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Gone are the days when students could take care of their health
knowing nothing about health insurance and payment. Today,
students need to be familiar with the general concepts of
health insurance and with the type of insurance they have.
While health insurance may seem somewhat confusing to you
(at best) or incomprehensible (at worst), with a little help
and a little effort you can become adept at interpreting and
using your health insurance.
Every Brown student
is required...
- to pay the Health Services Fee (for primary
care), and
- to have health insurance to cover additional
health care expenses. Some students buy the health insurance
plan offered through the University. Students who are already
covered under an insurance plan (owned by the student, a
parent or a spouse) may waive the University-sponsored insurance
plan but not the Health Services Fee.
This document contains..
Why have
insurance?
Be prepared when you
come to Brown!
Paying
the bills
Confidentiality
Prescriptions
Lab
tests
X-rays
Insurance
terminology you need to understand
Information
and assistance at Brown
How
to choose your health insurance
Why
have insurance?
In general, health insurance protects you and
your family against major medical expenses. Paying a fixed
annual amount (premium) to an insurance company guarantees
full or partial payment (coverage) for medical expenses incurred
by you or your family. The details of your policy will tell
you the type of services that are covered, any special exclusions
or restrictions, and what part of the cost you will have to
pay.(1)
Be
prepared when you come to Brown!
Know who your health insurance company is and
have your insurance card with you every time you seek health
care. Carry your insurance ID cards as well as your student
ID card. If you are covered by the University-sponsored plans,
you will be sent a plastic insurance card. If you are covered
by another plan, call the company to get your own card. It
is also a good idea to have a copy of your insurance policy
with you on campus so you can refer to it when needed.
Be sure to give Health Services your most up-to-date
health insurance information. Health Services is your primary
provider; we are not your health insurance company. A student
may be insured under the plan Brown sponsors or may be insured
under a parental or personal plan (e.g., Blue Cross/Blue Shield
of Michigan, SelectCare, Harvard Pilgrim Health Plan, Kaiser-Permanente,
Nebraska Group Health).
Paying
the bills
As the patient, you are responsible for
paying costs that are not covered by the Health Services Fee.
You may bill these costs to your insurance company, to be
paid according to the details of your policy. Bills can be
sent to the student on campus; you must arrange this at the
time the services are provided (e.g., when blood is drawn)
not later. Remember to request that bills be sent to your
box on campus, if that is what you want.
Confidentiality
Insurance companies may send to the policy subscriber
periodic summary statements of payments made. If a parent
is the subscriber, and you are concerned about parental notification
about your health care, you need to know if your insurance
company sends statements of payment, to whom the statements
are sent, and how services are described in the statement;
call your insurance company to find out. If you ask the insurance
company to pay the bills, the subscriber may receive a summary
of payments made, even if you have the bill sent to you on
campus; ask your insurance company. One way to maintain control
of all information related to your health care is to pay the
cost without asking the insurance to cover part or all of
the cost.
Prescriptions
Most prescriptions at UHS cost less than
at a local pharmacy. Your cost for a specific prescription
may change throughout the year as we pay different prices
to get the medication. Many insurance policies have a prescription
co-payment-- the patient pays part, the insurance pays part.
If you have the University plan, please have your insurance
ID card with you when you come to the Pharmacy. This plan
has a co-pay for generic and brand-name prescriptions -- you
pay the copay, the insurance pays the rest. Many of the prescriptions
you purchase at UHS may be less than the copay. If you have
insurance other than the University plan, you may need to
pay the full cost of the prescription at the time of purchase
and then submit a claim to your insurance company to request
reimbursement. Your insurance may or may not pay for prescriptions.
Check your policy. Some insurance companies require you to
purchase your prescriptions at specific pharmacies (participating
pharmacies). Find out ahead of time if your policy has such
restrictions, and confirm with the specific pharmacy when
your order your prescription that they participate in your
insurance plan.
Lab
tests
Most lab tests (e.g., Pap smear, throat culture,
blood work, skin biopsy) are not covered by the Health Services
Fee. Lab samples may be collected at Health Services and forwarded
to an independent lab with whom we contract for laboratory
services. You may be billed for these tests directly or may
choose to submit the bill to your insurance company according
to the terms of your policy. Again, a student needs to make
certain where the bill will be sent, arranging at the time
the service is provided to have the bill sent to their campus
address if desired.
X-Rays
Many x-rays can be provided at Health Services;
some x-rays are not available on site but can be arranged
at a radiology facility in the Providence community. Health
Services or the radiology group will bill you or your insurance;
check your policy for terms of payment for x-rays.
Insurance
terminology you need to understand
Claim
Co-payment
(or Co-pay)
Deductible
Health Services
Fee
HMO
Insurance
company or insurance carrier
Maximum Eligible
Allowance (MEA)
Out-of-Network
Preauthorization
Preexisting
condition
Primary
provider
Provider
Referral
Subscriber
Term
Term limit
Usual and customary
charges
Health
Services Fee
Being seen (examined) by a Health Services provider
is prepaid as part of the Health Services Fee; appointment
or urgent care. Every student is required to pay this fee,
which pays for visits to Health Services, Health Education,
Psychological Services; inpatient services; treatment and
transport by Brown University EMS (transport by any EMS other
than Brown EMS, and costs incurred at the hospital are not
covered by the Health Services Fee). Visits to dermatology
consultant who comes to Health Services is prepaid under the
Health Services Fee; however, lab work ordered by the consultant
(such as examination of skin biopsy) is not covered by the
Fee.
Claim
The written form you submit to the insurance
company to receive payment for health care expenses.
Co-payment
(or Co-pay)
Some insurance requires the patient to
pay a fixed amount (e.g., $10, $25) for a service (e.g., office
visit, prescription, emergency treatment) before the insurance
is applied to the rest of the cost for that service.
Deductible
Some insurance companies require a person
to pay a fixed amount in a year before the health insurance
company starts picking up the bills. For example, an insurance
policy may have a deductible of $400 per year for hospitalization;
thus, if you are hospitalized, you must pay the first $400
of charges before insurance coverage begins.
You also need to know if your insurance covers 100% of costs
after the deductible, or covers something less than 100% after
the deductible. For example, if your plan covers 80% after
a $400 deductible, you must pay the first $400 and then 20%
of costs above $400.
HMO
Health Maintenance Organization. A prepaid,
managed-care, health care provider group providing health
care services for a fixed fee to subscribers in a given geographic
area. (2)
Health
insurance company/carrier
The company that insures you for hospital
stays, surgery, provider visits, immunizations, x-rays, lab
tests, etc. Health insurance policies may or may not cover
mental health care, prescriptions, dental care, eye care and
prescription lenses.
Maximum
Eligible Allowance (MEA)
Sometimes written "our allowance"
on insurance statements, this is the price or charge the insurance
company will allow for a particular service. Providers "in-network"
have agreed to charge this price; providers "out-of-network"
may charge more. If you go "out-of-network", the
insurance company will determine reimbursement based on the
in-network charge not on the price you actually paid. For
example: if the MEA for an in-network office visit is $40
but you go out-of-network and pay $60, the insurance company
will reimburse at 80% of $40 not 80% of $60. If you choose
to go out-of-network, expect to pay more.
Out-of-Network
Your insurance plan may have a list of providers,
labs, pharmacies, x-ray facilities, etc. designated as "in-network"
or affiliated with the plan. Providers not on the list are
"out-of-network". If you choose to obtain services
out-of-network, the insurance will generally pay a lesser
portion of the cost of the service. If you go out-of-network,
be prepared to pay more. See "maximum eligible allowance"
described herein.
Preauthorization
Insurance companies often require that a patient
or provider notify them ahead of time of services desired
(e.g., hospital admissions, surgery, mental health care).
"Ahead of time" may mean 24-hours or several weeks.
The company must pre-approve payment for the services.
Preexisting
condition
Any health condition known to exist before a
contract is made with the insurance company. Health care for
preexisting conditions may not be covered at all until a specified
amount of time has elapsed (e.g., 6 months). Often includes
psychological therapy and treatment.
Primary
Provider
Provider who provides most of your health care;
your family doctor or provider. In this case, Health Services
is your primary provider. You may also select one person in
Health Services to be your preferred provider and see her/him
every time (or almost every time) you come in.
Provider
Doctor, nurse, nurse practitioner, physician
assistant or psychotherapist; lab, clinic, pharmacy, X-ray
facility or hospital.
Referral
When your provider at Brown asks you to or
suggests you visit a provider in order to receive services
not offered at Brown. This is called making a referral. Many
insurance companies require you to see your primary provider
first to determine if your condition requires a specialist.
In a managed-care system, the insurance may not pay for the
services if you refer yourself to a specialist. See co-payment,
out-of-network and maximum eligible allowance described here.
Subscriber
Person named as the owner of the policy. May
be student, parent or spouse.
Term
The period of time the insurance policy is in
effect; usually 12 months. The term of the Brown-sponsored
plan is mid-August to mid-August; check for specific dates.
Term
limit
The most the insurance will pay out for that
specific category of costs in that term. This is an upper
limit set by the insurance company. For example, if your surgery
coverage is 80% of costs with a term limit of $5000, your
insurance company will pay for 80% of any surgery costs you
incur in that term up to $5000. You are responsible for the
other 20% of costs; and after $5000 you are on your own, responsible
for 100% of costs above the term limit.
Usual
and customary charges
Usual and customary (U&C) or reasonable and
customary (R&C) charges are determined according to average
price charged for a given procedure by providers in a particular
geographic area. This is another way insurance companies use
to determine an approved fee for a given medical procedure.
The amount the insurance will pay according to their U&C or
R&C schedule may be less than the actual bill. The patient
is responsible for paying the part of the bill above the company's
U&C allowance.
Information
and assistance at Brown University
Health Services 863-3953; Health
Services Pharmacy 863-7882; Student
Insurance Office ; 863-1703; Psychological
Services 863-3476 for information about using mental health
coverage, call the Brown Psychological Services.
How
to choose your health insurance
Health insurance plans differ according to what
they pay for, how much they pay, etc. When you choose a plan,
you have to consider all of the variables and decide in what
areas you want the most coverage and where you are willing
to take some risks. You also have to decide how much you can
pay for insurance. If you wanted everything covered to the
utmost, the cost of your insurance might exceed your income.
References
(1) Novo Nordisk Pharmaceuticals, Inc. (1991).
Inside Information on Health Insurance.
(2) Rowell, JoAnn C. (1994). Understanding Medical
Insurance: A Step-by-Step Guide.New York: Delmar Publishers
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