Decode Your Insurance Coverage

0:00 The topics and opinions expressed on the following show are solely those of the hosts and their guests, and not those of W four WN Radio It's employees or affiliates. We make no recommendations or endorsement for radio show programs, services, or products mentioned on air or on our web. No liability, explicit or implied shall be extended to W four WN Radio It's employees or affiliates. Any questions or common should be directed to those show hosts. Thank you for choosing W four WN Radio. This is Beyond Confidence with your host DV park. Do you want to live a more fulfilling life? Do you want to live your legacy and achieve your personal, professional, and financial goals? Well? Coming up on ZVA Parks Beyond Confidence, you will hear real stories of leaders, entrepreneurs, and achievers who have steps into discomfort, shattered their status quo, and are living the life they want. You will learn how relationships are the key to achieving your aspirations and financial goals.

0:52 Moving your career business forward does not have to happen at the expense of your personal or family life or vice versa. Learn more at www dot Divpork dot com and you can connect with vats contact eds dvpark dot com. This is beyond confidence and now here's your host. W Park A good morning listeners. That's Tuesday and I get to be with you, so thank you for being part of us. And it was Memori Levey Can. I wanna be a tribute to all our fallen heroes and heroes because of whom we have our freedom. So very thankful for their services and for their families as well.

1:40 So we always talk about kindness Circle and the story that I want to share is the story of Johanna, one of our audiences. So what Johanna shared was that she lives in an apartment building and what she found was that a mom had, you know, she had her two year old like down there, and it's like, you know, the mom was apparently on the first floor. So what Johanna said was like, you know what, why don't you bring your baby down first, and I'll watch the baby while your son is playing inside the house, and then bring your son down. So just that little kindness went such a long way and mom was so profusely grateful.

2:36 So just kind of think about it, and of course, you know, you just don't want to jump into help because people can take it another way. So just kind of ask them and said, okay, and I'm your neighbor, you know, identify yourself. And that's what Johanna did. So thank you Johanna for keeping it going. For those of you who have got our books, we thank you because partial profits go to keep it our organ For those who have not got our books, get the books, any of the books that we have written. Entrepreneurs got in expert to influencer, your masterpiece and actually my another book will be coming out this year, so very excited about it.

3:17 Get it and help us spread the message. And let's welcome our guests. Welcome Monica, Welcome Joanna. Thank you. It's nice to bear with you. Oh it's wonderful to have y'all, so share it with us. If you'll recall any times from your childhood or youth when somebody left or it was just an incident like that left to positive. Mark on you, well, that is a very broad question. I would say that. Maybe not from just from childhood, but I think that in my career there have been many times in doing the work that I've been doing where people actually took the time to share the impact that it had on them, and I think that that.

4:17 Is incredibly rewarding in the work. That we do. But it also helps drive you. And it also helped give me perspective on the challenges that people that other people are experiencing. So it gives me perspective on my own life and how fortunate I am in many ways. Absolutely, how about you, Monica, I. Would certainly go what Joanna just shared. I will also say that through my professional life, I have had the absolute honor to work with some incredibly brilliant and hard working women, and a couple of those women really took the time to mentor me and to support me as I began my career, and that really showed me that the power of community can mean so many different things. And in that specific instance, you know, the community of strong, intelligent, driven women can really lift each other up and they can just do incredible things in life.

5:27 So, Joanna, what got you into becoming a lawyer? Well, I have to admit that when I went to law school, I knew that I didn't want to be a. Litigator or be in the courtroom. I really found that there was power in the law that it creates the systems that we have to navigate and has an impact on our daily lives. And so I really wanted to be able to engage in the policy aspects of being a lawyer and being able to shape laws in a way that have a positive impact on our society.

6:13 And how did you get involved in that? Well, I went to law school thinking that I wanted to do that on an international level. I was an international relations major in undergrad but then when I got. To law school, I found that there were a lot. Of places in our domestic policy that could be improved, and so I did an internship. Well, I was in law school that focused on providing services to people with disabilities and cancer and that is really what led me down the path to my current career.

6:58 So it wasn't planned, but. It found Well, that's how life is. So many times we have plans and life takes a detour and sometimes we don't know. And that's the beauty of every day and it's a beautiful gift that we all have. Someone is go about you, how did you get into the career. Well, I'm sorry for the technical difficulties, but I too had a windy path towards becoming a cancer rights attorney. I went to law school knowing that I wanted to have. An understanding of how everyday.

7:40 People could use the law to improve society, and so I started off working in Congress in trying to shape do my small part in shaping public policy and laws that would really uplift the lives of day Americans. Personal reasons had me leaving Washington, d C. And then I really struggled to find a career where I could use my knowledge of both policy and how laws were made and implemented, but in a really tangible way help a community. And thankfully, through Joanna's support, that led me to the cancer community and I've been here ever since.

8:26 So how did you get together? So? Monica and I are actually sisters, so people know us in the cancer community as sisters, but we effectively grew up in a healthcare community. Our parents are both doctors and worked in the oncology space and gave us. Perspective and an introduction. To the challenges that patients and caregivers experience when diagnosed with sterious medical condition. So so many times what happens to Joanna is that you know you're working in the corporations, the daily conundrums and the daily humdown of life, and then all of a sudden, I mean, of course there are pressures. You know that you may have kids, you may not have kids, doesn't matter whether you're single or spouse or in partnership, wherever you are at, just that daily pressures are enough as it is, and then all of a sudden, any life threatening illness or cancer like immune and it's it is so traumatic in itself. So now you're in that situation or one of your loved ones is in that situation.

9:47 So initially, like you know, I've heard stories from my clients. They've said that, you know, the bosses, everybody's been very supportive, but that support kind of seems to keep on drying up if it lingers around long. And these are like, you know, long driven illnesses. So tell us, like, you know, how can people get through all of that? There are laws that do provide protections related to employment, both for employees who are diagnosed with serious medical conditions like cancer, but also for caregivers. But there are also employer policies that provide additional benefits and protections that can be supportive. And so when we're talking about employment, we're also trying to teach employers about the ways that they can support their employees dealing with chronic or serious medical conditions, because at the end of the day, employers want to keep valued employees, and so we have to remember that employers and employees they have a mutually beneficial relationship, and there's value in creating an environment that.

10:59 Supports both the needs of both. And so while we are generally teaching employees about their rights, we also try to teach employers about what their legal responsibilities are under the law, but also ways to proactively try to support employees in those situations. But I fully realize that that is easier said than done, and we see the full spectrum of employee experience. So we see employees who have really supportive employers throughout their. Health condition experience. But then we also, unfortunately see the downsides of when employers.

11:42 Don't understand their legal obligations or are less concerned with supporting their employees. So let's say, let's begin with an employer, what can they already put in place so if something like this happens to prepared for it well. From an employee perspective, I think the most important thing is to understand your rights and where the laws do and don't apply to. Excuse me, they're specific employer. So every law that we talk about actually applies to different types of employers. So if you're looking for protection under the Family and Medical Leave Act, for example, which is a federal law, it only applies to private employers with fifty or more employees, or to state, local, or federal government employees. So if you know that that's a benefit that you want to have access to, if you're looking to work for a smaller employer that might not be the right fit for you, or understanding what additional benefits that smaller employer might be willing to provide even though they're not legally required to do it. So you can be strategic in looking for employment opportunities.

12:59 But in order to do that, you have to kind of understand the laws that would be helpful to. You in dealing with a chronic or serious medical condition and then look for employers that are actually bound by those laws. The same thing is true though when you're looking at benefits, so looking at employer health insurance benefits, for example, if you know that you have a chronic or serious medical condition, making sure that you have access to quality health insurance coverage is key. We sometimes assume that all employers have the same health insurance coverage or it's going to be good health insurance coverage because it's being provided by an employer, and that might not be true.

13:43 So understanding how to look at those options and figure out if it's going to meet your needs is also something that employees can proactively do when looking at employment opportunities. Yeah, no, that's definitely because that is the time they can negotiate and they can make the decisions. You know, which company to even look for. So as you mentioned that, if you have that, you also talked about insurance. So there's so many different types of insurances. So let's kind of explore, like, you know, a couple of options. One is insurance given by the companies. One is there are a lot of contractors a lot of entrepreneurs, So in both situations, what options they can consider and what they can go with.

14:33 For individuals who aren't working for an employer that is going to offer them benefit, there are specific options available and so then it might come down to where you live and your income level. But generally speaking, if you're not taking those two things into consideration. There are private health insurance plans that are offered through state health insurance marketplaces. So those marketplaces are often called exchanges or sometimes people call them ACA plans or Obamacare plans, but effectively, the government created a shopping mall for health insurance coverage called marketplace, and in going to the marketplace, you can find all of the private health insurance plans that are offered to you in your state that also have to provide some consumer protections, and depending on your income level, you might qualify for financial help to actually buy your health insurance plan or to lower some of your out of pocket costs.

15:38 So depending on your employment, if you're in contract employment, or you're an entrepreneur, or even in some gig jobs, those are all times where you might not have access to employer sponsored insurance and you could look at the marketplace to see what health insurance options are available to you. And then depending on your state and your income level, you might also qualify for medicaid in your state. Yeah, these are some very important points in your experience. Are there any criterias that people need to keep in mind as they're making their selections. I think there are definitely some key things that we want people to understand when looking at their insurance options.

16:23 I would say there are three key things. The first is make sure you know all of your options, because you can't effectively compare your options and pick the best plan for you if you actually don't know. What all of your options are. And I think that's true of somebody who's shopping in the marketplace, but it's also true if somebody's getting different choices from an employer. So if your employer gives you three options for insurance, that's also an opportunity to actually compare your options. The second piece is, once you know your options, how do you compare them? And you do that by making. Sure that you're looking at the cost that you're looking at whether or not it actually covers your providers and your prescription drugs. So if you pick a plan that doesn't cover the doctors and the hospitals and the pharmacies that you go to or the prescription drugs that you take, it's a pretty ineffective plan for you. And so comparing those three things are going to help make sure that you're picking the best plan for you. The third thing that you have to do is to actually do the math because most people are only picking a health insurance plan by looking at the monthly premium, but that is only one small piece of the cost of health insurance coverage.

17:42 If you're dealing with a chronic or a serious medical condition, the chances. Are you're going to have a lot of. Out of pocket expenses because when you're using healthcare, you have to pay those out of pocket costs like copays and co insurance amounts. So what most people don't realize is that there's something called an out of pocket maximum, and that is a cap on how much you have to pay out of pocket each year, and when you reach that cap, your. Insurance will kick in at one hundred percent for the rest of the year. So you could have a one thousand dollars out of pocket maximum, or you could have a ten thousand dollars out. Of pocket maximum, depending on the plant.

18:25 And so when you have a chronic or serious medical condition, you want to take into consideration not just the monthly premium, but. The out of pocket maximum. So we have a pretty easy math formula to help people figure it out. You just take the monthly premium and you multiply it by twelve, because that's how much it's going to cost you to have the plan for the year, and then you add that to the out of pocket maximum, which is the most that you'll pay out of pocket for the year for your medical expenses, and that's going to give you the real cost of not just having insurance for the year, but also what you would pay out of pocket for your care, and that's the most that you would pay. So in doing that math, you can easily figure out which plan is going to actually cost you the most or the least by the end of the year.

19:12 And that is really key in the work that. We do because most people are going to hit their out of pocket maximum if they have a chronic or serious medical commission right now. That's definitely a great point to consider. And also some of the plans having being through the Ringers myself and with some of my clients is that there is another catch if you can elaborate on that, like sometimes that out of pocket can be just for individual or for family. That's true, so you also have to understand how the out of pocket maximum works for your specific plan. So if we're talking about marketplace plans, those marketplace plans are actually the most protective from a consumer standpoint, because it requires those plans to include to the out of pocket in the out of pocket maximum, your copays, your deductibles, co insurance amounts that you pay both for your medical care and for your prescription drugs.

20:11 So everything gets to help you meet your out of pocket maximum. Employer plans are allowed to carve things out, so they might say, we are going to not include the deductible in your out of pocket maximum, so you have to pay both your deductible and then you have to also meet your out of pocket maximum. Or some will say we're not going to include your deductible or your co payments, We're only going to include co insurance amounts in your deductible. And then some. Employer plans will say, well, we're going to give you a separate out of pocket maximum for your prescription drugs, So you not only have to meet an out of pocket maximum for your general medical care like office visits or hospitalizations, but you also have an out of.

20:54 Pocket maximum for prescription drugs. So understanding how yours specific plan it deals with out of pocket maximums is key. To understanding it. It's also key to understanding how to do the math, because if you have two separate out of pocket maximums for prescription drugs and for medical care. You have to add those things together plus the premiums. And then if you do have a family plan, you not only have your individual out of pocket maximum, you also have a family. Out of pocket maximum. That is only really helpful if you have more than two people on your family plan because generally the way that it works is once two people on the plan meet their out of pocket maximum, the family out of pocket maximum is also met, So that means anybody else on the family plan for the rest of the year could basically get.

21:47 Free access to medical care. So that's not helpful if you only have two people on the plan because you still have to meet your own out of pocket maximums. Yeah, and that's really good for nation. So now, okay, you've gone through looked at your options, and you've decided on your medical coverage, and like you know, the years are going through and sometimes you know the transitions. It could be people are changing jobs, people could be moving. There are some family changes, like you know, you'll get married or retired or getting eligible for many cares, so there's so different things. How can people navigate those changes?

22:33 Unfortunately, picking a health insurance plan is not a one time chore for us to engage in, so. We think we've picked the best plan. Unfortunately, every single year those plan options change, the costs change with the cover change, the networks of providers change, So every single year, even if we're getting coverage through an employer, we should still be looking at our insurance options and making sure it still covers the things we need it to cover, and looking at that math to see which is most cost effective. But when you're. Trying to deal with changes in your other circumstances, if you're moving, then that adds an additional layer of complication because if you're moving even zip codes, so not even if you're moving out of state, but if you're moving zip codes, that might change your insurance options. So if you're changing if you have a marketplace plan and you change zip codes, the plan you have right now might not be available in that new zip code.

23:37 Same thing if you're moving states. If you're moving states, you definitely want to take. A look at the new state's marketplace plans. But that's almost a true of employer plans. So if you are. Living in one state and maybe you're a remote worker, if you move to a new state, you want to make sure that whatever health insurance plan your employer provid you is going to cover you if you go to providers in that new state, So you have to actually pay attention to make sure. Some employer plans have national. Networks of providers, so that isn't a problem. But if your employer offers you an HMO, that's generally going to come with a limited network of providers that is geographically specific, So making sure that you can still use that plan is part of that analysis. If you're thinking about retiring and you haven't yet turned sixty five, then you're going to be looking at the marketplace and then, depending on your income level, medicaid.

24:41 So the marketplace is. Really a place where we're seeing a lot more movement because we do see a lot of people in entrepreneur roles and contract work and in a gig economy, many more people are using the marketplace, but also because many employers are offering health insurance coverage, so it provides that additional way to get access to insurance if somebody has turned sixty five and is eligible for Medicare. Medicare is incredibly complicated, so trying to understand how you actually make good Medicare decisions is very difficult for the average person.

25:24 I mean, I have a law degree and I do this work on a daily basis. And Medicare stumps us all the time. Because there's so much nuance to the way that it gets implemented. But on a very kind of basic introduction to Medicare, there's generally two lanes that people can drive down to get access to Medicare coverage. You can either. Get what's called traditional Medicare, which is basically fee for service. You can go to any provider across the country who accepts Medicare. But then you can also. Get access to your Medicare benefits through a managed care plan, which is sold by a private insurance company and has a specific network of providers that you go to and is usually geographically specific to where you live.

26:10 So when you make. Those initial choices about Medicare, there are pros and cons to each lane, and you have to figure out which is really going to be. The best for you. So, talking about Medicare, there you know so many people and who are retiring, and especially the baby boomers and all that you know. As they were saying, I think so I don't know where I read that. How many millions of people are going to be toning sixty five and retiring or whatever looking for the Medicare. So do you have any resources or options that can help people or do you help people across the whole you know, United States or is it different for different states?

26:57 We do so Medicare options, depending on kind of which lane you're choosing to drive down. Are going to be specific to where you live. So at Stratage Cancer we have a lot of resources to help people navigate Medicare. We also have a program called Triage Health, which is for anyone trying to navigate healthcare related issues like trying to figure out what your health insurance options are. So at triageealth dot org if somebody wants to learn about Medicare. We actually have a Medicare Topics. Page where there are guides to help people understand the different types of Medicare options. We have a worksheet to help people do the math to make their Medicare choices.

27:41 We even have some animated videos to explain that some of the key aspects of Medicare. But we do also have recorded and live events to help educate people on their Medicare choices. So really they're getting access to the care that they need and not experiencing the financial burden that can come along with. A serious medical condition. That's fantastic. You know, you're doing some great work out there. So now, coming back to the original scenario that we had talked about, somebody's in the corporation, all of a sudden they find out that, you know, they are experiencing life threatening disease, and it could be anything as you had mentioned earlier, cancer or otherwise, what's their best choice?

28:30 I mean, you know, they are so bogged down during that time, So how can they keep their cool and what are some of the steps that they can take to ensure that they are aware of their rights and also, like you know, ensuring that they're forming that partnership with the employer to kind of work through this hard time. I think dealing with work and a serious medical condition and making decisions about what to do next involves a lot of factors. It might be about somebody's work environment and whether or not they feel comfortable disclosing if they have a supportive work environment.

29:16 It could be about the size of their employer. And what laws and legal protections they have access to. It could be about benefits they have access to. It could also just be a very personal decision about whether or not somebody wants to focus on their health or try to balance work and their health. So there's a. Lot of pieces that go into those types of decisions, but. I think really at the core of. It is understanding how your medical condition is going to impact you and your ability to do your job. There are certainly types of medical conditions and types of jobs, and those medical conditions are going to prevent so from doing their job. But at Triash Cancer, our goal is to help people understand what their goals are and then how do we help someone meet their goals. So, if their goals are to stay at work, Understanding how the Americans the Disabilities Act provide someone access to accommodations so that they can get help in doing their job or even returning to work, if it's about taking time off, if that's their goal, Understanding how the ADA and the FMLA provides those legal.

30:31 Protections to be able to do that. Maybe somebody has access to state disability insurance options and that makes it easier for someone to decide to take time off work or not so the decisions around what to do next, I think are really rooted in figuring out what your goals are with work, and then how you can meet those goals using the laws and protections and benefits and programs that are available to help you do that. And that's really the core of what we do at Triage Cancer is helping people understand what those laws are and what their options are so that people can make the best.

31:11 Decision for them. And just like you had shed, like you know, there were like two to three points people could keep in mind as they were going and looking for different options for the insurance. Are there any key points that people need to keep in mind as they're making these decisions? I would say the first is talk to your healthcare team. So if you haven't yet maybe started treatment, and you're not sure how your medical condition is going to impact you, or even if you've just started, what the long term implications of that could look like. But talking to. Your healthcare team and understanding how your medical condition is going to impact you and the treatment.

31:52 That you're going through. The second piece is understanding what your rights are, and then three figuring out what. Is important to you, What are your goals. So if your goals are to stay at work and to stay in your career, and you know, some people actually like their jobs and that's where they find their support system, and so it is sometimes very important for people to stay at work. Other people that is less important, and they're more focused about how can they take the time off. To focus on their health. So figuring out you know, how your health is being impacted, your rights, and then your goals I think would be the first three things to do. And then sorting through that information is actually why we came to our organizational name.

32:37 The action of triaging through that information and then figuring out what needs to be dealt with first and what can be waiting until later. And what can people do if insurance denies coverage to them. I think this is something that we see a lot. We're seeing it in the news, discussions around how health insurance companies are denying coverage for care and or denying coverage for prior authorizations to get access to care. And unfortunately, we know that most people take no for an answer, and that is really unfortunate because we know, based on data that when somebody is denied a coverage for care ninety nine point nine percent of the time, they're not appealing even to the first level of appeal. So even though we hear about appeals in the work that we do, very few people are actually taking advantage of that consumer protection where you not only have a right to appeal that insurance company's decision if they say no, and you have a private insurance plan, like through an employer or an individual plan, you can go outside the insurance company to an independent entity, to what's called an external medical review or an independent medical review, and they decide whether or not the care that you've been prescribed by your healthcare team is medically necessary. And if they decide that

34:08 it is, that decision is binding on the insurance company they have to cover it. And we know based on data that about on average fifty percent of the time patients are successful when they go through that external appeal. So if ninety nine point nine percent of people are taking no for an answer, but if they got to the external appeal stage, they would actually win their appeal fifty percent of the time, that's a lot of people who That is a lot to how long here. That people can receive Yeah, and really that. God, what that translates to is that people either aren't getting care that their healthcare team prescribed or they're paying for it out of pocket. So that just contributes to the financial burden if they're paying for something out of pocket that their insurance company should have covered.

35:01 Right, Yeah, and I'm assuming that you help out with that as well. We do. So your ability to appeal depends on the type of insurance that you have, but across all types of insurance you have the right to appeal. It's just that the details of how you actually go about doing that are different based on the different types of insurance that are available, whether it's an employer plan or Medicaid or Medicare or maybe even VA Healthcare. So the process is different based on the plan. Absolutely, So quick question for you, given all of this, this is very very important topic that you brought it up.

35:47 Thank you for that. How can people connect with you and Monica? How can access the Initially it's strategicancer dot org. Outside of that, like you know, just reach out to you through your website or any other venues. Yes, absolutely, you can visit triage cancer dot org or Triage health dot org and you will find a plethora of information about a variety of different topics that come up when navigating healthcare, whether it be health internt GO, our employment issues, or disability insurance, but also finances and consumer rights and managing medical bills or maybe estate planning documents and medical decision making documents like advanced healthcare directives.

36:35 We provide information about all of. Those legal issues that are also state specific, and then if somebody would like to learn more, they can attend our free educational events, which they can sign up for on our website. And then we also have a free legal and financial navigation program where we will answer people's one. On one questions. So if somebody was going through of those healthcare transitions or is newly eligible for Medicare and isn't sure how to make the right decision, we can help someone understand their options so that they can make the best decisions for them. Absolutely. And if also y'all have written a book, correct.

37:20 We have. So Monica and I have both taught law school classes on cancer rights law and there wasn't a book. So teaching a law school class without a book is a lot of work because we have to compile the readings for each class. So seeing that gap in the literature. We actually co. Wrote cancer rights Law that was published by the American Bar Association, so that not only we can use the book in class, but that. Others can as well. But we also wrote it in a way that it's interdisciplinary, so healthcare professionals can also use this information to support patients and caregivers, but also advocates and others who just want to understand their rights in many of those areas I mentioned are covered in that book.

38:16 Any last thoughts you would like to share, I would just encourage people to understand what their options are even if you're not dealing with the serious medical condition. One of the reasons we created Triage Health was to try to help people understand these issues before they need it, so that they have a good health insurance plan so that if they are diagnosed with a serious medical condition, they're already prepared and certainly to understand what your employment rights are because in looking at job opportunities, you can take that information into consideration when making employment choices as well.

38:56 Very powerful, Well, thank you for joining us and share hearing all these details, and like you know, Joanna and Monica Yola doing such great work, so thank you for doing it. And keep helping people and so listeners, I pray to God that none of you have to face any of these, but if you do, you know where to go. You know, definitely check out their website and our prayers and thoughts would be with you through the tough times. So thank you for being part of our show, and be careful you. We want you to have happy, healthy life and that also means good healthy financial life as well, So take care of yourself and also want thank you for making the show technically possible. Until next time, be well and take care.

39:58 Thank you for being part of Beyond With your host v Park, we hope you have learned more about how to start living the life you want. Each week on Beyond Confidence, you hear stories of real people who've experienced growth by overcoming their fears and building meaningful relationships. During Beyond Confidence, Dvpark shares what happened to her when she stepped out of her comfort zone to work directly with people across the globe. She not only coaches people how to form hard connections, but also transform relationships to mutually beneficial partnerships as they strive to live the life they want. If you are ready to live the life you want and leverage your strengths. Learn more at www dot dwpark dot com, and you can connect with vat contact at dvpark dot com. We look forward to you joining us next week