional for 2011 for all employers.
The IRS further delayed the reporting requirement for small employers (those that file fewer than 250 Forms W-2) by making it optional for these employers until further guidance is issued. For the larger employers, the reporting requirement was mandatory for the 2012 Forms W-2 and continues.
ACA DISCLOSURE REQUIREMENTS
Summary of Benefits and Coverage
The ACA requires health plans and health insurance issuers to provide an SBC to applicants and enrollees to help them understand their coverage and make coverage decisions. Plans and issuers must provide the SBC to participants and beneficiaries who enroll or re-enroll during an open enrollment period. The SBC also must be provided to participants and beneficiaries who enroll other than through an open enrollment period (including those who are newly eligible for coverage and special enrollees).
In connection with a plan’s 2023 open enrollment period, the SBC should be included with the plan’s application materials. If coverage automatically renews for current participants, the SBC must generally be provided no later than 30 days before the beginning of the new plan year.
For self-funded plans, the plan administrator is responsible for providing the SBC. For insured plans, both the plan and the issuer are obligated to provide the SBC, although this obligation is satisfied for both parties if either one provides the SBC. Thus, if you have an insured plan, you should confirm that your health insurance issuer will assume responsibility for providing the SBCs.
SBCs must be given to anyone who enrolls in benefits, during or outside of open enrollment.. Generally, provide no later than 30 days before the start of the plan year.
Self-funded plans: Plan sponsor is responsible for SBC distribution.
Grandfathered Plan Notice
If you have a grandfathered plan, make sure to include information about the plan’s grandfathered status in plan materials describing the coverage under the plan, such as SPDs and open enrollment materials. Model language is available from the DOL.
Notice of Patient Protections
Under the ACA, non-grandfathered group health plans and issuers that require designation of a participating primary care provider must permit each participant, beneficiary and enrollee to designate any available participating primary care provider (including a pediatrician for children). Also, plans and issuers that provide obstetrical/gynecological care and require a designation of a participating primary care provider may not require preauthorization or referral for obstetrical/gynecological care.
If a non-grandfathered plan requires participants to designate a participating primary care provider, the plan or issuer must provide a notice of these patient protections whenever the SPD or similar description of benefits is provided to a participant. If your plan is subject to this notice requirement, you should confirm that it is included in the plan’s open enrollment materials. Model language is available from the DOL.
OTHER NOTICES
Group health plan sponsors should consider including the following enrollment and annual notices with the plan’s open enrollment materials.
Initial COBRA Notice
The Consolidated Omnibus Budget Reconciliation Act (COBRA) applies to employers with 20+ employees that sponsor group health plans. Plan administrators must provide an initial COBRA notice to new participants and certain dependents within 90 days after plan coverage begins. The initial COBRA notice may be incorporated into the plan’s SPD. A model initial COBRA notice is available from the DOL.
Notice of HIPAA Special Enrollment Rights
At or prior to the time of enrollment, a group health plan must provide each eligible employee with a notice of his or her special enrollment rights under HIPAA. This notice may be included in the plan’s SPD. Notice must be given to participants before or at the time of group health plan enrollment. Model language for this disclosure is available on the DOL’s website.
Annual CHIPRA Notice
Group health plans covering residents in a state that provides a premium subsidy to low-income children and their families to help pay for employer-sponsored coverage must send an annual notice about the available assistance to all employees residing in that state. The DOL has provided a model notice.
WHCRA Notice
Plans and issuers must provide notice of participants’ rights to mastectomy-related benefits under the Women’s Health and Cancer Rights Act (WHCRA) at the time of enrollment and on an annual basis. Model language for this disclosure is available on the DOL’s website.
NMHPA Notice
Plan administrators must include a statement within the Summary Plan Description (SPD) timeframe describing requirements relating to any hospital length of stay in connection with childbirth for a mother or newborn child under the Newborns’ and Mothers’ Health Protections Act. Model language for this disclosure is available on the DOL’s website.
Medicare Part D Notices
Group health plan sponsors must provide a notice of creditable or non-creditable prescription drug coverage to Medicare Part D eligible individuals who are covered by, or who apply for, prescription drug coverage under the health plan. This creditable coverage notice alerts the individuals as to whether or not their prescription drug coverage is at least as good as the Medicare Part D coverage. The notice generally must be provided at various times, including when an individual enrolls in the plan and each year before Oct. 15th(when the Medicare annual open enrollment period begins). Model notices are available on the Centers for Medicare and Medicaid Services’ website.
HIPAA Privacy Notice
The HIPAA Privacy Rule requires covered entities (including group health plans and issuers) to provide a Notice of Privacy Practices (or Privacy Notice) to each individual who is the subject of protected health information (PHI). Health plans are required to send the Privacy Notice at certain times, including to new enrollees at the time of enrollment. Also, at least once every three years, health plans must either redistribute the Privacy Notice or notify participants that the Privacy Notice is available and explain how to obtain a copy.
Self-insured health plans are required to maintain and provide their own Privacy Notices. Special rules, however, apply for fully insured plans. Under these rules, the health insurance issuer, and not the health plan itself, is primarily responsible for the Privacy Notice.
Model Privacy Notices are available through the Department of Health and Human Services
Summary Plan Description (SPD)
Plan administrators must provide an SPD to new participants within 90 days after plan coverage begins. Any changes that are made to the plan should be reflected in an updated SPD booklet or described to participants through a summary of material modifications (SMM).
Also, an updated SPD must be furnished every five years if changes are made to SPD information or the plan is amended. Otherwise, a new SPD must be provided every 10 years.
Summary Annual Report
Plan administrators that are required to file a Form 5500 (> 100 participants in plan) must provide participants with a narrative summary of the information in the Form 5500, called a summary annual report (SAR). The plan administrator generally must provide the SAR within nine months of the close of the plan year. If an extension of time to file the Form 5500 is obtained, the plan administrator must furnish the SAR within two months after the close of the extension period.
Wellness Program Notices
Group health plans that include wellness programs may be required to provide certain notices regarding the program’s design. As a general rule, these notices should be provided when the wellness program is communicated to employees and before employees provide any health-related information or undergo medical examinations.
HIPAA Wellness Program Notice—HIPAA imposes a notice requirement on health-contingent wellness programs that are offered under group health plans. Health-contingent wellness plans require individuals to satisfy standards related to health factors (for example, not smoking) in order to obtain rewards. The notice must disclose the availability of a reasonable alternative standard to qualify for the reward (and, if applicable, the possibility of waiver of the otherwise applicable standard) in all plan materials describing the terms of a health-contingent wellness program. Final regulations provide sample language that can be used to satisfy this requirement.
ADA Wellness Program Notice—Employers with 15+ employees are subject to the Americans with Disabilities Act (ADA). Wellness programs that include health-related questions or medical examinations must comply with the ADA’s requirements, including an employee notice requirement. Employers must give participating employees a notice that tells them what information will be collected as part of the wellness program, with whom it will be shared and for what purpose, the limits on disclosure and the way information will be kept confidential. The Equal Employment Opportunity Commission (EEOC) has provided a sample notice to help employers comply with this ADA requirement.
Enhance Your Employee Benefits Package. A competitive benefits package is key to keeping and attracting top talent.Assess your current benefits package and consider making necessary adjustments to include options, such as expanded mental health support, for example.
GENERAL HR
Review Employee Records. The fourth quarter is a good time to review your employee records and check record retention guidelines. Don’t forget to dispose of outdated termination and outdated job applications properly. With W2s around the corner, make sure all addresses and information are updated.
Develop and Distribute Your 2023 Calendar. Create and distribute a calendar outlining important dates, vacation time, pay dates, and company-observed holidays for 2023.
Review and Update Employee Handbook. Review your employee handbook to make sure it is up-to-date and addresses areas, such as employment law mandates, new COVID-related policies, guidelines for remote working, privacy policies, compensation and performance reviews, social media policies, attendance, and time-off, break periods, benefits, and procedures for termination, discipline, workplace safety, and emergency procedures.
PLEASE NOTE: This information is for general reference purposes only. Because laws, regulations, and filing deadlines are likely to change, please check with the appropriate organizations or government agencies for the latest information and consult your employment attorney and/or benefits advisor regarding your responsibilities. In addition, your business may be exempt from certain requirements and/or be subject to different requirements under the laws of your state. (Updated Oct. 3, 2022)
Contact us at (855) 667-4621 or email us at info@medicalsolutionscorp.com
New technologies, evolving customer demands, societal shifts, and the COVID-19 pandemic are rapidly changing the business landscape. These factors paved the way for new innovations that can help companies cope with the demands of their target audience using technology and modern resources.
2023 Innovations that will change businesses
1. Adoption of Disruptive Technology
Robots that have Artificial Intelligence powers are said to be rising this year. Now that these robots can now accomplish tasks previously completed by humans only, employers are left to figure out the balance between the robots and their human employees.
When employers properly know what roles and responsibilities robots and humans have respectively, their business will surely flourish.
Now that everything seems to be possibly done online, cyber security has been strengthened.
However, since work has been almost done entirely remotely, different kinds of cyberattacks have been destructing the systems and software of businesses, whether they may be start-ups or have been in the industry for years.
PEOs provide companies with HR and admin tasks and functions. Some of these functions are but are not limited to payroll, benefits, taxes, training, and compensation.PEOs are considered to be co-employment to companies. With these arrangements, start-ups no longer need to worry about mastering the whole aspects of human resource management. Instead, businesses can now focus on improving their growth.
PEOs for start-ups are considered to be one of the most important innovations for this year because it allows businesses to focus on marketing and strategizing their products or services. Removing the unnecessary burden that HRtasks and functions bring to employers and employees.
4. Remote Work
OK not new but trending nonetheless. This trend is real because it serves vested interests on both sides of the equation, especially as US continues to fail to manage traffic (and associated pollution), healthcare and childcare, which are all intertwined with remote work.
5. Going Virtual
Virtual Interfaces via AR(artificial reality), VR (virtual reality) or even Metaverse will be evolving. This is at the nexus of the natural progression of digital evolution and easy adoption especially true with hardware costs expected to fall below the $400 threshold. “You got your goggles?” will be the new “can we Zoom?” call to action.
Winter holidays are a festive joyful time but also a time of experienced anxiety by many as well. While eliminating all seasonal stressors isn’t likely, there may be ways you can minimize and manage them. Here are three ideas to help you get through the holiday season with minimal stress:
1. Create a plan. Have you been easily overwhelmed by the extra activities and responsibilities of the holiday season in the past? This year, think about setting up a more realistic plan for yourself.
You don’t have to create the perfect holiday for others or attend every party you’re invited to. Instead, consider setting boundaries and attending only the events that mean the most to you.
2. Set up a holiday budget. Overspending is always a concern but even more so during the holidays. That’s why budgeting for gifts and holiday extras is a good idea.
It’s okay to put purchases on your credit card if you’ve saved up for them ahead of time. It can even be a great way to earn a sign-up bonus on a new card if you have very good credit. Pay your balance in full by the due date to avoid interest and fees.
Tempted to try the ubiquitous buy now, pay later loans for online purchases? Carefully review their interest rates and fees first.
3. Take time for self-care. Sticking with healthy eating and self-care habits may also help you better deal with anxiety. Get plenty of rest (including naps) and take time to decompress when you need to — it can really help.
Finally, don’t expect conflicts or old patterns to be resolved over the holidays. This can be a stressful time for families, and thus likely not the ideal time to try to work out long-standing issues. It’s not a personal failure if you can’t “fix” your family. Focus on taking care of yourself. And if you feel like you might benefit from professional help, don’t be afraid to seek it out. Many insurance plans offer mental health benefits that can make this care more affordable.
If you need help choosing a health or life insurance plan, need to make changes for the new year, or have questions about your coverage, contact us anytime.
Some organizations are facing a movement known as the “Great Return” as they reopen in-person workplaces and require employees to come into the office.
Many workers are paying more attention to their benefits and wondering how to stretch their dollars further. Employers are uniquely positioned to offer more than just a health care plan, including holistic benefits, resources and perks that today’s workers most need. This article highlights benefits that are likely to be popular in 2023.
Get a custom free review on your 2023 employee benefits offering before you renew. Contact info@medicalsolutionscorp.com or (855)667-4621
The IRS has released the 2023 Flexible Savings Account (FSA) inflation adjustments. These changes will take place for plan years that begin on or after January 1, 2023.
For employers who currently allow the FSA maximum, unless told otherwise, OCA will automatically amend the new FSA maximum to reflect the 2023 increase. OCA will also be providing additional 2023 employee guides/marketing material in the upcoming days. *The limit also applies to limited-purpose FSAs.
Workers seek empathy and flexibility in a post-pandemic work world
Benefits, empathy, and flexibility are close behind salary in terms of what matters most to workers when evaluating employment opportunities.
The dramatic impact of the events of the past two years has altered the traditional employer-employee contract. Workers are responding positively to the gains in flexibility, investments in technology, and additional mental health resources that were added during the pandemic. It’s in employers’ interest not to abandon that more empathetic mindset, especially from a retention perspective:
1 in 5 workers quit their job in the past two years due to inflexibility.
Workers who feel their employer cares about their well-being are more likely to want to stay at their job for 10+ years (58% versus 31% of those who don’t feel their employer cares).
Download the report for more insights on what your workforce is looking for when it comes to benefits, enrollment, and corporate culture.
Schedule your Open Enrollment review and our 2023 Open Enrollment checklist contact us at info@medicalsolutionscorp.com or (855)667-4621.
A little-known exception for small businesses but most important under Affordable Care Act (ACA) is for Health Insurers must waive their minimum employer-contribution and employee-participation rules once a year. ACA requires a one-month Special Open Enrollment Window for January 1st coverage.
Background
The ACA has a section in it called the “guaranteed issuance of coverage in the individual and group market.” It stipulates that “each health insurer that offers health insurance coverage in the individual or group market in the state must accept every employer and individual in the state that applies for such coverage.” The section also states that this guaranteed issuance of coverage can only be offered during (special) open enrollment periods, and that plans can only be offered to applicants that live in, work in, or reside in the plans’ service area(s).
Participation and Contribution Requirements
In many states (including California and Nevada), carriers can decline to issue group health coverage if fewer than 70% of employees elect to enroll in coverage. Some carriers may have even tighter participation requirements.
Generally speaking, employees with other coverage (Medicare, other group coverage, individual coverage through the Exchange, etc.) are removed from the participation requirement calculation – though it varies by insurance carrier.
Furthermore, employer contribution rules require employers to contribute a certain percentage of premium costs for all employees in order to attain group health coverage. Some businesses struggle to meet these contribution requirements for a variety of financial reasons.
Problem Solved: Special Open Enrollment Period
Many employers want to offer coverage to their employees, but are denied because they struggle to meet participation and/or contribution requirements. Employers cannot force employees to enroll in coverage unless the employer pays for 100% of the employees’ premiums, which many employers cannot afford. Even with moderate to generous employer contributions, many employers still find young and lower-income employees waiving coverage. This was even more evident in 2019 with the ACA’s federal Individual Mandate non-compliance penalty reduced to $0.00.
The U.S. Department of Health & Human Services provides final guidance on this in regulation 147.104(b)(1): “In the case of health insurance coverage offered in the small group market, a health insurance issuer may limit the availability of coverage to an annual enrollment period that begins November 15 and extends through December 15 of each year in the case of a plan sponsor that is unable to comply with a material plan provision relating to employer contribution or group participation rules.”
Timeline:
The annual Federal Employees Health Benefits (FEHB) Open Season is taking place from November 14, 2022 – December 12, 2022 this year. The annual open season provides federal employees, annuitants, and other eligible individuals the opportunity to review their plan options, make changes, and enroll for the upcoming benefit year that begins January 1, 2023.
Employers, if your group struggling with participation and/or contribution, the Special Open Enrollment Window is the time to enroll them in coverage.
Stress is common for most people. Still, if you’ve felt off-kilter at work lately, it could be burnout instead of temporary job stress.
How to Identify Burnout From Work
Essentially, job burnout is unmanaged work stress — although that’s not a medical diagnosis. Job burnout isn’t the same as depression or anxiety because the former is specific to work situations while the latter two are not.
If you’re burned out at work, you may be unable to concentrate, irritable, experiencing relationship conflicts, lacking in energy or having other issues. You could also have physical symptoms including muscle tension, insomnia or pain. If you’re feeling overworked, cynical and detached or incompetent, you likely have job burnout.
Ways to Ease Job Burnout
Recognizing burnout is only part of the solution. The only way to relieve burnout is to make changes (and possibly a few hard choices).
Small changes could include getting more sleep, hiring help at home or prioritizing self-care. Of course, not all solutions are simple, especially if you have caregiving responsibilities and a limited budget.
You may need to take time off work, if possible, or add breaks to your workday. Or, you could discuss your workload with your boss to ask if additional personnel could be hired or certain tasks reassigned. If your employer won’t work with you, you may need to find a new job.
How Can We Help?
Many health insurance policies provide mental health benefits that can help with burnout, such as reduced-cost therapy and meditation apps. If you have any questions about your coverage, we’re here to help.
Learn more about how we are successfully helping navigate SMB for 20+ years. If you have any questions or would like additional information, please contact us at 855-667-4621 or info@medicalsolutionscorp.com.
The PFL rate to .455% of taxable wages. The maximum an employee will contribute in 2023 will be: $399.43/year
The PFL maximum benefit will increase to: 67% of the average weekly wage to a maximum $1131.09/week.
Duration remains the same at 12 weeks.
The Statewide Average Annual Wage cap increases to $87,785.88 ($1688.19 per week).
Learn more about how we are successfully helping navigate SMB for 20+ years. If you have any questions or would like additional information, please contact us at 855-667-4621 or info@medicalsolutionscorp.com.
Yesterday, NYS Dept of Financial Services approved 2023 health insurance rate requests yesterday. Small group rates increased by 7.9% and 9.7% for individuals.
As per NY State Law, Health Insurers are required to send out early notices of rate request filings to groups and subscribers see original –2023 NY Small Group Carrier Rate Filings. Despite only 3 months of mature claims data experience for 2022 health insurers’ original requests were noticeably above the average of 16.5%/individuals and 19% for small groups. For example, regulators last year approved average rate increases of 3.7% for individuals and 7.6% for small group plans. Over 1.1 million New Yorkers are enrolled in individual and small group plans impacted by the rate increases, the state agency noted.
The recent COVID-19 surge irony reflected a lower cost utilization due to COVID-19. The average medical-loss ratio, which represents the portion of premiums spent on medical claims and quality improvement, was 70% in recent years years. That said, in an anticipation of spikes in claims submissions + overall inflation, a larger than average increase is needed. This is in addition to increases in pricing by hospitals, consolidated IPA groups, and pharmaceuticals.
Rate Factors
The state noted that the premiums increase main drivers are medications. “Rising medical costs and inflation continue to put upward pressure on premiums,” said Superintendent Harris. “With our rate actions announced today, we continue to prioritize the financial wellbeing of consumers while ensuring that New Yorkers have access to a robust, stable health insurance market.”Also, DFS, recognizing the continued uncertainty of the pandemic’s effect on consumers’ health care costs and the economy, held insurers’ profit provisions to a historically low 0.5%.
Health Insurers
Oxford/Unitedhealthcare, notably, got only a 6% rate increase approval for next year. This is a sharp reduction from the original 16.8% request in part by disagreed anticipated costs, held reserves, overall market pricing, and reinsurance gained from ACA’s Risk Corridor. See more info here, https://medicalsolutionscorp.com/risk-adjustment-reinsurance-and-risk-corridors/.
Small Group Market
Almost 850,000 New Yorkers are enrolled in small group plans, which cover employers with up to 100 employees. Insurers requested an average rate increase of 16.5% in the small group market, which DFS cut by 52% to 7.9% for 2023, saving small businesses $632.4 million. A number of small businesses also will be eligible for tax credits that may lower those premium costs even further, such as the Small Business Health Care Tax Credit.
DFS SMALL GROUP MARKET RATE ACTIONS
*Indicates the Company will offer products on NY State of Health Marketplace in 2023.
PEO Alternatives to Small Group
Before you consider renewing automatically, you should first find out what is a PEO so that you can know exactly what to expect from it. PEO’s are large-group markets underwritten. With the right PEO, you will be able to manage your business’s demand for growth and your employees as well.
Clients on average save 15-40% off the small group market. If you are looking for a complete insurance solution for your business, go to our website and check out our business insurance solutions.Contact usfor more information today.
Learn how a PEO can make a difference for your group. For more information on how Employer-Sponsored Insurance and a PEO can make difference for your small business please contact us at info@medicalsolutionscorp.com or 855-667-4621.
Inflation Reduction Act to be Signed into Law, Includes Multiple Medicare Drug Pricing Reforms
On Aug. 12, the Inflation Reduction Act of 2022 (IRA) passed the U.S. House by a vote of 220-207, and President Biden is expected to sign it into law today. First passed by the U.S. Senate on Aug. 7, the $740 billion budget reconciliation package includes policies on Medicare drug pricing, Affordable Care Act (ACA) subsidies, energy, climate, and taxes. This update provides high-level details on the notable health care-related provisions in the IRA.
Allowing Medicare to Negotiate Drug Prices
With the goal of improving affordability for high-priced drugs in Medicare Parts B and D, the IRA directs the Department of Health and Human Services (HHS) to establish a drug price negotiation program for certain high-priced, single-source drugs and biological products. Under this program, the HHS Secretary will publish a list of selected drugs that meet certain criteria, then negotiate (and renegotiate as needed) maximum fair prices with manufacturers of those drugs. Drugs eligible for negotiation include the 50 Part B and 50 Part D single-source drugs with the highest total expenditures during the most recent 12-month period; however, negotiation is limited to Part D drugs for 2026 and 2027. Negotiated prices must take effect for 10 eligible drugs in 2026, increasing to 20 drugs in 2029. For 2026, the expenditure period to be reviewed is June 1, 2022 through May 31, 2023, and the selected drug list publication date will be Sept. 1, 2023.
Redesigning the Medicare Part D Program, Including Capping Annual Out-of-Pocket Costs for Beneficiaries
The IRA significantly reforms the Medicare Part D benefit design, including capping maximum out-of-pocket (OOP) costs at $2,000 annually, with a copay smoothing component; capping annual premium growth at 6%; and expanding eligibility in the Low-Income Subsidy (LIS) program.
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Beneficiary Cost-Sharing Changes:
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Beginning in 2024, beneficiaries will be responsible for $0 in the catastrophic benefit phase. There are no changes to the initial coverage phase or coverage gap phase.
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Beginning in 2025, the coverage gap phase will be eliminated, and a new $2,000 OOP cap will be applicable with the option to spread OOP payments out over the course of the year. The initial coverage phase remains unchanged.
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Part D Benefit Design: The bill restructures plan, manufacturer, and federal government liabilities for the different benefit phases beginning in 2025:
Initial Phase
Catastrophic Phase
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Beneficiary: 25%
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Plan: 65% for brands, 75% for generics
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Manufacturer: 10% for brands, 0% for generics
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Beneficiary: 0%
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Plan: 60%
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Manufacturer: 20% for brands, 0% for generics
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Federal Government: 20% for brands, 40% for generics
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Premium Stabilization: For 2024 through 2029, any increase in the Part D base beneficiary premium is limited to the lesser of a 6% increase from the previous year or the premium that would have been applied if the stabilization program was not established. In 2030 and subsequent years, the HHS Secretary is authorized to make adjustments necessary to the base Part D premium to ensure that premium is increased by the lesser of 6% or what the premium would have been if the stabilization program was not established.
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Expanded LIS Eligibility: The bill expands eligibility for the Part D LIS program from 135% of the federal poverty level to 150% beginning in 2024.
Capping Insulin Cost-Sharing in Medicare
For 2023 through 2025, the bill caps beneficiary cost-sharing at $35 a month for Medicare Part D or Medicare Advantage Prescription Drug Plan (MA-PD) covered insulin products. In 2026 and beyond, it caps cost-sharing at the lesser of $35 or 25% of the maximum fair price or 25% of the plan’s negotiated price. The cost-sharing is capped regardless of where the beneficiary is in the benefit phase, and Part D and MA-PD plans are eligible for a retroactive subsidy in 2023 equal to the aggregate reduction in cost-sharing and deductible due to implementing this provision.
Implementing Drug Manufacturer Inflationary Rebates in Medicare
The legislation requires drug manufacturers to pay rebates to the government if drug prices in Medicare Part B and Part D rise faster than inflation, with rebates equaling the rate at which the price of the drug exceeds inflation. This rebate provision goes into effect Jan. 1, 2023 for Part B rebatable drugs and Oct. 1, 2022 for Part D rebatable drugs. Drugs with an average cost of less than $100 are excluded. Additionally, HHS is instructed to reduce or waive the rebate amount for a Part D rebatable drug if it is on the drug shortage list, per the Federal Food, Drug, and Cosmetic Act.
Requiring Vaccine Coverage in Medicare Part D
Beginning in 2023, Part D plans are required to cover all adult vaccines recommended by the Advisory Committee on Immunization Practices, without cost-sharing or the application of a deductible (other than vaccines covered under Part B). Part D and MA-PD plans are eligible for a retroactive subsidy in 2023 equal to the aggregate reduction in cost-sharing and deductible due to implementing this provision.
Extended Delay of the Medicare Part D Rebate Rule
The legislation includes an additional five-year delay of the implementation of a rule that would prohibit manufacturer rebates in Part D, to Jan. 1, 2032.
Extending Enhanced ACA Subsidies Through 2025
Originally set to expire at the end of this year, the IRA extends the enhanced American Rescue Plan Act (ARPA) ACA premium tax credit subsidies through 2025.
Article credited to CIGNA.
Learn more about how we are successfully helping navigate SMB for 25+ years. If you have any questions or would like additional information, please contact us at 855-667-4621 or info@medicalsolutionscorp.com.
On September 1, 2022, Empire BlueCross BlueShield will begin partnering with CareMount Medical, the largest independent, multi-specialty group in New York State, to provide access to affordable care throughout New York City, Westchester, Putnam, Dutchess, Columbia, and Ulster counties.
CareMount will now be part of Empire’s Blue Access and Connection Networks for all Large Group and Small Group members. This will mean greater access to more affordable care throughout Westchester and surrounding markets.
Contact us to learn how Empire can fit your employee’s needs.
Learn more about how we are successfully helping navigate SMB for 25+ years. If you have any questions or would like additional information, please contact us at 855-667-4621 or info@medicalsolutionscorp.com.