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.
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.
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.
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.
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
What is SHP?
Do I have to buy SHP? What if I am already covered through my parents or spouse?
How can i see the SHP brochure?
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?
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?
Will SHP cover the cost of any lab tests or x-rays? What if I have private insurance?
Are my medical records confidential? Do my parents, spouse or partner find out about every visit?
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?
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
I didn’t go onto Sage to report my private insurance. I ended up with SHP by default. What can I do?
I wanted SHP and rather than electing to enroll though Sage, I was enrolled by default and had to pay for my prescriptions in September.
I enrolled for SHIP in Sage on August 17. I went to the pharmacy on August 20 and they told me I wasn’t insured.
For claims reimbursement information go to gallagherkoster.com/brandeis
For years I used a particular pharmacy. Now they do not cover my medicine. Why?
I had difficulty getting claims paid. How do I get assistance?
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 email@example.com.