Insurance Definitions

HMO (Health Maintenance Organization)

An HMO is a group of health care providers who provide care through the HMO for a flat rate. Only visits to professionals within the HMO network are covered by the policy. All visits, prescriptions and other care must be cleared by the HMO in order to be covered. A primary care physician within the HMO, selected by the patient, handles referrals. The Brandeis Health Center is not an in-network provider.


PPO (Preferred Provider Organization)

A PPO is a health care organization composed of physicians, hospitals or other providers which provides health care services at a reduced fee. A PPO is similar to an HMO, but care is paid for as it is received instead of in advance in the form of a scheduled fee. PPOs may also offer more flexibility by allowing for visits to out-of-network professionals at a greater expense to the policy holder. Visits within the network require only the payment of a small fee. There is often a deductible for out-of-network expenses and a higher co-payment. 

Primary Care Provider

A Nurse Practitioner (usually a family adult or pediatric provider) or Medical Doctor (usually an internist, pediatric, or family practitioner) who has you enrolled as patient in their practice . You see them for your preventive wellness consultations and screenings as well as for your illness and injury care.

Deductible
The amount a patient has to pay out of pocket before the insurance policy will begin to cover services.  Certain preventive services are exempt for deductibles. Can be funded through a Health Savings Account.

Copayment
A predetermined, flat fee an individual pays out of pocket for every prescription and health care visit. Certain preventive services are exempt from copayments. Can be funded through a Health Savings Account.

Coinsurance
The amount of a services costs that the consumer is expected to pay out of pocket , often 10, 20, or 30% of the total costs after the above out of pocket expenses are met. Amount can vary by whether the service is in or out of network. Can be funded through a Health Savings Account.

In Network
Services provided by a health care provider who is a member of the plan’s Preferred Provider Organization (PPO) or HMO.

Out of Network

Services provided by a health care provider who is NOT a member of the plan’s Preferred Provider Organization (PPO) and HMO.

Health Insurance Frequently Asked Questions

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What is SHP?
SHP stands for a Student Health Insurance Plan. The University is required by Massachusetts Regulations to offer a qualifying insurance plan for its students.  This plan meets Ma State Regulations, Federal ACA Requirements, and J-1 visa requirements. Students may purchase the qualifying SHP or request to waive the SHP and report their own plan.
Do I have to buy SHP? What if I am already covered through my parents or spouse?
You do not need to purchase SHP if you are already covered by a qualifying insurance plan. Annually all enrolled students are required to either purchase the SHP or to report their own comparable insurance information to the University.  Of note,  International plans are acceptable only if they have been purchased through a US based carrier company, regardless of the claims address location. The SHP must cover emergency services, surgical services, hospitalizations, primary and preventive services, ambulatory patient services, mental health services, and prescription drugs IN THE AREA YOU ARE ATTENDING UNIVERSITY.
How can i see the SHP brochure?
The plan covering summer 2014 enrollees is available for view through www.gallagherkoster.com. The 2014-2015 plan will be posted when available.
Can I use the Health Center if I don't have SHP?

All undergraduates have unlimited access to the  Health Center regardless of insurance. Graduate students may elect to pay the Health Center Fee to be seen at the Health Center.  If graduate students choose to not pay this fee, we recommend that they get a primary care provider while they are students for optimal access to health service.  There is never a co-payment or charge for services at the Health Center, regardless of your insurance plan. Off campus services such as labs, urgent care, off campus providers and pharmaceuticals may apply deductibles, copays, and coinsurance charges per your insurance plan.

I never got a SHP insurance card (or I may have lost it). How can I get a replacement?

For students using the Summer 2014 plan or the school  year 2013-2014 plan-Visit gallagherkoster.com, and select Brandeis from the drop down menu. Click on Generate Replacement ID card from the left side menu. You must log in to use this page. Once on the Generate Replacement ID Card page loads, click on Authorize Your User Account. Here you will enter your Student ID (Sage ID number), date of birth, and Brandeis. Once the account has been authenticated, click on Generate Replacement ID Card in the left hand menu and click on the checkbox next to Yes! I would like to generate a replacement card! And click on the Generate Card button. A new ID card will print on your printer. 

Do I need a referral from the Health Center to see an outside doctor or specialist?
No referrals are needed with the SHPs, although at times a doctor's office may request one. When we refer you to a specialist, we will have you sign a release which will allow us to exchange information and records about your health care.  For many other types of insurance policies, a valid referral must come from your primary care doctor's office, or by calling your insurance company directly.
Will SHP cover the cost of any lab tests or x-rays? What if I have private insurance?
Outside providers bill insurances including the SHP directly for their services. Any uncovered costs must be discussed with the billing offices at those providers. The Health Center assists in advocacy as able and has a staff person here Mondays, Wednesdays and Fridays to help you navigate health care systems. It is your responsibility to know if your insurance requires you to use a specific lab or testing site for lab tests or x-rays. We try to accommodate all plans used by our students, but cannot be responsible to know which insurance plans have specific requirements. The customer  service number on the back of your card will get you answers to your coverage concerns.
Are my medical records confidential? Do my parents, spouse or partner find out about every visit?
Medical records are confidential. We cannot release any information to parents or others without your consent. If you are over 18, you are considered an adult, and your records are protected by federal law. If you want us to speak with your parents, spouse or partner, you will need to give us consent to do so. 

If you have  insurance through a family member, you may want to check with your insurance company, to see if any billing information will go to the primary subscriber. If you are over 18 you can call your insurance company to request that billing or explanations of Benefits (EOB) be sent to your personal address.
What should I do if I have a problem with my SHP?
If you have a problem with your insurance or don’t understand a bill you’ve received, please contact the customer service number on your card. If you have the Brandeis 2013-2014 SHP  you may contact the broker  (Gallagher Koster) directly at brandeistudent@kosterins.com or 617-769-6011 or 800-397-1837. If you would like some advocacy support please bring your paperwork to Diana Baccari at the health center M-W-or F 1-4.
I’m a graduate student. Where can I go for health care if I do not pay the Health Services Fee?

See Emergencies: Urgent Care/Walk-In Centers.  If it is not emergent and you do not use SHP call the customer service number on the back of your card to find local in-network health care providers. For SHP users go to the  online provider search engine found under  important insurance contact information

For years I used a particular pharmacy. Now they do not cover my medicine. Why?
Unfortunately, not all insurers contract with all pharmacies and not all insurers cover all medicines. Use the customer service phone numbers on the back of your card or your insurance websites  to ask about pharmacy access and pharmaceutical  coverage limitations. Then you can call your prescribing provider with this information.
I had difficulty getting claims paid. How do I get assistance?
Your SHP ID card states “Student Health Plan” and has the name and address of the claims administrator on the back of the card. Your providers will all need this information to submit their claims.
We are happy to help you resolve any problems you may have. Do not hesitate to contact us.
           
If you have any questions, please call us at 781-736-3677 or contact Diana Baccari atbaccari@brandeis.edu.