Benefits

When will my coverage become effective under the policy?

Some plans have voluntary enrollment. Coverage under these plans usually becomes effective on the effective date of the policy, or the post mark date of premium payment, whichever is later. Some colleges have mandatory or waiver enrollment requirements and coverage under these programs is often made effective on the effective date of the policy. The college usually makes the policy effective on the first day residence halls are open to students. Your insurance identification card will list the beginning and ending dates of coverage.

Will I be notified that my premium has been received?

Yes. Soon (one to two weeks) after we receive your enrollment information an insurance identification card will be sent to you. Remember, if the college is involved in the enrollment process (for example on waiver enrollment programs), the college may not be able to notify our office as to who is insured until after the academic enrollment process is complete.

Do I need to be referred by my Student Health Service or Infirmary in order to file a claim against the plan?

It is always recommended that you first seek treatment at your health service when practical. They have your medical records, provide many services free-of-charge, and have practical knowledge of the local medical community. Some plans do require that you first be treated at the health service. Your brochure and student handbook will provide specific information.

What type of medical expenses are covered by the policy?

Usually those that are medically necessary, that do not exceed reasonable & customary charges, and that are not specifically excluded in the policy

What is a Benefit Period versus a Contract Year provision in the policy?

A benefit period is the period of time that medical expenses will be considered under the policy following the date of an accident or commencement of a sickness typically 52 weeks. A policy with a contract year will pay expenses on a covered condition only while coverage is in-force.

If I do not enroll in the student insurance plan during the open enrollment period at the beginning of the year, can I enroll later?

As a general rule you have only one opportunity to enroll at the beginning of the fall semester, or at the beginning of the spring semester if that is when you first enter the college. There are exceptions so please ask us for a decision concerning your specific situation.

Plans say they pay for Usual, Customary & Reasonable (UCR) or Reasonable & Customary (R&C) charges. What does UCR or R&C mean and how is it determined?

UCR and R&C are interchangeable terms. They refer to a method by which the insurance industry determines what most providers charge for a specific service in a specific area of the country. These standards are developed based on actual charges and are updated constantly based on current pricing.

Claims

What if a condition exceeds the benefit period or maximum amount payable?

No more benefits are payable for that condition. However, most policies offer options to apply for coverage that would provide additional benefits (these benefits must be in-force prior to the commencement of the condition).

When an expense is incurred, do I pay the medical provider or does the insurance company?

It is common for a hospital to bill your Claims Administrator but many private physicians require payment at the time of treatment. If you pay a medical bill, submit the paid receipt to the company with the itemized bill and any payment due will be sent to you; otherwise, payment is made to the provider.

If I have family insurance in addition to my student insurance and incur a medical expense, with which company should I file the claim first?

This can vary, but in general we suggest that charges first be submitted to family insurance and submit any outstanding balances against the student insurance. If so, we suggest that you complete a student insurance claim form and indicate that the bill has been submitted to your family insurance (this way the Claims Administrator is ready to receive your balance due statements).

Doctors

Can I see any doctor I want?

That depends. If you have a “PPO” plan you can see any doctor that you want, however you will find that the plan will pay more for healthcare providers who are in your PPO Network.

What is a Preferred Provider Organization (PPO) Network?

A PPO is a group of independent doctors, hospitals and health care professionals organized into a network for the purpose of delivering quality health care at affordable prices. PPO’s should not be confused with Health Maintenance Organizations (HMO). Very simply stated, an HMO is a group of medical providers controlled by a common employer. An HMO requires that all of your care be managed by an appointed primary care gatekeeper. A PPO is a group of independent medical providers affiliated simply by a common agreement to discount the price of their services to individuals insured under specified insurance policies.

Do all student insurance plans involve PPO Networks?

No. If your plan refers to in-network and out-of-network benefits, then it includes a PPO Network. PPO-type plans may provide substantially higher benefit levels, with substantially lower out-of-pocket expenses than do plans that do not involve PPO’s.

Are PPO Network providers just located in the area around my college campus?

No. Your PPO has both a strong local presence and national representation. While most of your care is expected to be in the area of the college, we also know you may need medical attention when you are at home or traveling.

How do I find a PPO Network physician or hospital?

here are usually a variety of sources to obtain information about who is a Network approved provider. Visit the Health Insurance Plan Details section of this site, where we include links to the appropriate PPO Network. There is a toll-free phone number listed on your insurance brochure and insurance identification card. The best, most up-to-date and flexible method is to access the PPO’s Web Site. The address is also printed on your brochure.

Do I need to be referred from a family or primary physician before I can see a PPO Network physician? If my student plan is a PPO type plan, do I need to be referred from a family or primary physician before I can see a PPO Network physician?

If your plan is a PPO-type plan you do not need a referral. Referral from a primary physician is a common requirement of an HMO but not of a PPO

How can my charges be lowered by using a PPO Network approved provider?

Network providers have already signed agreements discounting their standard charges for insureds associated with a specific insurance plan.

How does a PPO provider know that my plan has access to the Network?

Your provider will know when you present your student insurance ID card at the time of service