Under The Coverage

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.