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What is the Difference Between an EAP vs. Mental Health Benefits?

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Mental Health is a serious matter!

Watch and share our brief video, as we explore and clarify the distinction between Employee Assistance Programs (EAP) and Mental Health benefits available in your health insurance plan.

Whether you are an employer wanting to enhance your benefit offerings or an employee seeing assistance, this video will provide you with some insights to make informed decisions about your mental health support options.

If you have any questions regarding your mental health benefits and/or resources, please reach out to MNJ Insurance Solutions.

#mentalhealthawareness #mentalhealthmatters #endthestigma

Second Rx Report Due June 1, 2023

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Health plan and health insurance issues must submit their second prescription drug data report by June 1, 2023, as part of the annual reporting requirements. Employers and insurance carriers will generally submit these reports on an annual basis no later than June 1st of each year, reporting information for the prior calendar year.

 

RxDc Compliance Guide

To comply with the RxDC reporting requirements, employers should consider doing the following:

  • Contact issuers, such as TPAs o PBMs, to ask if they will submit the report for your health plan
  • Ensure your third-party RxDC submission agreement is updated
  • Monitor the third party’s adherence to the RxDC reporting requirement for self-funded health plans.
  • Provide any information that is requested by the third party submitting the RxDC report for your health plan as soon as possible.

 

Third Party Issuers

Health plans can use third-party issuers, such as TPA and PBM, to submit an RxDc report on their behalf. Health plans may submit RxDC reports on their own, but the occurrence is uncommon. The following information outlines procedures and rules that should be considered when using an issuer:

  • A formal agreement between the plan and the third party must be constructed to address this reporting obligation.
  • The issuer, not the plan, is in violation of the reporting requirements if it fails to submit the RxDC report when required to do so.

 

General Deadlines

The initial RxDC report was due December 27, 2022, with a grace period through January 31, 2023. The first report should contain prescription drug data from 2020 and 2021. The second RxDC report should contain prescription drug data from 2022 and meet the June 1, 2023 deadline.

 

Resources

CMS.gov provides the following resources:

  • On Nov. 23, 2021, the Departments published an interim final ruleregarding the requirement to report pharmacy and drug costs.
  • Transparency in coverage FAQswere released on Aug. 20, 2021.
  • An FAQabout the submission grace period and reporting flexibilities for 2020 and 2021 data was released on Dec. 23, 2022.
  • More information, including RxDC reporting instructions, is available through the HHS’ RxDC website.
  • Prescription Drug Data Collection (RxDC) Reporting Instructions: https://regtap.cms.gov/reg_librarye.php?i=3860

 

For more information on this topic, please contact MNJ Insurance Solutions.

This Rx reporting summary is provided for informational purposes only and should not be construed as legal or a recommendation of any kind. While we have attempted to provide current, accurate, and clearly expressed information, this information is provided “as is,” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy and completeness.

COVID-19 National and Public Health Emergencies Will Terminate May 11, 2023

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While California’s COVID-19 state of emergency ended on February 28, 2023, the national COVID-19 Public Health Emergency is still active and will terminate on May 11, 2023. Consumers impacted by the COVID-19 Public Health Emergency may qualify for Special Enrollment using the “Public Health Emergency” Qualifying Life Event to enroll and make changes to their coverage.

The Department of Labor’s Employee Benefits Security Administration (EBSA) is committed to working with employers and other plan sponsors to ensure a smooth transition as the federal government unwinds some of the policies that have been in place during the COVID-19 public health emergency and National Emergency. To partner with you through this process, the Departments of Labor, Health and Human Services, and the Treasury issued guidance today in an effort to ensure that workers and their families are aware of any changes that may be coming their way:

 

As a reminder, states that administer Medicaid, such as Medi-Cal in California, were prohibited from terminating a beneficiary’s enrollment during the national COVID Public Health Emergency unless they moved out of state, became deceased, or the beneficiary requested a voluntary termination of eligibility. Beginning as of April 1, 2023, the Department of Health Care Services will begin to “unwind” this policy and resume its annual eligibility review process for members enrolled in Medi-Cal, which could possible result in a beneficiary being determined no longer eligible for Medi-Cal.  This would allow eligible individuals to enroll in a qualified health plan and possibly gain eligibility for advanced premium tax credits with a July 1, 2023 effective date.  The other option for members who lose eligibility with Medi-Cal is they could enroll in their employer group plan (if they meet the employer’s eligibility requirements), as this is a qualifying life event.  Please reference Covered California’s Public Health Emergency & Medi-Cal to Marketplace Automatic Enrollment Program Toolkit for additional program information and support materials.

 

If you have any questions or would like more information, please reach out to MNJ Insurance Solutions.

 

This summary is provided for informational purposes only and should not be construed as legal or a recommendation of any kind. While we have attempted to provide current, accurate, and clearly expressed information, this information is provided “as is,” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy and completeness.

2024 ACA Pay or Play Increasing Penalties

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On March 9, 2023, the IRS revised the penalty amounts for the employer shared responsibility (pay or play) rules under the Affordable Care Act (ACA) for 2024. For the calendar year 2024, the adjusted $2,000 penalty amount is $2,970, and the revised $3,000 penalty amount is $4,460.

 

Pay Or Play Penalty

An applicable large employer (ALE) that complies with the pay or play regulations is only subject to penalties if at least one full-time employee receives a subsidy for Exchange coverage. Employees provided affordable minimum value (MV) coverage must be qualified for these Exchange subsidies. Based on the circumstances, the pay-or-play rules allow for applying either the 4980H(a) penalty or the 4980H(b) penalty.

 

  • Under Section 4980H(a): If an ALE does not provide coverage to typically at least 95% of its full-time workers (and dependents), and any full-time worker obtains a subsidy toward their Exchange plan, the ALE will be subject to a penalty. For any applicable month, the monthly fine imposed on ALEs that do not provide coverage to almost all full-time employees and their families equals the number of full-time employees at the ALE (minus 30), multiplied by 1/12 of $2,000 (as adjusted).

 

  • Under Section 4980H(b): If at least one full-time employee receives a subsidy through an Exchange due to the ALE not providing coverage to all full-time employees, the ALE’s coverage being prohibitively expensive, or the ALE’s coverage not providing MV, the ALE may still be subject to a penalty even if it offers coverage to nearly all full-time employees (and dependents). For each full-time employee who receives a subsidy, an ALE is subject to a monthly fine equal to 1/12 of $3,000 (as adjusted) for any applicable month. Nevertheless, the 4980H(a) penalty amount is the maximum punishment for an ALE.

 

Important Dates Description
August 16, 2022 For 2023, the IRS published revised pay-or-play penalty amounts.
March 9, 2023 For 2024, the IRS published revised pay-or-play penalty amounts.
2024 Calendar year 2024 penalty amounts are based on a failure to provide affordable minimum value coverage during the 2024 calendar year

 

IRS Pay Resources

The following IRS websites are available to employers for more information and updates regarding. pay or play provisions:

 

 

This ACA Pay Penalty Outline is provided for informational purposes only and should not be construed as legal or a recommendation of any kind. While we have attempted to provide current, accurate, and clearly expressed information, this information is provided “as is,” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy and completeness.

 

*sourcehttps://content.zywave.com/file/b1f47fcf-ae5c-4d8a-a1b2-1d74f01159e9/ACA%20Pay%20or%20Play%20Penalties%20Will%20Increase%20for%202024.pdf *

Benefits of a Grandfathered Plan

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Grandfathered Plan Overview

The grandfathered plan was created on March 23, 2010, with few changes implemented since then. Plans with grandfathered status are exempt from some Affordable Care Act (ACA) regulations, but if that status is lost, the plan must adhere to more ACA criteria. An attempt by employers to scale back the benefits of plans or raise participant expenses will result in the loss of grandfathered status. So, it is essential to note that employers are limited in what changes they can make to grandfathered plans’ benefits and costs. It is also important to note that an employer can decide it makes sense to give up the plan’s grandfathered status and adhere to the new ACA standards to make more significant changes to its health plan.

 

Grandfathered Health Plans are exempt from the following ACA requirements:

Coverage of Preventive Health Services

For plan years beginning on or after September 23, 2010, certain preventive health care must be covered by company health plans and group or individual health insurance policies without requiring cost-sharing requirements. In addition, for years beginning on or after August 1, 2012, preventative health treatments for women must be offered without cost-sharing.

 

Patient Protections (for plan years beginning before January 1, 2022)

The ACA requires the following patient protections that are effective for plan years beginning on or after September 23, 2010:

  • Any primary care physician, including a pediatrician for children, who are available and participates in the plan or network must be available to enrollees.
  • Emergency services provided by group health plans and group or individual health insurance policies are not subject to increased cost-sharing or pre-authorization restrictions.
  • For OB/GYN care, corporate health plans and individual or group health insurance policies may not demand preauthorization or referral.

*For plan years beginning on or after January 1, 2022, the No surprise act (NSA) has expanded the ACA’s patient protection, which applies to protections for patients under health plans with grandfathered status.*

 

Nondiscrimination Rules for Fully Insured Plans

Once regulations are issued, fully insured plans must comply with section 105(h)(2) of the Internal Revenue Code. According to that clause, a plan and the benefits provided in the plan may not favor highly compensated people when determining who is eligible to participate.

 

Quality of Care Reporting

Reporting requirements will be implemented for group health plans and health insurance providers who provide group or individual health insurance coverage. The reports will deal with benefit and payment plans that are intended to enhance patient safety, lower medical errors, avoid readmissions to the hospital, and implement wellness programs.

 

Improved Appeals Process

For plan years starting on or after September 23, 2010, group health plans and health insurance providers that provide group or individual health insurance coverage must strengthen their internal appeals procedures and adhere to minimum standards for external reviews.

 

Insurance Premium Restrictions.

Premiums for health insurance coverage in the individual or small group market may not be discriminatory. They may differ solely by individual or family coverage, rating region, age, and tobacco use for plan years beginning on or after January 1, 2014.

 

Guaranteed Issue and Renewal of Coverage

For plan years starting on or after January 1, 2014, health insurance issuers that provide health insurance coverage in a state’s individual or group market must accept every employer and person who applies for coverage in the state. They also must renew or continue the coverage at the individual’s or plan sponsor’s discretion.

 

Nondiscrimination in Health Care

Group health plans and health insurance providers that provide group or individual insurance coverage may not discriminate against any provider practicing within their scope of practice as of January 1, 2014, or for plan years beginning on or after that date. This clause, however, does not mandate that a plan only work with agreeable providers or forbid tiered networks. In addition, plans and issuers are prohibited from treating people differently based on whether they accept subsidies or assist an inquiry under the Fair Labor Standards Act.

 

Comprehensive Health Insurance Coverage

For plan years beginning on or after January 1, 2014, health insurance issues that offer group or individual health insurance coverage need to provide the minimum set of benefits demanded of policies sold through health insurance exchanges.

 

Limits on Cost-Sharing.

For their coverage of essential health benefits, plan years starting on or after January 1, 2014, must employ a cost-sharing limit (total yearly limit) for solo and family coverage.

 

Coverage for Clinical Trials

For plan years beginning on or after January 1, 2014, group health plans and health insurance providers providing group or individual insurance coverage must allow certain enrollees to participate in specific clinical trials, with the recurring costs covered for participation. In addition, discrimination against the enrollees for the trial is prohibited.

 

Key Considerations for Employers

At each renewal, employers will need to decide whether to renew with their current Grandfathered plans or make changes to ACA plans.  It is important to know that once an employer no longer offers a Grandfathered plan or moves to a new carrier, the employer can no longer go back to the Grandfathered status. It is important to weigh all of your options, the pros and cons, at your renewal period.

If you are an employer, who still has Grandfathered plans, and are interested in a second opinion or evaluation of your benefits, please contact MNJ Insurance Solutions at (714) 716-4303 ext. 102 or sales@mnjinsurance.com.

 

This Grandfathered Plan Overview is provided for informational purposes only and should not be construed as legal or a recommendation of any kind. While we have attempted to provide current, accurate, and clearly expressed information, this information is provided “as is,” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy and completeness.

 

*source:https://content.zywave.com/file/4180adb7-d393-4c8f-9210-f99b31832eb8/Health%20Care%20Reform%3A%20What%20Are%20the%20Benefits%20of%20Having%20a%20Grandfathered%20Plan%3F%20.pdf *

CA Bereavement Leave as of January 2023

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Starting Jan 1, 2023, employers with five or more employees must abide by new bereavement leave provisions. This is due to an amendment that was made to California Family Rights Act (CFRA) on September 29, 2022. This modification included the implementation of Assembly Bill No. 1949 (AB-1949). Under this bill, eligible employees may take up to five days of bereavement leave as a result of the death of a family member.

 

Overview

The following information outlines the implications of a bereavement leave:

  • A leave must be completed within three months of the dated death
  • Leave may be unpaid however, employees are entitled to use other leave balances, such as available sick leave
  • Days taken for leave are not required to be taken consecutively
  • The leave must be taken in accordance with any current leave policy, with the assurance that the employee is granted no less than five days of bereavement leave.
  • An employee must provide documentation of the death of a family member within 30 days of the first leave if requested by an employer.
  • A covered employer is required to maintain confidentiality regarding the employee’s request and documentation for bereavement leave.

 

This Bereavement Leave Update is provided for informational purposes only and should not be construed as legal or a recommendation of any kind. While we have attempted to provide current, accurate, and clearly expressed information, this information is provided “as is,” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy and completeness.

The Basics Employers Need to Know About CAA Prescription Drug Reporting

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Rx reporting is a federal mandate that requires insurance companies and group health plans to provide a report of prescription drug data to the government. Logistics regarding the act can be found under Section 204 (of Title II, Division BB) of the Consolidated Appropriations Act, 2021 (CAA).

 

CAA Submission Requirements

The following list includes the information that the CAA requires insurance companies and employer-based health plans to submit:

  • Prescription drugs that are the most frequently prescribed
  • Prescription drugs that account for the most spending
  • Spending reports on prescription drugs and healthcare services
  • Prescription drug rebates from drug manufacturers
  • Premiums and cost-sharing that patients pay

 

            What does the government do with this information?

The federal government wants to use the information and data to examine the prescription drug industry with the potential to make legislative or regulatory changes. Centers for Medicare & Medicaid Services (CMS.gov) expresses that this information will be helpful to:

  • Identify the central causes of increases in prescription drug and healthcare spending
  • Understand how prescription drug rebates impact premiums and out-of-pocket costs
  • Promote transparency in prescription drug pricing

 

Important information and deadlines

This is an annual reporting requirement; plans an issuers will generally submit these reports in June each year, reporting information for the prior calendar year. Please note that it is required to comply with this mandate regardless if your company is fully insured or self-funded. The following deadlines should be noted:

 

Calendar Year to Report Deadline
2022 June 1, 2023
Subsequent calendar years June 1st of each year

 

For more information on this topic, please contact MNJ Insurance Solutions.

 

This Rx reporting summary is provided for informational purposes only and should not be construed as legal or a recommendation of any kind. While we have attempted to provide current, accurate, and clearly expressed information, this information is provided “as is,” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy and completeness.

 

Resources

CMS.gov provides the following resource:

  • On Nov. 23, 2021, the Departments published an interim final ruleregarding the requirement to report pharmacy and drug costs.
  • Transparency in coverage FAQswere released on Aug. 20, 2021.
  • An FAQabout the submission grace period and reporting flexibilities for 2020 and 2021 data was released on Dec. 23, 2022.
  • More information, including RxDC reporting instructions, is available through the HHS’ RxDC website.
  • Prescription Drug Data Collection (RxDC) Reporting Instructions: https://regtap.cms.gov/reg_librarye.php?i=3860

 

 

No Surprises Act Summary and What Employers and Employees Need to Know

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As of January 2022, the “No Surprise Act” provides protection for consumers from unexpected bills for out-of-network care in an emergency and certain non-emergency settings. By enforcing better consumer protection and price transparency, the new regulations will help create better patient experiences and provide better financial protection for individuals.

Here are a few of the protections you should be aware of:

  1. The No Surprise Act protects patients from receiving surprise medical bills or balance billing resulting from emergency services from out-of-network providers or out-of-network air ambulance services without prior authorization. In other words, you should not be charged more than in-network cost-sharing for specific out-of-network services.
  2. The Act bans out-of-network charges for certain services if the individual is at an in-network facility, including services such as anesthesiology or radiology provided by out-of-network providers. The reason for this is because individuals would not know that the provider is out-of-network if they are at an in-network facility.
  3. The Act requires health care providers and facilities to provide individuals with an easy-to-understand notice explaining the applicable billing provisions and who to contact if the provider or facility has violated the individual’s new protections.
  4. The Act also includes requirements that facilities provide “Good Faith Estimates” to individuals and Advance Explanation of Benefits. More guidance on this provision are still being formalized as of 2022.

We believe that The No Surprise Act creates better financial protection for consumers.

For more information on how MNJ Insurance Solutions can help your company and employees, please contact us today.

2023 ACA Pay or Play Increasing Penalties

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On August 16, 2022, the IRS revised the penalty amounts for the employer shared responsibility (pay or play) rules under the Affordable Care Act (ACA) for 2023. For the calendar year 2023, the adjusted $2,000 penalty amount is $2,880, and the revised $3,000 penalty amount is $4,320.

 

Pay Or Play Penalty

An applicable large employer (ALE) that complies with the pay or play regulations is only subject to penalties if at least one full-time employee receives a subsidy for Exchange coverage. In general, employees provided affordable minimum value (MV) coverage are not qualified for these Exchange subsidies. Based on the circumstances, the pay-or-play rules allow for applying either the 4980H(a) penalty or the 4980H(b) penalty.

 

  • Under Section 4980H(a): If an ALE does not provide coverage to around 95% of its full-time workers (and dependents), and any full-time worker obtains a subsidy toward their Exchange plan, the ALE will be subject to a penalty. For any applicable month, the monthly fine imposed on ALEs that do not provide coverage to almost all full-time employees and their families equals the number of full-time employees at the ALE (minus 30), multiplied by 1/12 of $2,000 (as adjusted).

 

  • Under Section 4980H(b): If at least one full-time employee receives a subsidy through an Exchange due to the ALE not providing coverage to all full-time employees, the ALE’s coverage being prohibitively expensive, or the ALE’s coverage not providing MV, the ALE may still be subject to a penalty even if it offers coverage to nearly all full-time employees (and dependents). For each full-time employee who receives a subsidy, an ALE is subject to a monthly fine equal to 1/12 of $3,000 (as adjusted) for any applicable month. Nevertheless, the 4980H(a) penalty amount is the maximum punishment for an ALE.

 

 

Important Dates Description
August 16, 2022 For 2023, the IRS published revised pay-or-play penalty amounts.
March 1, 2022 Prior to this, the IRS updated the 2023 affordability percentage to 9.12%
2024 Calendar year Updates are based on coverage offered during the 2023 calendar year

 

This ACA Pay Penalty Outline is provided for informational purposes only and should not be construed as legal or a recommendation of any kind. While we have attempted to provide current, accurate, and clearly expressed information, this information is provided “as is,” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy and completeness.

 

*source:https://content.zywave.com/file/b1f47fcf-ae5c-4d8a-a1b2-1d74f01159e9/ACA%20Pay%20or%20Play%20Penalties%20Will%20Increase%20for%202024.pdf *

 

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