Mario Gosalvez

From conference calls to construction sites: how musculoskeletal conditions impact workforce health https://lnkd.in/gpwMRJ84 #Healthcare #EmployeeHealth #MusculoskeletalHealth #WorkforceWellness #KaiserPermanente

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My Medicare team and I have been energized with optimism and momentum since the Annual Enrollment Period began on October 15. Consumers are beginning to explore and appreciate the value-added coverage options we at Blue Shield of California offer members for 2025 through our combination of cutting-edge technology and high- touch care. Our goal is to simplify healthcare, support comprehensive care, and reduce costs for our Medicare beneficiaries. A few highlights of our 2025 pharmacy offerings include: Price Check My RX tool: We are working hard to improve the end-to-end pharmacy experience for Medicare members. This new tool allows members to find the lowest price for their medications with easy side-by-side comparisons of drug alternatives and pharmacies. Also, members can opt-in to receive a text alert when there is a lower cost option available for their prescription. https://lnkd.in/gjMSi7Ss Amazon Pharmacy: Starting January 1, 2025, Blue Shield will offer additional pharmacy service options for members, including home delivery from Amazon Pharmacy at no additional cost, and tools to find the lowest-cost medications. Members also will have phone access to pharmacists 24/7 through Amazon Pharmacy. https://lnkd.in/gSciTw_F Medicare Prescription Payment Plan (M3P): A new, federally mandated Medicate prescription payment plan called M3P offers Medicare Part D enrollees the option to pay their out-of-pocket Medicare Part D drugs costs through monthly payments over the course of the plan year. It’s designed to provide better financial predictability and expense management for members with chronic conditions or high-cost medications. Member participation is voluntary and there is no cost to participate. More information about M3P is available from the Centers for Medicare and Medicaid Services: https://lnkd.in/gPS5ZMJk Learn more about Blue Shield’s AEP for 2025 here: https://lnkd.in/gtQ_gf3j #WhatWeStandFor #WeNeverStop #Medicare #AEP #HealthcareInnovation #SeniorCare

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SB 525 will necessitate significant changes in California healthcare organizations’ compensation programs. And rather than simply bringing all applicable employees to the new minimum wage levels, many organizations will consider nuanced pay adjustment strategies and optimizing their broader total rewards strategies. Find out more about the impacts of SB 525 today. #HumanResources #compensation #healthcare

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I am happy to share some great news: The Sacramento Bee has published the first of its four-part series on Medicare, featuring Blue Shield of California as its source of information and insights. The first article, "Mastering Medicare, Part 1: What you need to know before enrollment, from A to D and more," provides a comprehensive overview of the key differences among Medicare Parts A, B, C, and D. It covers essential information such as: Medicare Part A: Covers inpatient hospital care, skilled nursing facility care, hospice, lab tests, surgery, and home health care. Medicare Part B: Includes medically necessary services and preventive health care services. Medicare Part C (Medicare Advantage): Combines Parts A and B and often Part D for prescription coverage, with additional benefits like dental, vision, and hearing care. Medicare Part D: Offers prescription drug coverage. The article also highlights important dates for Medicare enrollment and addresses common misconceptions about Medicare coverage. Recent changes to Medicare, driven by the Inflation Reduction Act (IRA), aim to make coverage more affordable and improve access to behavioral health services. If you are 65 years and older, navigating Medicare can be challenging, but remember that you are not alone. We are here to support you every step of the way, ensuring you have access to the information and resources you need to make informed decisions about your health care. We look forward to continuing to share additional Medicare information with you through The Sacramento Bee in the coming weeks. #WeNeverStop #WhatWeStandFor #Medicare #Healthcare https://lnkd.in/gNhaKRUk

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❗ ❗ California Mandates IVF Coverage for Group Health Plans Starting July 2025, California's Senate Bill 729 will require group health plans to cover certain fertility treatments, including IVF, for policies written or renewed on or after July 1, 2025. Large plans must cover up to three IVF cycles, while small plans must offer the option to cover infertility services. Read more to stay prepared in our latest edition of Compliance Directions. https://lnkd.in/g6Vsp2JK #EmployeeBenefits #ComplianceConsulting #ComplianceDirections

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In our latest Bottom Line Thursday, we discuss California's ambitious plan to limit healthcare cost growth. The state aims to cap annual growth at 3.5%, dropping to 3% by 2029. But is this realistic? We talk about the pushback from hospitals citing an aging population, the ongoing challenge of controlling prescription drug costs, and potential impacts on care access and quality. Join us as we discuss the implications of this initiative and its potential ripple effects across the healthcare industry. Can California succeed where others have struggled? Tune in to hear our thoughts California’s proposal. #HealthcarePolicy #CostContainment #EmployeeBenefits #BottomLineThursday

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In our latest Bottom Line Thursday, we discuss California's ambitious plan to limit healthcare cost growth. The state aims to cap annual growth at 3.5%, dropping to 3% by 2029. But is this realistic? We talk about the pushback from hospitals citing an aging population, the ongoing challenge of controlling prescription drug costs, and potential impacts on care access and quality. Join us as we discuss the implications of this initiative and its potential ripple effects across the healthcare industry. Can California succeed where others have struggled? Tune in to hear our thoughts California’s proposal. #HealthcarePolicy #CostContainment #EmployeeBenefits #BottomLineThursday Brad Johnson Chris Boling - PPACA

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❗ ❗ California Mandates IVF Coverage for Group Health Plans Starting July 2025, California's Senate Bill 729 will require group health plans to cover certain fertility treatments, including IVF, for policies written or renewed on or after July 1, 2025. Large plans must cover up to three IVF cycles, while small plans must offer the option to cover infertility services. Read more to stay prepared in our latest edition of Compliance Directions. https://lnkd.in/g6Vsp2JK #EmployeeBenefits #ComplianceConsulting #ComplianceDirections

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What if I told you transparency and innovation in healthcare means making it more complex? Blue Cross of California (d/b/a Anthem Blue Cross) announces reimagining pharmacy care. Let’s get up to speed -- Aug 2023 – BCBS CA announces ditching CVS Caremark for claims processing (however CVS Caremark continues specialty drug network management) and replacing CVS Caremark with at least 5 other vendors. Aug 2024 – BCBS CA announces 8 vendors replace CVS Caremark claims processing, including Amazon Pharmacy for prescription delivery Abarca Health for Rx claims processing Navitus Health Solutions for pharmacy retail network oversight/management (??) Unclear why a separate company is needed to manage the retail network oversight and management when there is an Rx claims processor vendor duplicating the same function. Prime Therapeutics for drug rebates through a GPO, called Ascent. Ascent is a Switzerland-based Group Purchasing Organization (GPO) formed in 2019. Ascent is majority controlled by Cigna’s Evernorth segment with Prime therapeutics as a minority owner. Do we get more or less transparency when the GPO is headquartered outside the US? BTW, the State of Ohio filed a lawsuit in March 2023 against Ascent and several PBMs, alleging primarily that these entities colluded to fix drug prices and inputs to drug prices (e.g., manufacturer rebates). Prime Therapeutics was called out among 5 other PBMs (the Big Six), together controlling 90%+ of the prescription claims in the country, in the Interim PBM report published by the Federal Trade Commission in July 2024 -- “Although the FTC issued its Orders to the PBMs over two years ago, some of the PBM respondents have not yet fully complied; they have not yet completed their required submissions.” CVS Health Specialty for specialty prescription drug network management (!!) BCBS CA removes CVS Caremark as the PBM (claims processor, network management, rebates, etc.) only to keep the highest cost specialty drugs through CVS Specialty? Will CVS Specialty dictate the formulary? Do specialty rebates flow through this CVS Specialty administration? If so, will members have options for generic and biosimilar alternatives that aren’t already sourced directly from CVS Specialty owned manufacturers? Gemini for state-of-the-art digital tools Evio Pharmacy Services for value/outcome based arrangements with drug manufacturers Synergie Medication collective for savings on medically administered drugs I have a few more questions Does 8 more vendors with increased pharmacy benefits complexity help patients better navigate access to medicines or make it harder? Will BCBS CA limit medication access through Amazon Pharmacy and Mark Cuban Cost Plus Drug Company or are these options among all pharmacy providers? Maybe there is an incentive to use these pharmacies? Would multiple vendors replacing one add more unnecessary costs to make drugs more expensive or more affordable? What do you think?

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📣 California IVF Coverage Mandate Raises Questions  California Governor Gavin Newsom has signed SB 729, which requires large group insured plans (100+) cover up to three cycles of oocyte (egg) retrievals for IVF purposes. It applies to policies issued, amended, or renewed on or after July 1, 2025. For a calendar year plan, it will apply to the January 1, 2026, plan year. It does not apply to self-funded plans. However, the law attempts to apply extraterritorially, which means that it seeks to regulate any insurance policy issued in any state that covers California residents. It is unclear how California could enforce extraterritorial application of this law, but insured employer plan sponsors with contracts sitused in other states that cover California residents may want to reach out to those carriers to discuss their approach to this law. Otherwise, this issue will largely be about increased costs to insured plans and whether insured plans that have partnered with fertility vendors want to continue those relationships. Note that other states, including Colorado, New York, and Vermont, have similar coverage mandates but do not attempt extraterritorial application. As is the case with all state insurance code mandates, insurance carriers are the regulated entity and should be able to address questions from employer plan sponsors.

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#AI is one of the hottest buzzwords today, see how Regence BlueShield is moving beyond the buzz and making meaningful change in the health care experience by leaning into the power of AI.

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Most workplace benefits prioritize supporting plan members over cost containment, yet the question remains: How can the costs of these plans be managed in the long run? One key cost-containment measure to consider: with Pillcheck plan sponsors avoid the costs of covering ineffective, sometimes harmful prescriptions, and lost productivity until the right treatment is found. 👀   Drug claims for women are growing higher year after year. Women experiencing depression, hot flashes, gastrointestinal problems, or medication-induced side effects may benefit from personalized medication optimization. https://lnkd.in/dXzhqn3S #womenhealth #wellness #groupbenefits

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Interesting read here on new attempts to cap health care cost increases to 3% annually. And by interesting, I mean pretty void of common sense and basic math. A couple of questions come up when reading this. 1. Does anyone want any more government involvement in healthcare, especially in California? We are all familiar with the Affordable Care Act currently and not sure anyone would argue that is affordable anymore. 2. When you require hospitals and health clinics to increase their minimum wage to $21/hour, but cap the amount they can be reimbursed for services, what did you think would happen? Having 10-12 clients in this space and seeing the impact this is having on them obviously makes me a little biased, but like most things coming out of the legislature in Sacramento, the opposite effect of their intended goal is what usually occurs. This may potentially cause more facilities to close and thus reducing access to care for more residents and employees.

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California has seen a significant rise in interest among employers for self-funding and employee benefits captives, largely due to increasing healthcare costs and the flexibility these models offer. Many California businesses, particularly mid-sized firms, are turning to self-funded plans, often coupled with stop-loss insurance, to manage expenses and have more control over benefits. A survey indicates that over 80% of health insurance executives report a growing employer interest in self-funding, driven by the need to avoid certain ACA-related fees and to gain control over claims data and cost containment strategies. Companies are increasingly adopting self-funded plans to reap the benefits of their cost-saving wellness initiatives directly rather than paying a fixed premium to traditional insurers. Employee benefits captives are also emerging as a compelling choice, especially among organizations with 100 to 900 employees. Captives allow groups of like-minded employers to share risks while enjoying potential savings if claims are low, providing a buffer against high-cost years. By pooling resources, these employers benefit from a shared stop-loss premium, which is often less volatile than self-insuring alone. With this structure, businesses not only control plan design and costs but also gain insights into participant healthcare usage, which can guide more targeted and efficient healthcare solutions. Some captives even offer added benefits like pharmacy coalitions and catastrophic claims technology, making them attractive for cost-conscious employers aiming for better financial stability and improved benefits​ Conner Strong ​ California Broker ​ Self-Insurers' Publishing Corp. .

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Establishing a self-insured medical reimbursement program can bring substantial benefits to companies with 10 or more full-time employees. Our national program offers significant savings, particularly advantageous for businesses in California. With potential savings of 20% or more, this program is especially beneficial in a state where workers' compensation policies are audited based on gross wages. Employees can enjoy a comprehensive benefits package, including Critical Illness, Life Insurance, Dental Insurance, Accident & Disability, at no additional cost. Implementing this program is seamless and efficient, with a quick setup that takes only 3-4 weeks. Importantly, this transition does not require switching providers or impacting employee pay. Want to see firsthand how this can positively impact your business? Reach out to us to schedule a Zoom presentation and learn more about our self-insured medical reimbursement program. Curious about the difference this program can make? Check out the comparison - a paycheck with a SIMRP versus one without. Discover the potential savings and benefits that await your company with our tailored solution.

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❗ ❗ California Mandates IVF Coverage for Group Health Plans Starting July 2025, California's Senate Bill 729 will require group health plans to cover certain fertility treatments, including IVF, for policies written or renewed on or after July 1, 2025. Large plans must cover up to three IVF cycles, while small plans must offer the option to cover infertility services. Read more to stay prepared in our latest edition of Compliance Directions. https://lnkd.in/g6Vsp2JK #EmployeeBenefits #ComplianceConsulting #ComplianceDirections

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Proud to share our latest article discussing the transformative impact of nurse triage programs on workers' comp claims management. Check it out to learn how early intervention is shaping the future of healthcare! #NurseTriage #WorkersComp #Healthcare #ExperiencetheBroadspireDifference #BetterWithBroadspire"

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