Strategies for Selecting the Right TPA

Finding the right third-party administrator (TPA) can be challenging, and organizations often underestimate the time and resources required to select the best candidate for their needs. However, understanding the importance of finding the right TPA and exercising due diligence can pay dividends by ensuring smooth and cost-effective plan operation and minimizing legal risks.

Why Organizations Use TPAs

Unlike insurance providers that sell coverage, TPAs provide administrative and operational service to employers. Some examples of services they provide are claims processing, management and reporting. TPAs can also help organizations with plan design and implementation. TPAs charge fees for their services and may earn commissions from premiums paid to an insurer.
Administering benefits can be overwhelming. Many organizations rely on TPAs to, for example, meet regulatory standards more efficiently than they could on their own. By outsourcing administrative and operational services to TPAs, organizations can focus their efforts and attention elsewhere, thereby conserving time, resources, and efforts.
gente helps employers with administration and compliance for:
    • Consumer-Driven/Tax-Favored Accounts
      • HRA – Health Reimbursement Arrangements
        • ICHRA – Individual Coverage Health Reimbursement Arrangement
        • QSEHRA – Qualified Small Employer Health Reimbursement Arrangement
        • EBHRA – Excepted Benefits Health Reimbursement Arrangement
        • HSA Compatible Health Reimbursement Arrangements
      • HSA -Health Savings Accounts
      • FSA – Flexible Spending Accounts (Including HSA-Compatible FSAs)
      • DCAP – Dependent Care Assistance Programs
      • Commuter Benefits – Mass Transit and Parking
    • COBRA Administration
    • FMLA Administration
    • ERISA Plan Documents
    • 5500 Preparation and Filing
    • ACA Reporting (State and Federal Filings, 1094-B/1095-B and 1094-C/1095-C)
    • ACA Consulting
      • Pay or Play Strategies
      • 226-J Assistance
      • 5699 Assistance
    • HR Consulting
      • Human support from a single project to embedded on-site
    • Payroll Processing
    • Online Enrollment

Benefits of Selecting the Right TPA

It’s crucial for an organization to choose the right TPA for its needs. An organization’s goals should match the TPA’s offerings; otherwise, it may pay for services it does not need. Worse, choosing the wrong TPA can lead to poor claim outcomes, legal exposures, and higher insurance costs.
Choosing the right TPA can provide an organization with responsive, flexible, and personalized service. It can enable an organization to operate more efficiently by minimizing claim and administrative costs. The appropriate TPA can also offer an organization considerable knowledge and experience in administering health plans. A TPA can identify potential trouble spots and reduce an organization’s legal risks.

Strategies for Selecting the Right TPA

Each organization is unique. Selecting the right TPA depends on an organization’s specific health plan and related needs. However, a potential TPA’s qualifications, quality of services, and fees should also be considered when deciding if it’s the right fit.
Consider the following strategies when searching for a TPA:
  • Understand the organization’s needs and priorities. Plans have different needs depending on the type, design, asset size, and number of participants. Knowing what an organization needs and setting priorities to meet those needs can go a long way toward finding a TPA. A suitable TPA will be able to provide answers to problems and solve issues quickly.  Our service team sits together in Wayne, New Jersey, and is always eager to help.


  • Determine whether a TPA can meet needs. TPAs offer various services, and they should be reviewed individually. By understanding a TPA’s services and how it administers them, an organization can determine whether the TPA will meet its needs. Each of gente’s services is available individually.


  • Ensure legal compliance. The regulatory landscape is constantly changing, so organizations should consider how a TPA remains current on legal developments and how it can help with compliance. The right TPA should be able to guide an organization through its legal issues. gente provides the highest level of support in resolving difficult compliance issues, though employer’s counsel should always be involved.


  • Compare candidates. An organization’s relationship with a TPA is based on reliability, so any potential TPA must be able to work effectively with their client. Organizations may review metrics of a TPA’s actual claim outcomes and know how fast it pays claims as well as its error rates. By comparing these metrics to other TPAs, organizations can select the right TPA for them. gente has been proudly serving employers for more than twenty years and has well-earned reputation for high-touch, responsive service.


  • Check references. Organizations can ask a potential TPA about other clients of similar size and needs. Then, those clients can be contacted to discuss their experience working with the TPA.  gente is happy to share references with prospective clients.


  • Know costs. Organizations should be aware of all services offered by a TPA and know the costs of each. Understanding the terms of any agreement with a TPA, especially fees and expenses, is essential when choosing a TPA.  gente’s costs are all-inclusive and fully transparent. There are no hidden fees for any of our services.


  • Assess data security. TPAs should have safeguards in place to handle and protect clients’ data. Verifying a TPA’s security protocols and standards will help an organization determine whether the TPA is a good fit. gente keeps ahead of security threats with a number of protections to store and transmit data securely and prevent unauthorized access.
Reviewing all relevant factors, quality, and cost of services can help an organization choose a TPA. After making a selection, it’s important to regularly review the TPA’s performance to ensure it is meeting the organization’s needs.


There’s a lot at stake for an organization when selecting a TPA. The right TPA can improve an organization’s claim outcomes, reduce legal exposures, and lower benefits costs. Implementing these strategies can help an organization find the best candidate for them.
For the best in third-party administration, contact gente today at sales@gente.soutions. 

IRS Notice – Increase to Mileage Rate for Second Half of 2022

IR-2022-124, June 9, 2022

WASHINGTON — The Internal Revenue Service today announced an increase in the optional standard mileage rate for the final 6 months of 2022. Taxpayers may use the optional standard mileage rates to calculate the deductible costs of operating an automobile for business and certain other purposes.

For the final 6 months of 2022, the standard mileage rate for business travel will be 62.5 cents per mile, up 4 cents from the rate effective at the start of the year. The new rate for deductible medical or moving expenses (available for active-duty members of the military) will be 22 cents for the remainder of 2022, up 4 cents from the rate effective at the start of 2022. These new rates become effective July 1, 2022. The IRS provided legal guidance on the new rates in Announcement 2022-13, issued today.

In recognition of recent gasoline price increases, the IRS made this special adjustment for the final months of 2022. The IRS normally updates the mileage rates once a year in the fall for the next calendar year. For travel from January 1 through June 30, 2022, taxpayers should use the rates set forth in Notice 2022-03.

“The IRS is adjusting the standard mileage rates to better reflect the recent increase in fuel prices,” said IRS Commissioner Chuck Rettig. “We are aware a number of unusual factors have come into play involving fuel costs, and we are taking this special step to help taxpayers, businesses and others who use this rate.” 

While fuel costs are a significant factor in the mileage figure, other items enter into the calculation of mileage rates, such as depreciation and insurance, and other fixed and variable costs. 

The optional business standard mileage rate is used to compute the deductible costs of operating an automobile for business use in lieu of tracking actual costs. This rate is also used as a benchmark by the federal government and many businesses to reimburse their employees for mileage. 

Taxpayers always have the option of calculating the actual costs of using their vehicle rather than using the standard mileage rates.

The 14 cents per mile rate for charitable organizations remains unchanged as it is set by statute.

Midyear increases in the optional mileage rates are rare, the last time the IRS made such an increase was in 2011.

Mileage Rate Changes

Purpose Rates 1/1 through 6/30/2022 Rates 7/1 through 12/31/2022
Business 58.5¢ 62.5¢
Medical/Moving 18¢ 22¢
Charitable 14¢ 14¢

IRS announces 2023 Limits for HSA, EBHRA.

Text of IRS Rev. Proc. 2022-24: 2023 Inflation Adjusted Amounts for Health Savings Accounts (HSAs) and Excepted Benefit Reimbursement Arrangements (HRAs) (PDF)

“For calendar year 2023, the annual limitation on deductions under Section 223(b)(2)(A)for an individual with self-only coverage under a high deductible health plan is $3,850. For calendar year 2023, the annual limitation on deductions under Section 223(b)(2)(B) for an individual with family coverage under a high deductible health plan is $7,750.”

“For calendar year 2023, a ‘high deductible health plan’ is defined under Section 223(c)(2)(A) as a health plan with an annual deductible that is not less than $1,500 for self-only coverage or $3,000 for family coverage, and for which the annual out-of-pocket expenses (deductibles, co-payments, and other amounts, but not premiums) do not exceed $7,500 for self-only coverage or $15,000 for family coverage.”

For plan years beginning in 2023, the maximum amount that may be made newly available for the plan year for an excepted benefit HRA under Section 54.9831-1(c)(3)(viii)is $1,950.”

IRS: Unused Commuter Benefits Cannot Be Transferred to Health FSA

Key Points

  • Generally, unused compensation reduction amounts under an employer’s qualified transportation plan may be carried over to subsequent years for future commuting expenses.
  • Cash reimbursements that may be used for any purpose are not allowed.
  • IRS rules do not permit unused transportation benefits to be transferred to a health FSA under a cafeteria plan.

An employee may receive a cash reimbursement only as reimbursement of transportation benefits and not for any other fringe.

On March 25, 2022, the IRS issued an information letter to explain that taxpayers cannot transfer unused amounts in a commuter benefits plan (CBP) to a health flexible spending arrangement (FSA). The IRS issued the information letter in response to a taxpayer who had unused amounts in his employer’s CBP because his employer decided that he could work from home permanently due to COVID-19.

Options for Transportation Benefits

Employers who provide transportation benefits to employees can exclude the benefit from an employee’s gross income if it is a “qualified transportation fringe” under the tax code. A qualified transportation fringe includes travel in a commuter highway vehicle between home and work, any transit pass, and qualified parking.

The tax code allows employers to offer a choice between cash compensation and any qualified transportation fringe. Thus, employers may provide qualified transportation fringe benefits up to the applicable monthly limit either in addition to employees’ compensation or by reducing employees’ compensation (compensation reduction).

When an employee elects to reduce their compensation for a month by an amount that exceeds the qualified transportation fringe benefits actually provided in that month, the employer may apply this excess towards qualified transportation fringe benefits in subsequent years. However, an employer cannot provide a cash refund, even when the employee’s compensation reduction exceeds the employee’s qualified transportation fringe benefits.

In other words, an employee may receive a cash reimbursement of compensation reduction amounts only as reimbursement of qualified transportation fringe benefits and not for any other fringe benefit. IRS rules do not permit unused qualified transportation fringe benefits to be contributed to a health FSA under a Section 125 cafeteria plan.

IRS Suspends Notices to Filers of Forms 5500, 990 and Others

On March 22, 2022, the IRS announced it will temporarily stop sending written notices to certain entities that fall behind on filing obligations related to Forms 5500, 990 and others. The IRS usually mails these notices to tax-exempt or governmental entities in case of a delinquent return.

IRS Backlog

The IRS is currently experiencing a backlog of over several million unprocessed returns due to the COVID-19 pandemic. This backlog involves returns filed by both individuals and entities. According to the agency, the suspension of notices will help avoid confusion when a filing is still in process.

Duration of Notice Suspension

The IRS indicated that it would continue to assess its inventory of pending returns to determine the appropriate time to resume mailing the suspended notices. Meanwhile, some taxpayers and tax professionals may still receive the notices over the next several weeks.

Affected Notices

The suspension applies to the following 10 notices:
  • Reminder Notice About Your Form 5500-EZ or 5500-SF Filing Requirement
  • Form 940 Not Required—Federal, State, and Local Government Agencies
  • First Taxpayer Delinquency Investigation Notice—Forms 990/990EZ/990N, 990PF, 990T, 5227, 1120-POL, and 990/990EZ
  • First Delinquency Notice—Forms 5500 and 5500-SF
  • Second Delinquency Notice—Form 5500
Entities affected by the suspension should ensure their procedures for timely filing returns do not rely on any of these notices.

What the EEOC’s FY 2023 Budget Justification Means for Employers

The Equal Employment Opportunity Commission (EEOC) recently presented its budget for fiscal year 2023. Examining how the EEOC intends to spend its money can help with gauging where the agency may soon be focusing its enforcement efforts, an important consideration for employers.
This article explores where EEOC enforcement may be headed in the near future.

EEOC Enforcement Refresher

Before looking toward enforcement trends, it’s important to first keep in mind the types of workplace laws the EEOC upholds.
The EEOC is responsible for the following laws:
  • Title VII of the Civil Rights Act
  • The Age Discrimination in Employment Act
  • The Pregnancy Discrimination Act
  • The Equal Pay Act (included in the Fair Labor Standards Act)
  • Titles I and V of the Americans with Disabilities Act
  • Sections 501 and 505 of the Rehabilitation Act of 1973
  • Title II of the Genetic Information Nondiscrimination Act
These laws protect individuals from workplace discrimination and retaliation for opposing such discrimination. The laws also limit the types of personal health information an employer may obtain and restrict how it may be used.
When an employer runs afoul of these laws, the EEOC may get involved after an employee files a complaint. Notably, with a larger operating budget, the agency’s involvement may be more commonplace in the immediate future.

2023 Budget Justification Overview

President Joe Biden’s proposed budget for next year includes $464.65 million for the EEOC, an increase of about 10% ($60 million) from its 2022 allotment. This amount will allow the EEOC to continue pursuing anti-discrimination efforts at an effective pace, aligning with the president’s goal of having a “whole-of-government” approach for addressing discrimination and advancing equality.
More specifically, EEOC Chair Charlotte A. Burrows justified the budget increase by outlining the agency’s broad goals for 2023, which include:
  • Combating racial injustice and systemic discrimination on all protected bases
  • Improving pay equity
  • Addressing the civil rights impact of the COVID-19 pandemic
  • Strengthening the agency
These goals echo past efforts of the EEOC, which has always sought to advance workplace equality. Perhaps the most noteworthy addition to the 2023 goals is the “strengthening of the agency.” In 2021, the EEOC added over 450 front-line employees, including investigators. In 2023, the agency intends to expand its ranks even further.

Employer Takeaways

From a high level, the EEOC’s 2023 goals indicate the potential for increased enforcement. After all, the agency will fill hundreds of vacant front-line positions in 2022 and seeks to do so again next year.
It’s critical for employers to understand their obligations under EEOC-enforced regulations as well as how to handle an investigation. Being prepared with relevant documentation and other information can help reduce an EEOC investigation’s potential disruption.


EEOC investigations are essential for maintaining equitable working environments. In 2023, employers may see increased enforcement as the agency continues to expand its workforce and efforts to reduce workplace discrimination.
Reach out to gente to learn more about your potential EEOC obligations, including what to expect from an investigation.
This HR Insights is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice. © 2022 Zywave, Inc. All rights reserved

CDC No Longer Enforcing Mask Mandate on Air Travel and Public Transit

On Monday, April 18, 2022, a federal judge invalidated the national mask-wearing requirement for public transit, airplanes and transportation hubs. In their decision, the federal judge for the Middle District of Florida said the CDC exceeded its authority to enforce mask-wearing.
Initially, the mask-wearing requirement had been extended by the Centers for Disease Control and Prevention (CDC) until May 3 in an effort to curb outbreaks of new COVID-19 variants. However, as a result of the court order, the CDC will no longer enforce the mandate, effective immediately. It now falls on individual transit authorities and airliners to determine if they wish to enforce mask-wearing or similar COVID-19 prevention measures.

What’s Next?

In response to the decision, President Joe Biden noted that the Transportation Security Administration would not be enforcing mask-wearing in transit hubs.
Additionally, it’s unclear how public and private transportation agencies will respond. At the time of this writing, the largest U.S. airliners have all stated that mask-wearing will now be optional. These companies include Delta Air Lines, American Airlines, United Airlines, Southwest Airlines, Alaska Airlines and JetBlue.
Amtrak released a similar statement saying masks are no longer required on their trains for passengers or employees.
For its part, the CDC is still encouraging individuals to wear masks while on public transit or airplanes. The agency is concerned about the growing spread of the Omicron coronavirus subvariant known as BA.2.
It’s also important to note that some localities may be enforcing mask-wearing despite the overturned federal mask mandate. Philadelphia, for instance, reinstated its mask-wearing rule to help curb the new wave of COVID-19.
Knowing this, individuals traveling to different parts of the country should plan ahead to ensure compliance with their destinations’ rules.
Continue monitoring guidance from states, localities and individual businesses. gente will keep you updated with any notable COVID-19 policy changes.
The content of this News Brief is of general interest and is not intended to apply to specific circumstances. It should not be regarded as legal advice and not be relied upon as such. In relation to any particular problem which they may have, readers are advised to seek specific advice. © 2022 Zywave, Inc. All rights reserved.

Wearable Technology and the Workforce






Wearable technology isn’t a new feature. For years, personal gadgets such as smartwatches have been gaining popularity among people who want better insight into their health trends. According to Pew Research Center data, nearly 1 in 5 Americans (21%) say they regularly wear a smartwatch or fitness tracker. In fact, wearable technology has grown so commonplace that employers have been exploring ways to leverage it among their workforce.

This article outlines the basics of wearable technology and its potential workplace benefits.



Wearable Technology Overview

“Wearable technology” typically invokes images of smartwatches or fitness trackers, but it isn’t limited to those electronics. Rather, wearable technology can be any device kept on someone’s person that connects to the internet and logs activity—even a cellphone can be considered wearable technology.

Typically, such devices interface with apps or websites that present tracked data in a readable or visual format. For instance, a smartwatch might track someone’s heart rate during a workout; the person wearing the device could then go to their corresponding phone app and see a graph of their average heart rate for the week.

In recent years, wearable technology has evolved from the realm of personal activity monitoring into a viable business solution. Essentially, employers are looking into how they might be able to track worker productivity, identify potential efficiencies and otherwise leverage this burgeoning technology.

The adoption of wearable technology has been particularly prevalent among manufacturing and warehousing employers. Some of these employers are exploring technology that monitors how employees physically move when accomplishing daily tasks as a way to identify and prevent ergonomic issues. Other employers are using devices to help employees track their work schedules, communicate with co-workers and find products located in a store or warehouse.

Beyond workflow efficiencies, wearable technology has also seen adoption among workplace wellness plans. Some employers provide fitness trackers to employees as a way to incentivize healthier habits. Workplaces may even offer prizes based on monitored data, such as most steps walked in a week. 


Potential Benefits for Employees

At its core, wearable technology is intended to gain better insight into how employees work and improve efficiencies. Knowing this, there are a variety of ways employees can benefit from using such devices, depending on the solution adopted. Beyond helping with daily tasks, preventing ergonomic issues and providing employees with an easy way to communicate with their workplaces, most wearable technology offers a look into an individual’s well-being habits. As such, an employee could also use the technology to keep track of their health trends and make personal improvements. 


Potential Benefits for Employers

Wearable technology offers a detailed view of how employees work on a daily basis and allows employers to analyze this data in impactful ways. Mapping these trends can help improve productivity and reduce worker injuries, such as in the case of ergonomic issues.

Certain devices can also provide more tangible benefits by allowing employees to communicate with their workplaces more efficiently. This could include asking a floor manager a question from across a store or having a system-generated checklist of daily workplace duties updated in real-time.

Summarily, wearable technology can make workplaces more efficient by mapping critical productivity trends and giving employees meaningful tools to monitor their own health and productivity. 


Potential Pitfalls

There are two primary pitfalls surrounding wearable technology employers should be aware of:

  •    Employee buy-in
  •     Legal concerns

Employee Buy-in Concerns

When it comes to employee buy-in, some pushback can be expected. To some, wearable technology that tracks their performance might feel like having a manager peeking over their shoulder at all times. Introducing such technology would also likely cause employees to ask, “Exactly what data is being collected?”

Employers can proactively address wearable technology pushback by explaining the concept in detail to employees before adoption. Employers should clearly articulate the purpose of the tech, what data is being collected, when the data will be collected, how the data will be used and how the data may apply to workplace policies. During this conversation, employers should be sure to emphasize how the technology can help employees with their day-to-day responsibilities.

Legal Concerns

In terms of legal issues, there are various potential concerns for employers when it comes to wearable technology. Unfortunately, the guidance surrounding this topic varies widely depending on the technology, how it’s used and the workplace location. It will fall on employers to research laws that may apply to them and their specific technology solutions.

Generally speaking, wearable technology policies may be governed by laws including but not limited to:

  •      Americans with Disabilities Act (ADA)
  •      Affordable Care Act
  •      Genetic Information Nondiscrimination Act
  •      Health Insurance Portability and Accountability Act


At a federal level, these laws regulate the accessibility of workplace programs and specify how data may be collected and used. For instance, an employer will violate the ADA if employees are subject to continuous observation.

Employers should speak with legal counsel when determining a potential wearable technology policy for their workplaces to ensure compliance with all applicable laws.



Wearable technology presents an exciting opportunity for workplaces. For employees, it can improve daily workflows, team collaboration and personal well-being; for employers, the technology enables game-changing metrics and adaptability. Individual employers will need to examine available wearable technology and choose solutions that will be most impactful to their organizations.

Reach out to gente for additional workplace guidance.



This Benefits Insights is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice. © 2022 Zywave, Inc. All rights reserved.


Transparency in Health Coverage – Resources, Rules, and Deadlines




Transparency in Health Coverage


New transparency in coverage requirements apply to group health plans and health insurers in the individual and group markets. These rules require plans and issuers to disclose certain price and cost information to participants, beneficiaries and enrollees.


These provisions only apply to non-grandfathered coverage, including both insured and self-insured group health plan sponsors. The requirements take effect in three phases, as follows:


·   Jan. 1, 2022: Detailed pricing information must generally be made public for plan years beginning on or after Jan. 1, 2022.

·   Jan. 1, 2023: A list of 500 shoppable services must be available via the internet-based self-service tool for plan years beginning on or after Jan. 1, 2023.

·   Jan. 1, 2024: A list of the remainder of all items and services is required for plan years beginning on or after Jan. 1, 2024.




·   On Oct. 29, 2020, the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (Departments) issued a final rule regarding transparency in coverage.

·   Transparency in coverage FAQs were released on Aug. 20, 2021.


Transparency in Coverage Requirements


The Transparency in Coverage Final Rules (TiC Final Rules) require non-grandfathered group health plans and health insurance issuers offering non-grandfathered coverage in the group and individual markets to disclose certain information. The final rule includes two approaches to make health care price information accessible to consumers and other stakeholders, allowing for easy comparison shopping.


Participant, Beneficiary and Enrollee Disclosures


First, most non-grandfathered group health plans and health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets will be required to disclose personalized price and cost-sharing information to participants, beneficiaries and enrollees (or their authorized representatives). Specifically, plans and issuers must provide personalized out-of-pocket cost information and the underlying negotiated rates for all covered health care items and services, including prescription drugs, through an internet-based self-service tool and in paper form upon request.


·   An initial list of 500 shoppable services, as determined by the Departments, is required to be available via the internet based self-service tool for plan years that begin on or after Jan. 1, 2023.

·   A list of the remainder of all items and services will be required for these self-service tools for plan years that begin on or after Jan. 1, 2024.


Machine-readable Files


Second, most non-grandfathered group health plans or health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets will be required to make available to the public (including stakeholders such as consumers, researchers, employers and third-party developers) three separate machine-readable files that include detailed pricing information.


·   The first file must show negotiated rates for all covered items and services between the plan or issuer and in-network providers;

·   The second file must show both the historical payments to, and billed charges from, out-of-network providers (historical payments must have a minimum of 20 entries in order to protect consumer privacy); and

·   The third file must detail the in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level.


Plans and issuers will display these data files in a standardized format and provide monthly updates.


These machine-readable files are required to be made public for plan years that begin on or after Jan. 1, 2022. However, the Departments reserved enforcement discretion in their FAQs to apply the following two exceptions:


1.   Under the first exception, the Departments will defer enforcement of the machine-readable files requirement relating to prescription drug pricing pending further rulemaking. Following the enactment of the Consolidated Appropriations Act, 2021 (CAA)–which imposes potentially duplicative and overlapping reporting requirements for prescription drugsthe Departments are currently considering whether the prescription drug machine-readable file requirement remains appropriate.

2.   Under the second exception, the Department will defer enforcement of the requirement to publish the remaining machine-readable files until July 1, 2022. On July 1, 2022, the Departments intend to begin enforcing the requirement that plans and issuers publicly disclose information related to in-network rates and out-of-network allowed amounts and billed charges for plan years (in the individual market, policy years) beginning on or after Jan. 1, 2022. For 2022 plan years and policy years beginning subsequent to July 1, 2022, plans and issuers should thus post the machine-readable files in the month in which the plan year (in the individual market, policy year) begins, consistent with the applicability provision of the TiC Final Rules.


HHS encourages states that are primary enforcers of these requirements with regard to issuers to take a similar enforcement approach, and will not determine that a state is failing to substantially enforce this requirement if it takes this approach.


MLR “Shared Savings” Credits


The TiC Final Rules also allow issuers that share savings with consumers resulting from plan provisions encouraging consumers to shop for services from lower-cost, higher-value providers, to take credit for those “shared savings” payments in their medical loss ratio (MLR) calculations. This is intended to ensure that issuers would not be required to pay MLR rebates based on a plan design that would provide a benefit to consumers that is not currently captured in any existing MLR revenue or expense category.




How to Get Your Free At-home COVID-19 Tests

If you participate in a health plan—through an employer or otherwise—you are likely eligible for free, over-the-counter COVID-19 tests for home use.


Depending on your plan, your COVID-19 tests will be paid for directly by insurance, or you will be reimbursed later for the cost. The human resources (HR) department will be able to tell you which applies to you.


Keep reading to learn more about this cost-saving opportunity.


Up to what price is covered?


In many instances, insurance companies are only required to reimburse you at a rate of up to $12 per individual test (or the cost of the test if it’s less than $12). This is typically the case when your insurance company has specific locations they want you to get your test from.


However, if your insurance company doesn’t specify where you may get a COVID-19 test, you may be able to be reimbursed for your full test cost, even if it exceeds $12. In all cases, keep your receipts!


Speak with HR to learn more about your plan’s cost limits and preferred purchasing locations.


Do I need to purchase the test at a certain location for it to be free?


Employer Plans may have specific locations (e.g., pharmacies) where you can pick up a free test that is paid for directly by your insurance. HR will be able to tell you.


However, you can also purchase a COVID-19 test from anywhere you like (i.e., online or in-person at a store) and still be reimbursed up to $12 for the test (or more, depending on your plan). Be sure to keep your receipts in order to be reimbursed.


How will I be reimbursed for my test?


If you need to be reimbursed for a COVID-19 test (i.e., it was not free at the point of sale), keep your receipts. Then, reach out to HR—they will be able to tell you how to submit the receipt for reimbursement from your insurance company.


How long will reimbursement take?


Reimbursement is typically prompt, but it may vary. HR will be able to provide a more accurate time estimate.


What if I cannot afford to pay for a test upfront and wait for reimbursement?


There are a number of low- or no-cost COVID-19 testing options. You can find community-based testing sites here.


Alternatively, COVID-19 tests are also available without cost sharing or limitations to covered individuals when administered by a health care provider (e.g., a nurse, doctor or pharmacist).


Can I be reimbursed for past COVID-19 tests I purchased?


Insurance companies are only obligated to reimburse you for COVID-19 tests purchased on or after Jan. 15, 2022. Any tests bought before then are not covered.


However, while the answer will generally be no, you still can speak with your plan sponsor about potential reimbursement for COVID-19 tests you bought previously.


Is there a limit on the number of tests I can be reimbursed for?


Your plan is required to provide reimbursement for eight tests per month, regardless of whether the tests are bought all at once or at separate times throughout the month.


My workplace requires weekly COVID-19 testing. Can I be reimbursed for these tests?


Plans are not required to provide coverage for testing (including at-home COVID-19 tests) that is for employment purposes.


Speak with your HR department to learn more about your employer’s testing requirements and your potential related costs.


Where can I learn more?


If you have any questions about the information in this article, reach out to your HR department.


This Know Your Benefits article is provided by gente and is to be used for informational purposes only and is not intended to replace the advice of an insurance professional. © 2022 Zywave, Inc. All rights reserved.