The Student Insurance Plan, like any insurance plan, has certain policy provisions, exclusions and limitations that the insured student must know and comply with to ensure that claims are not delayed or denied. There are some common mistakes that insured students make when utilizing the Student Insurance Plan.
1. Not using the Student Health Center first when required.
The Student Insurance Plan requires that students use the services of the Student Health Center (SHC) FIRST where treatment will be administered or a SHC Referral issued. Medical expenses for which no prior approval or SHC Referral is obtained will be excluded from coverage. Exceptions to this requirement are when it is a Medical Emergency (students must return to the SHC for follow-up care); when the SHC is closed; when service is rendered at another facility during a school break or vacation period; when the medical care is received when the student is more than 10 miles from campus; when the student is no longer eligible to use the SHC due to a change in student status; maternity; or psychotherapy.
2. Not reading your plan brochure and knowing your policy provisions.
Insured students have access to an electronic copy of their current plan brochure and should keep it on hand for future reference. Review your current plan brochure and familiarize yourself with what medical expenses are covered, what are not and the level at which these expenses will be covered. This information is found in the Schedule of Benefits (what is covered) and the Exclusions and Limitations (what is not covered) in the plan brochure. The Student Insurance plan is a comprehensive health insurance policy, but does NOT provide coverage for all medical expenses nor does it pay 100% of the cost of covered medical expenses. You will be required to pay a portion of your covered medical expenses either in the form of a deductible, copayment or coinsurance. In addition, there are certain provisions and benefit maximums within the policy, know what these are so that you follow your plan provisions and avoid exceeding policy maximums. Review your plan brochure frequently as you will not likely remember all the specifics of your health insurance plan.
3. Not responding to the Insurance Company's request for additional information in a timely manner.
The Student Insurance Plan has certain plan provisions, exclusions and limitations that must be followed. Since certain medical conditions or types of medical expenses are not covered, there are times when the Insurance Company may place claims into a pending status and ask the insured student to provide more information to determine if the medical expense is payable under the university-endorsed plan. UnitedHealthcare StudentResources may ask insured students to provide accident details or other insurance information. If the medical expenses are due to an accident, they will ask you whether it was a work, auto, intercollegiate sport or intramural sport accident. If an outside medical provider was used, they will need to know if a Student Health Center (SHC) Referral was obtained, if the SHC was closed, if it was a medical emergency or if you were more than 10 miles from campus. If the medical expenses are due to a sickness or injury that could have existed prior to your enrollment in the Student Insurance Plan, they may ask whether you have suffered the same or similar condition in the past. They may even ask you for the names of physicians you have used in the past and request medical records from them. These things are all done so that the claims office can determine if benefits are payable under the policy. It is important to note that if you do not respond to these requests for additional information within 30 days, the pending claims will be rejected because the insurance company has insufficient information to determine if it is payable under the policy.
4. Not using a Preferred Provider.
The Student Insurance Plan utilizes a national PPO network of Physicians, Hospitals and other health care providers who have contracted with UnitedHealthcare through the Options PPO network to provide their services at negotiated prices. You benefit when a Preferred Provider is used by receiving a higher level of coverage as well as receiving the discounted Preferred Provider rate. To maximize your healthcare dollars, you should try to use a Preferred Provider whenever possible. Insured students may use Out-of-Network providers but your coverage will be reduced and the applicable coinsurance will only be applied to the allowable charges that do not exceed the usual, reasonable and customary fee for that particular service. Any amount that exceeds the allowable charge will be the responsibility of the insured student. So you may incur significant out-of-pocket expenses when Out-of-Network providers are used. It is important to note that regardless of the provider, each insured student is responsible for the payment of their deductible before benefits are paid. The deductible for the university-endorsed Insurance Plan is $200 per insured person per policy year and there is an additional $250 inpatient deductible per insured person per policy year should you require hospitalization.
5. Not using the Collegiate Assistance Program for nurse advice or health information.
Insured students do not always know ways to stay healthy, understand their medications or medical procedures and cannot determine if they need to seek medical care. But, you do not have to be a medical expert or know the answers to these questions because there is a resource available to you that can help. Before you schedule an appointment for medical care that you may not need, contact the Collegiate Assistance Program at (877) 499-3568 for more information. The Collegiate Assistance Program is staffed by Registered Nurses and Licensed Clinicians who can offer reliable and confidential health information and assistance 24 hours a day, 7 days a week. Of course, if you are suffering from a condition that does requires medical attention, use the Student Health Center if you are within 10 miles of campus or an urgent care facility, an outside physician's office or the nearest emergency room (when appropriate).
6. Using the Emergency Room for non-medical emergencies.
Insured students sometimes do not know if their condition is emergent, urgent or if it can wait until the following business day. When it is a life threatening condition or is a true medical emergency, insured students should either call 911 or go to the emergency department at your nearest hospital. A medical emergency is defined as a sudden, serious and unexpected sickness or injury that could result in death; placing of one's health in jeopardy; serious bodily impairment; serious dysfunction of a body part or organ; or in the case of a pregnant woman, serious jeopardy to the fetus. Examples may include, but are not limited to, choking, not breathing or difficulty breathing; severe injuries such as suspected broken bones, head injuries or heaving bleeding; seizures or convulsions; numbness or paralysis of a limb or one side of the body; and a sudden, severe headache especially if there is neck pain, a change in consciousness or changes in vision. Otherwise, students should access the Collegiate Assistance Program at (877) 449-3568 to determine if you need to seek after-hour urgent care or if it can wait until the Student Health Center re-opens the next business day. It is important to note that students who utilize the Emergency Room for non-medical emergencies or who utilize Urgent Care facilities in Williamsburg Monday through Friday during regular office hours without a SHC Referral will have claims denied and incur significant out-of-pocket expenses. Remember, the applicable copay/deductible per visit for emergency room and urgent care visits is in addition to the policy deductible.