Under The Coverage

Your mental health matters - and knowing your benefits is the first step toward getting the right care and support. In this episode of Under the Coverage, we break down common mental health benefits, including therapy coverage, Employee Assistance Programs (EAPs), and what to expect when accessing care through your workplace. We also share resources for immediate support: -Visit 988lifeline.org or call/text 988 to connect with the Suicide and Crisis Lifeline. -Explore tools and links at samhsa.gov or call 1-800-622-HELP (4357). -Learn more at mhanational.org from Mental Health America. -Contact the National Alliance on Mental Illness (NAMI) at 1-800-950-NAMI (6264) or visit nami.org/help

Isn’t preventive care supposed to be free? Then why did you get a bill after your screening? In this episode, we explain the difference between preventive and diagnostic care, and why asking one extra question at your checkup might change what ends up on your bill. Learn what to ask your provider so you’re not caught off guard.

Ever get a bill in the mail and wonder if it’s actually a bill? Enter the Explanation of Benefits (EOB). In this episode, we'll review what an EOB is and what it tells you about your care and costs. You’ll also learn what steps to take if something doesn’t look right.

Still confused by the difference between a deductible, copay, and coinsurance? You’re not alone. In this episode, we break down the health insurance terms that show up on nearly every benefit plan. We’re here to help you figure out what you’re spending where so you can make the best decision for you and your wallet. If you’re looking for even more information, check out our previous episode: https://youtu.be/47bJ6iU97jI?feature=shared

You always hear that you need to look for an in-network provider but do you really know why? In this episode, we explain how provider networks work, why staying in-network can save you money and how to identify what your costs might be if you choose to see an out-of-network provider.

Wondering how to use an HSA or FSA—or decide which one is better? In this episode, we break down the rules, tax savings, and pros and cons of each so you can take advantage of these powerful benefits.

Trying to figure out which health plan is best for you? In this episode, we break down the key differences between copay-based plans and high-deductible health plans (HDHPs), and explain how provider networks can impact your choices. Whether you’re comparing premiums, thinking about out-of-pocket costs, or wondering which plan fits your lifestyle, we’ll give you the tools to make a smarter, more confident decision this enrollment season.

It’s that time of year again, open enrollment season! If you (or your spouse) are the subscriber for your health insurance, chances are you’ll be hearing from your HR team soon with reminders to review your benefits. But did you know there are also certain life events, like getting married, having a baby, or changing jobs, that let you make changes to your coverage outside of the open enrollment window? In this episode, we break down the basics of choosing and updating your benefits, so you feel confident about your options when it matters most. Want more? Check out our earlier conversation with Carey about what happens when you age off your parent’s health plan: https://www.youtube.com/watch?v=T3xP8x5zjBw&list=PL78gefbzNivQBmnlgBkdyo_mL9KP3nz6G&index=38.

🚑 Ever wondered why a quick trip to the ER or a ride in an ambulance can lead to a shocking bill in your mailbox? In this episode, we break down everything you need to know about emergency services and the costs that come with them. From understanding when to dial 911, to the hidden fees that could catch you off guard, we’ve got you covered. We’ll also dive into the No Surprises Act—what it protects you from, and where it falls short—especially when it comes to those pricey ambulance rides. Whether you're trying to avoid financial surprises in an emergency or just want to be better prepared, this episode is a must-listen. Tune in and take control of your health care costs before the unexpected happens! 🔑 Episode Highlights: - When to Use Emergency Services: Clear guidance on when to head to the ER vs. seeking care elsewhere. - Breaking Down Costs: A look at the fees you can incur - The No Surprises Act: What it covers, what it doesn’t, and how it impacts your emergency bills. - Avoiding Financial Shocks: Tips on how to protect yourself from unexpected charges in an emergency. - Advocating for Yourself: Practical advice on negotiating bills and ensuring you’re only paying for what you need. - Join us for a crash course in understanding emergency care costs—before you're faced with the bill! 🚑💡 Subscribe now and never miss an episode of health benefits know-how!

🩺Ever been faced with a scary, serious health situation and felt overwhelmed and unsure of where to turn for help? In this moving episode, we hear from Allison, a former patient whose life was profoundly impacted by the care and support provided by one of Nova's case management nurses. Allison recounts her journey, starting from the surprise of learning she was pregnant with twins to navigating a complicated pregnancy, serious health condition of one of her babies, and insurance challenges while out of state for specialized care. 🚼 🔑Episode highlights include: - The role of nurses in health insurance - How to stay organized and proactive to help better manage care - The importance of mental health and well-being when dealing with serious health diagnoses Allison shares her deep gratitude for the support she received, including nominating her case manager for a regional excellence award, which she won. The episode beautifully highlights how a compassionate case manager can make all the difference during medical crises. Tune in to hear about how the unique benefits of having knowledgeable nurses from the insurance side involved in the process, and how their understanding of both medical and insurance landscapes can play an instrumental role in guiding you through your most stressful health situations. 🎧

🩺 Ready to take control of your health? Join Jolene and Sara for a quick, fun, acronym-filled dive into the world of preventive services, zero dollar copays and the ACIF and USPSTF! In this short episode, you'll learn why preventive care is essential and how the Affordable Care Act (ACA) guides your zero copay benefits. We'll cover: - Who is the USPSTF and the ACIP? - What’s considered preventive - Key screenings, counseling, vaccines and medications you should know about. - How the Affordable Care Act (ACA) helps cover these preventive services. Tune in to get the scoop on keeping healthy, making informed choices, and ensuring you’re getting the preventive services you need—all with a smile and a bit of fun! Don’t miss out—hit play now and start your journey to better health! 🎧✨ Links to learn more: Looking for quick access to the USPSTF A&B Recommendations? https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations Find ACIP recommendations and guidelines for vaccines https://www.cdc.gov/vaccines/?CDC_AAref_Val=https://www.cdc.gov/vaccines/hcp/acip-recs/index.html#print Understanding the ACIP & How Vaccine Recommendations are Made in the US https://www.youtube.com/watch?v=WWf4xVw1-PE

💸 Ever wonder why your medical benefits cost an arm and a leg? Join Jolene and Sara in this short and lively episode as they dive into the reasons behind the high price tags on insurance premiums in the United States. This episode unpacks: • The average annual cost of coverage in the United States. • The pros and cons of cutting-edge treatments and pricey new drugs. • The role of chronic diseases and an aging population in driving up costs. Get ready for a quick, engaging, and informative discussion that makes sense of the dollars and cents behind your medical benefits. Hit play to become a smarter healthcare consumer! Subscribe now and never miss an episode of healthcare know-how! 🎧💡

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. 🎧💡

🏥 Whether it’s you or a loved one in the hospital you know that going home is a great relief, but it can also be worrisome. It can be a challenge to absorb and remember all the notes you get before discharge. You can call the doctor’s office, but you might also get a phone call from a nurse at your insurance company. Have you ever wondered why they’re calling? Jolene and Sara are here to uncover the secrets with two industry experts! In this engaging and informative episode, we dive into the world of inpatient hospitalization and the critical role nurses play in keeping patients from bouncing back into the hospital. Join us for a lively conversation where Jolene and Sara talk to the experts to discuss: • Common challenges faced during the transition from hospital to home. • Why that post-discharge call from a nurse is a game-changer. • How nurses can help prevent costly readmissions. Get ready for a fun, quick, and eye-opening discussion that highlights the power of post-hospital care and how a simple phone call can make all the difference. Hit play and discover how to make the most of your recovery journey! Subscribe now and never miss out on these essential healthcare insights! 🎧💡

🏥 Ever wonder what exactly counts as Durable Medical Equipment (DME), a prosthetic, or an appliance? Join Jolene and Sara in this quick and lively episode as they team up with registered nurses Lorene and Stefanie to demystify these categories of medical devices. Our expert panel will break down the key differences, helping you understand what your plan covers and how to navigate your healthcare options like a pro. 🔑 Episode Highlights: • DME: Durable, reusable medical equipment for home use. • Prosthetics: Custom-made devices to replace missing body parts. • Appliances: Supportive devices that improve body function or stability. Get the lowdown on what makes each category unique and how to ensure you're covered. From wheelchairs to hearing aids, we’ve got the info you need to make informed decisions about your health care. Tune in for a quick, fun, and informative session that turns complex medical jargon into clear, actionable insights. Hit play and become the master of your medical benefits today! 🎧💡 Subscribe now and never miss an episode of healthcare know-how!

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. 🌟 **Highlights:** - What are out-of-network benefits and why should you care? - Step-by-step guide to finding out if you have these benefits. - Tips and tricks for using your network when you go out-of-network. - Real-life scenarios and expert advice to make you an insurance savvy superstar. Don't miss out—hit play and empower yourself with knowledge that could save you time, money, and stress. Because understanding your health insurance shouldn’t be a headache, it should be your superpower! 💪✨ Subscribe now and stay tuned for more quick and easy tips to master your health and wellness!

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. 🔑 Episode Highlights: • Discover why understanding insurance terms can be your secret weapon. • Learn how to ask the right questions to get the most out of your plan. • Real-life examples of how Jolene and Sara have used their knowledge to save money • Access our handy Glossary of Terms for quick reference anytime: Glossary of Benefit Plan Terms. Join us for a fun, fast, and informative episode that proves insurance doesn’t have to be dull. In one brief episode, you’ll be empowered with knowledge that can make a real difference in your everyday life. Who knew insurance could be so empowering? Hit play, and let Jolene and Sara guide you through the jargon jungle to become your own best advocate. Subscribe now and never miss a moment of money-saving wisdom! 💡💰 Tune in and transform the way you think about insurance—because a little knowledge goes a long way!

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! 💌🔍 Subscribe now and empower yourself with knowledge in every episode!

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.