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  • Governor Ron DeSantis signed an executive order on Friday, July 8th at Cape Coral High School to increase transparency for prescription drug prices in Florida. The order would help make pharmacy benefit managers and third-party administrators of prescription drug programs, accountable when managing prescription drug benefits for insurance companies.

    Gov. DeSantis’s goal in signing this order is to create lower costs for prescription drugs in Florida. DeSantis says, “With food and gas costs on the rise, addressing the pharmaceutical costs is one area I can make a difference in.” He continues to state, “This executive order requires accountability and transparency for pharmaceutical middlemen when doing business within the state, thereby reducing the upward pressure on prescription drug costs.”

    The order directs all executive agencies to include the following in future contracts:  

    • Prohibit spread pricing 
    • Prohibit reimbursement callbacks 
    • Include data transparency and reporting requirements 
    • Review all rebates, payments, and relationships between pharmacies, insurers, and manufacturers 
    • Amend all current contracts they can with the same provisions 

    Additional Programs In Progress

    During the Drug Transparency Order signing, Gov. DeSantis’ administration is working on the Canadian Prescription Drug Importation Program. This will allow prescriptions from Canada to be imported when their prices are significantly lower than those in the United States. The Food and Drug Administration (FDA) has been reviewing this for the past 600 days. 

    By developing new programs after the Drug Transparency executive order, Gov. DeSantis’ administration can find effective ways for Florida residents to save money.

    Navigating Prescription Drug Transparency

    By partnering with GMS, you gain access to a handful of resources beneficial for your business. At GMS, we have a designated Rx specialist who works with your employees to find them the most cost-effective options. Our promise is to make your business operations simpler, safer, and stronger. Learn more by contacting us today. 

  • President Joe Biden’s administration has requested state TennCare officials to make major revisions to the Medicaid block grant program. This program currently provides healthcare to 1.6 million Tennessee residents.

    Under the block grant program, Tennessee would receive a set amount of funding but have more flexibility in how they spend it. This will enable the state to retain savings for health care and health-supporting initiatives.

    State and Federal officials have been discussing these revisions for quite some time. The state has the option of approving or rejecting the changes, as this is a request from the federal government. Furthermore, Tennessee has until August 30th to decide if revisions will be made to the TennCare program. The benefits of 2021 will be preserved in the meantime.

    How Revisions Can Affect Tennessee Residents

    Some experts from Tennessee say that the revisions to the waiver grant program would be beneficial and is good news for Tennesseans. Organizations like the American Heart Association, the American Cancer Society, and many others opposed the granted waiver because of the harm it would do to 1.6 million Tennessee adults and children who rely on TennCare. Michele Johnson, Executive Director of the Tennessee Justice Center says, “all the groups warned it would damage the health care system on which we all depend and would worsen the rural health crisis across Tennessee.”

    On the other hand, by requesting the waiver in 2019, Tennessee Gov. Bill Lee’s administration hoped to save money by directing those funds into health care initiatives and programs. This was followed by a year of criticism from GOP lawmakers who did not want to expand the Medicaid program under the previous Affordable Care Act. By the beginning of 2021, the waiver grant program had finally been approved.

    Under Medicaid, the federal government pays two-thirds of TennCare’s costs. There are no spending caps on state Medicaid expenditures which means Tennessee could boost or even expand the existing TennCare programs if it wishes. Depending on how much more of its own money the state was willing to put into it.

    The Center for Medicare and Medicaid Services is recommending these other provisions:

    • The Center for Medicare and Medicaid Services’ letter states it supports Tennessee’s policy goals to expand coverage and benefits. But the letter says center officials propose that “instead of the current framework for savings and investment,” the federal agency will “work with the state on necessary expenditure authorities to meet common goals.”
    • Modify the waiver’s specific terms and conditions section to “more explicitly state” Tennessee cannot cut benefits or coverage in effect from Dec. 31, 2021, without a procedural amendment subject to an additional public comment period and Center for Medicare and Medicaid Services approval.

    How GMS Can Help

    GMS does more than offer coverage like a traditional medical insurance company. To help our clients find the right coverage solution, we offer a variety of tools and resources including:

    • Education- In addition to a dedicated benefits specialist, you gain access to a team of experts who can train employees on how your plan works and answer questions.
    • Guidance – Health insurance is complicated. Our experts provide guidance on how to best utilize your plans, maintain compliance, and stay on top of Affordable Care Act regulations.
    • Control – GMS gives you more control of your business. Partnering with a PEO for group health insurance lets you focus on growing your business while making your benefits administration more efficient.

    To learn more, contact us today!

  • Anthem, a large health insurance company, and Northside, an Atlanta hospital system, go head-to-head in a legal controversy in Georgia’s Supreme Court that could impact the state residents’ healthcare.

    In May 2021, Anthem decided to terminate Northside from its network due to the Atlanta hospital system billing overwhelming funds to Anthem. According to Insurance Newsnet, “One legal issue centers around the definition of “public health emergency.” That is because the General Assembly passed a law during the 2021 session prohibiting insurers from dropping health-care providers from their networks during and for 150 days after a “public health emergency.”

    A public health emergency, as declared by the city, the state, or the Federal Government, is an occurrence of a threatening illness or medical condition caused by an epidemic, pandemic, or an infectious agent. In the lawsuit, representatives of Anthem and Northside argue for different definitions for a public health emergency. Anthem argues for a “narrow” definition of a public health emergency meanwhile Northside argues for a “broad” definition of a public health emergency.

    What This Means For Georgia Residents

    It is possible that both parties may not be able to negotiate and reach an agreement, affecting Georgia Residents. With the extension of this case in the state Supreme Court, a decision will be made within the next six months. A public health emergency dispute that cannot be resolved affects state residents not only disrupts medical treatment but the collapse of healthcare facilities and systems, use of prescribed medications, and disrupts health surveillance and programs.

    How GMS Can Help

    Here at GMS, we have experts to assist with any healthcare inquiries you may have. Having an expert team by your side can be extremely beneficial for you and your employees. Let us assist in finding you the best healthcare plan, so you can focus on growing your business. Contact us today!

  • The House and Senate passed the American Rescue Plan Act of 2021 in effort to temporarily expand eligibility to pay for health insurance through 2022. As a result of this act, Production Tax Credits (PTCs) were formed. According to Insurance NewsNet, “For Florida, the number of uninsured residents would grow by 24.8% according to the estimates in the study. It would also mean a five million dollar drop in total spending on health care for non-elderly residents in the Sunshine State.”

    Before the ARPA (American Rescue Plan Act of 2022), Congress implemented the Affordable Care Act of 2010 that initially started to allow PTCs to be available to states across the U.S. Florida residents make up 513,000 of the three million Americans at risk of losing healthcare coverage since speculation began that the Affordable Care Act wouldn’t be extended.

    Why Florida Residents Are Affected

    Florida falls into the category of a non-expansion state. A non-expansion state does not have to expand access to Medicaid or Medicare eligibility by the federal government. Other non-expansion states include Texas, Georgia, and North Carolina. If the extension doesn’t pass, residents in these states, specifically Florida residents below the federal poverty line (FPL), are more at risk of losing their healthcare coverage.

    According to FamiliesUSA, a healthcare advocacy organization, Florida resident premiums could go up 61% if the PTCs expire or health provisions are not extended. At this rate, health insurance rates would increase to $1.6 billion in 2023. 

    Partnership Benefits With A PEO

    As a business owner, we understand you want to offer your employees the best healthcare plan. By partnering with a PEO, we can offer a benefits plan sponsor that includes benefit coverages, a flexible spending account, a comprehensive 401(k) plan, and more. You will have access to a team of experts who will answer any questions you may have. Contact us today.

  • Medicaid is undergoing a major expansion in the state of North Carolina. The bill, H.B. 149, was passed on June 2nd by the North Carolina Senate. This bill will expand Medicaid eligibility, allowing more than 600,000 North Carolinians to receive the life-saving health care they need. In addition to the Medicaid increase throughout the state, the bill contains a certificate-of-need (CON) law that expands nurses’ practice authority.

    The Importance

    One of the major attributes of passing the bill comes from the continued rise of inflation within the U.S. Over the past year, North Carolina has been overwhelmed by the increasing healthcare costs. Senator Ralph Hise, R-Mitchell addressed, “Everything is going up. But with the sector of cost rising farther than anything else, and that has been true for decades, is healthcare; and it’s not even close.”

    Hise mentioned several other factors that support the need for Medicaid in North Carolina:

    • Eight years of solid Medicaid budgets
    • Republican leadership in the General Assembly
    • Reform of the system associated with the Medicaid transformation in 2021

    What It Means

    Over the past year, North Carolina has ranked third in the nation for hospital closures. The bill further pushes insurance companies to cover telehealth visits, along with providing medical billing transparency. Patients must be notified at least 72 hours before a procedure or visit if they have an out-of-network provider.

    The bill also contains the SAVE Act, allowing nurses to practice without a doctor present. Senator Lisa Barnes, R-Nash Stated, “It’s a measure that doctors’ groups have opposed but is targeted to rural areas where staffing shortages have reduced access to health care.”

    How GMS Can Help

    GMS supports your business by ensuring you stay ahead of all legislative changes. As a result of the expansion of Medicaid, there will be various changes throughout the healthcare industry. At GMS, a benefits specialist can find a healthcare plan that gives your employees access to what they need. Contact us today to get started!

  • Effective January 1, 2022, the No Surprises Act went into effect with regard to emergency care and balance billing by non-network providers. An undoubtedly complex piece of legislation, GMS’ Vice President of Benefits Beth Kohmann experts share some of the key takeaways below.

    With this new ruling, if a group health plan covers any type of emergency care, then emergency care treatment rendered through the stabilization of the patient must be covered by the group health plan – even if services are rendered by a non-network provider. The group health plan must cover these services at the in-network level of benefits. The group health plan will consider these charges at a qualified payment amount level and negotiate (if the qualifying payment amount is appealed) with the non-network provider until an acceptable payment amount is reached. The patient cannot be balanced billed for the difference between the billed charge and the agreed-upon payment amount.

    This applies to such providers as facilities, emergency room physicians, anesthesiologists, and air ambulances. Ground ambulance providers are not subject to the above ruling and would be permitted to balance bill a patient for the difference between the total charge and the qualifying payment amount.

    The same applies to non-emergency care where the patient would have no choice of provider. For example, if a patient is having surgery at a network facility with a network surgeon and the anesthesiologist or outside laboratory are non-network providers, the group health plan must pay these providers at the in-network level of benefits and at a qualified payment amount (or a negotiated rate if the qualified payment amount is appealed). As above, the patient cannot be balance-billed for the difference between the billed charges and the agreed-upon payment amount.

    If the patient chooses treatment from a provider that is not in-network for services, for example, a surgical center or surgeon, that provider must inform the patient of the estimated fee, prior to rendering treatment, for their services and explain that they could be balance billed for any non-allowed amounts. This must be in writing and the patient will need to sign a document stating they acknowledge and understand that they could be balance billed.

    This ruling will apply to any claims incurred after January 1, 2022. To stay in the know with the latest legislation and compliance, be sure to subscribe to our email list. 

  • As we near a whopping two years since the beginning of the COVID-19 pandemic, President Biden doubles down on his actions to protect Americans. With 59.9% of people fully vaccinated in the United States and the expanded availability of both booster shots and testing, the Biden administration hopes to limit the pandemic’s ongoing devastation. 

    On Thursday, December 2nd, the president announced his efforts to push all private-sector employees to offer paid time off in an effort to encourage individuals to receive their vaccine(s) and/or booster dose – a measure already offered to federal employees. Outside of the PTO incentive, highlights of the administration’s plan include free at-home tests covered by insurance, more rapid response teams to assist medical staff, and accelerating vaccination efforts. Additionally, the Transportation Security Administration will extend its requirements for all travelers to wear masks on airplanes, trains, and buses and in airports or train stations, through March 18th. 

    For workplaces, the CDC guidelines state that they should keep following prevention strategies by wearing a mask indoors and in highly transmissible areas. The vaccine mandate is still not being implemented and the law has not been passed for private-sector companies. The best cause of action for small businesses across the board is preparation and understanding. By partnering with GMS, you’ll remain in the know with all of the latest legal changes.