Under The Coverage

Have you ever had a service reviewed or denied by your insurance with the explanation that it wasn't “medically necessary”? Join us as our medical management team helps us understand what medical necessity really means. We'll explore: • When something is reviewed for medical necessity • Real-life examples • Appeals process • Practical advice for navigating this complex part of health insurance. Tune in and empower yourself with the knowledge to navigate medical necessity determinations with confidence.

Ever felt like navigating your health insurance is like solving a riddle wrapped in a mystery? Fear not, dear listener! In this action-packed 10-minute episode, we're here to demystify the world of out-of-network benefits. Join us as we unveil the secrets to discovering if you have out-of-network benefits and how to use them like a pro. Whether you're planning a trip, switching doctors, or just want to be prepared for the unexpected, we've got you covered. Get ready to become the superhero of your own healthcare journey. Tune in for a quick, informative, and downright fun dive into the ins and outs of your insurance network. By the end of this episode, you'll have the tools to confidently navigate your benefits and make the most of your healthcare plan.

Leaving a job often means losing your employer-sponsored health insurance. But, COBRA, the Consolidated Omnibus Budget Reconciliation Act, can be your lifeline during this transition. COBRA allows you to temporarily continue your health coverage. It's like a bridge that helps you cross the gap between jobs without losing the benefit plan you have. In this episode, we'll dive into the world of COBRA, covering eligibility, enrollment, keeping your coverage, and canceling it when you've found your next opportunity. We'll share insider tips to help you navigate this process like a pro. Whether you're new to COBRA or you've been down this road before, join us for this informative discussion with our seasoned guide. Don't miss out on this essential resource for bridging the health insurance gap during job transitions.

✨ No one grows up dreaming of working in insurance, but let's face it—knowing the ins and outs can be a game-changer! Join industry veterans Jolene and Sara for a whirlwind tour through the surprisingly fascinating world of insurance lingo. With over a decade of experience each, Jolene and Sara have learned terms that might sound boring but are actually the keys to asking the right questions, saving money, and advocating for themselves and their loved ones. In this episode, they'll share their top tips and insider knowledge, breaking down those daunting terms into bite-sized, easy-to-understand pieces.

Ever received an EOB (Explanation of Benefits) from your insurance company and thought, "What even is this?" Spoiler alert: it's not a bill! But it is your crystal ball, giving you a heads-up about any upcoming bills. Join us in this quick, fun, and enlightening episode as we break down the mystery of the EOB. We'll walk you through the key info it contains, how to read it, and what it means for your wallet. Episode Highlights: - What exactly is an EOB and why should you care? - The must-know parts of an EOB to look out for. - How to use your EOB to anticipate bills and avoid surprises. For more hands-on learning, check out these sample EOBs: -- Sample EOB 1 - https://www.cms.gov/files/document/11819-sample-explanation-benefits-508.pdf -- Sample EOB 2 - https://www.patientadvocate.org/explore-our-resources/interacting-with-your-insurer/what-does-an-eob-look-like/ Join us for a bite-sized dive into the world of insurance paperwork that's both informative and surprisingly fun. By the end, you'll be an EOB-reading pro, ready to tackle your insurance mail with confidence. Hit play and demystify your EOB today!

Understanding health insurance benefits Ugh. Obviously, it's stressful and we often find out we're learning at the most vulnerable time – when we or one of our dependents are sick or are not feeling well. There's nothing worse than trying to make sense of something when you are feeling your worst. Tracey joins the podcast to help us walk through how she has learned to get in front of the problem by understanding what's not covered before the bill comes in!

Lower levels of literacy, English as a second language, transitioning to the United States from a foreign country – all of these factors make it increasingly more difficult to understand and use medical benefits. Abby Grainge works as a family nurse practitioner at Jericho Road Community Health Center in Buffalo, NY and is also the medical director of Vive, Jericho Road's shelter for asylum seekers. She joined the podcast to talk about the unique challenges the US health care system poses for those new to the country.

When you picture a nurse, you might envision a hospital or physician's office. But nurses also work in a clinical capacity for health plan administrators. Lorene wants the world to know she and her team and other nurses in the industry work hard to walk with members on their journey to better health. In this episode she discusses how nurses work to help members, how they help patients who may face barriers to care, and why she what she does.

Congratulations, you're hired! When you get a job offering health benefits it's important to understand the basics. Where do you go if you're sick? How much will it cost? Which physicians and facilities are in-network and what does that even mean? Jerame volunteers for a workplace readiness program where he often addresses health insurance questions. And he has some advice for you...

If there was a course in high school or college to help us understand how medical benefits work and what the terms mean, maybe we'd be better equipped to navigate health care systems. In this episode, Kyla talks to us about the questions she asks providers to avoid unnecessary cost, seeking the most cost-effective treatments for herself, and how she manages conversations around the cost of prescription drugs.

When you think of behavioral health and substance use services, you most likely don't think to call your health insurance company. Here's a secret: You can. And you should! Did you know there is a team of people working at your health insurance company who can help link you to in-network resources if you're in need of mental health guidance and support? Registered Nurses, Corrine and Molly share insights on the processes put in place that help members navigate behavioral health and substance use treatment options through the lens of their medical benefit plan.

Helping people become healthy and well is one of Steph's passions. We second that, which is why we invited him to join us to discuss his background story and shed light on how important it is to utilize your benefits properly. At the end of the day, you're paying for these services. Leveraging experience and advocacy can positively impact your health outcomes. Listen up!

High deductible health plans with health savings accounts can feel overwhelming. On one hand, the plan cost is usually less than that of a traditional copay plan but then you remember you may have to lay out a lot of money up front before your plan's copays kick in. Jenelle shares how she started building funds in her HSA a little at a time over time and how she thinks about health care expenses.

You head to the doctor for a routine appointment. A claim is born! In this episode Barb chats with us about a medical claim's journey in the health care delivery system. It isn't always a simple process but having a baseline understanding of how a claim gets processed might help you gain insight into industry timelines and requirements.

Do you want to learn more about the hottest couple in health insurance? Getting familiar with your benefit summary and ID card can help you out in the long run. During this episode we chat with Alicia about benefit summaries, ID cards, and walk through three network-related situations you may find yourself in.

Have you heard any chatter around price transparency tools? The average person spends more time reading Amazon reviews before buying a new blender than they do researching how much it costs to get a mammogram or MRI. Access to price transparency tools finally gives the patient access to the information allowing us to make more informed decisions about care that include the actual cost of it! Imagine having the ability to evaluate medical providers and services based on quality, cost, and location. Join us to learn how these tools function and how it will benefit us as consumers...we also share some caveats you'll want to know.

Is your medical network the same as your plan administrator? Do you know what medical network you use and how to find an in-network provider? Do you have more than one network you can use? In this episode we talk to Todd about how you can answer some of these questions just by looking at your ID card. And once you know what these logos mean, you can have better conversations to guide staff at the point of service to be sure your plan doesn't cause more headaches.

We've got a fever...and the only prescription is more understanding around pharmacy benefits. Are pharmacy benefits different from medical benefits? What's a formulary? How can someone save money by requesting a generic version of a brand name drug (if possible)? Carly loves these topics. She enjoys helping others understand the complex world of pharmacy benefits. And we're so happy she joined us to share insight around this facet of the insurance industry.

New season, new music, new guests and more to learn about medical insurance benefits, ID cards, price transparency tools, and networks. If this sounds like an awful semester of learning, think about it as an investment that will pay you back in spades. Most Americans spend more time researching their vacation than understanding medical plan benefits – and a vacation might happen once or twice a year. Most families use their insurance plan more often than that. Join us to learn what people in the industry know so they get the most out of their benefits.

FSAs are a “sleeper benefit” - in a world where the price of everything seems to be increasing before our eyes – a medical FSA can save you money on items you're buying anyway. The key is, understanding what's eligible so you can take advantage of the savings with as little frustration as possible.

Most members are accustomed to understanding which providers are in-network and out-of-network based on a logo on their insurance ID card. But the marketplace is changing and it's not the same for every plan member anymore. Some benefit plans offer a national network but others may feature a regional network and a wrap network for out-of-area coverage, reference-based pricing (RBP) without any network or direct primary care (DPC). It's important to understand which providers are covered with your plan so you can get the most out of your health care benefits. Regardless of the type of health plan you have, perhaps even more important is the relationship and access you have to a quality primary care physician (PCP).

Have you ever had a medication , benefit or medical visit denied by your plan? Can you appeal a decision? How do you know ? Join us and learn more about what you can do.

This week Jolene and Sara (who is somehow broadcasting from a submarine) are joined by Todd who helps them understand the difference between deductible, copay, coinsurance and out-of-pocket maximum. A deductible is the amount a member must spend out of pocket prior to the insurance plan covering a portion of the expenses. Coinsurance is the portion of the benefit expense the member is responsible for (e.g.: 20% for a service) after the deductible has been met. A copay is a flat fee for service (e.g. $25 for specialist visits). Short story is that coinsurance is a percentage paid for services and a copy is a flat dollar amount paid for services. Your out-of-pocket maximum is always more than your deductible and is inclusive of all plan spend including copays, deductibles, and coinsurance.

You See Your PCP? Yeah, You Know Me! by Nova Healthcare Administrators

Precertification and prior authorization. What is it? When is it needed? Who is responsible for obtaining it? In this episode, Charlene helps Sara and Jolene answers some of these confusing questions and Sara is still talking about the problem with her foot!

Welcome to the Land of Confusion. Pro: Your employer provides a benefit plan that offers a reimbursement account and you want to participate. Con: Sometimes the frustration you experience with the plan makes the benefit feel less beneficial and more problematic. Who needs that? We asked Jerame to come back and talk to us about what happens at the end of a plan year. It's helpful to understand if your plan has rollover or runout and if it includes a grace period.

Little help, please! There is so much to unpack when it comes to deciding if reimbursement benefits are right for you – and which option to choose. Reimbursement benefits offset expenses by setting aside pre-tax funds to pay for account-eligible expenses. FSAs, HSAs, and HRAs have a lot of rules around them that can make a reimbursement account tricky to use. Jolene and Sara are joined by resident-expert Prisilla who helps us figure out what to ask HR or your plan administrator so we can all use our plans better.

Looking for guidance on how to build a benefit plan that works for you and your employees? Listen up! In this bonus episode, Jolene and Sara speak to Niko Caparisos of Prosperity Benefits about building a benefit plan for small businesses. You don't need 1,000 employees to get a plan that works for you.

Life gets real when you welcome a bundle of joy to your world. Part of this new reality also includes assessing health plan coverage and benefits. Pete joined Jolene and Sara to discuss what happens to your benefits when you're planning for a new addition to the family. It's smart to evaluate how you think you'll use your benefits before you pick your plan. And, it's ok to change plans from year to year. As a dad in the industry, he's trodden this well-worn path.

Managing a new diagnosis involves a steep learning curve. Being diagnosed with a chronic condition while pregnant adds a new layer of complexity. And when it all happens at the start of a new plan year...well...we'll let Jamie guide you through that.

Your body, YOUR information! Requesting your medical records, copies of scans, and test results should be a common occurrence. Armed with this information you can save yourself from unnecessary duplication of services. Your records are also a great way to help a provider fill in the gaps between your last visit or when you transition from a different provider. Join Jolene (who reads her blood test results online at 1 a.m.) and Sara, WebMD (who has a scan of her foot in her office drawer) as they chat with Dr. Adnaan Sheriff who shares what he wishes all his patients knew.

If you're between the ages of 18 and 25 or if you're the parent of an 18-25 year old, listen up! Carey helps our listeners figure out if and when younger adults should change benefit plans.

Sara and Jolene promised short episodes and this one runs a little longer but it's worth it. Having conversations around end-of-life planning are not easy and the paperwork that accompanies them doesn't make it any easier. Teresa talks about the documents you'll want to have on hand and she shares why end of life conversations are vital to living. In this episode Teresa references two books: Being Mortal: Medicine and What Matters in the End by Atul Gawande and Elisabeth Kubler-Ross' book On Death & Dying.

When we're at the doctor's office, a lot of information is sometimes thrown at us in a short time. We may have questions but hesitate to ask for various reasons. But asking questions can save you some money. Al Lewis shared so many great tips we just kept recording and the listeners win. Al talks about a product through preTRM.com and about managing ER bills. You can learn more about Quizzify at www.quizzify.com/about

Have you ever considered Silver Diamine Fluoride (SDF) as an alternative to crowns or fillings? There may be a silver lining to Silver Diamine. Listen in to learn about a treatment option to ask your dentist about. Al Lewis of Quizzify joins Sara and Jolene to talk teeth. Visit www.quizzify.com to learn more about Quizzify.

Nurses are a force. They bring skill, compassion, and commitment to their role – whether they're in a medical office, a hospital, or an insurance company. Meet Nick to learn why you might benefit from talking to one.

Abigail shares what prior authorizations are and how to protect yourself. She also lets us know why you're being asked if you have “other insurance” which is referred to COB or Coordination of Benefits in the industry.

Hello, Nurse! In this episode Jolene and Sara talk to a nurse who also has health benefits. Anita shares how she advises patients she talks to during her workday and the importance of advocating for the patient.

Read your medical bills like you would any other bill. Billers and coders are human too. And if you're in a high deductible plan, you become keenly aware of the cost of billed services. And, if you're at a bonfire, don't discuss your medical benefits but do talk about this podcast.

Does your employer offer more than one health plan? Overwhelmed and need some direction? We get it. Listen in as Carey helps guide you through what you need to think about to make the right decision and pick the plan that's best for you and your wallet.

Marisa has worked in the healthcare industry for more than 22 years and she feels really strongly about her Explanation Of Benefits (EOBs) and getting in good with her sister-in-law. Marisa shares why an EOB should be read, even if it's electronic. #gogreen You can follow our podcast on Twitter @UndrTheCoverage

Tune in for some high-level guidance to determine if a high deductible health plan (HDHP) with a Health Savings Account (HSA) is a smart choice. And, if you are a Pearl Jam fan you can sing the episode title to the tune of Jeremy if you'd like!

Every week we interview people who spend their working days focused on health benefits and healthcare we ask them what they know now that they wish every healthcare consumer knew. Buckle your seatbelt. This should be over by the time you get to the grocery store.