Formerly Ascension Insurance. Touro University Student Health Insurance Plan Overview

Transcription

1 Formerly Ascension Insurance Touro University Student Health Insurance Plan Overview

2 Health Insurance Basics Because the U.S. does not offer free medical care to the general public and medical care is very expensive, having health insurance is critical. Average doctor s visit cost: $150 - $200 per visit Average hospital stay cost(room and board only): $1,800 - $2,500 per day Doctor s fees, lab charges, X-rays, surgery, etc. all cost extra $$$ SHIP is in place to help with the cost of unexpected injuries and illnesses, as well as to help prevent or curb potentially serious conditions that could otherwise keep you from completing your degree. It covers a certain percentage of the medical costs incurred, and you are ultimately responsible for paying what the insurance doesn t cover. If you are a full-time student (6 credit hours or more), Touro requires that you have adequate health insurance coverage. You will be automatically enrolled in SHIP unless you provide proof of comparable coverage and submit a waiver by your program s waiver deadline date. SHIP OVERVIEW / 2

3 Your Insurance ID Card Once you are enrolled in the plan, you will receive your permanent insurance ID card in the mail after the start of your first term of coverage under SHIP. Insurance ID cards will be mailed to the address provided by Touro. You may also download your insurance ID card at Only one permanent ID card will be mailed to you each school year. If you lose your ID card, you can download a replacement or request a replacement from Relation Client Services by calling (800) Carry your insurance ID card with you at all times. You will be asked for your insurance ID card when you go to the Student Health Center (SHC), physician s office, urgent care center, hospital, or pharmacy. SHIP OVERVIEW / 3

4 PPO v. Non-PPO PPO (aka in-network) PPO or in-network means that the doctor or medical facility is part of the Preferred Provider Organization. It is a network of doctors and hospitals that have contractually agreed to provide services at a lower rate. Because the insurance company saves money, you do too! Non-PPO (aka out-of-network) Non-PPO or out-of-network means that the doctor or facility has not agreed to a lower rate, resulting in more expensive care. Since these providers charge more, the insurance company will only pay a fraction of the cost. This results in you paying more money out of your pocket. You do not have to go to a PPO provider the plan will still cover you at the non-ppo level. However, choosing an in-network provider will save you more money than going to an out-of-network provider. While insured under this plan, your medical PPO provider network is Cigna and your pharmacy benefit manager network is Express Scripts (please note that Cigna is NOT the insurance company, just the PPO network). SHIP OVERVIEW / 4

5 Coverage Details SHIP benefits include: Unlimited plan benefit (maximum does not apply except where noted in the brochure) $4,000 out-of-pocket maximum per policy year for PPO / non-ppo combined $250 deductible when Cigna PPO provider is accessed (waived at the SHC), $500 deductible for non-ppo 100% of covered charges for PPO, 60% of reasonable and customary expenses for non-ppo $20 office visit/urgent care co-pay for PPO, $40 co-pay for non-ppo $20 prescription drug co-pay for generic / $35 for single-source brand / $60 for multi-source brand, Express Scripts pharmacies only SHIP does not cover Rx out-of-network Additional benefits can be found in your plan brochure. SHIP OVERVIEW / 5

6 Coverage Details SHIP limits coverage for the following: Dental for persons 19 and over: only covered in case of injury/accident Vision for persons 19 and over: one routine eye exam; otherwise only covered in case of injury/ accident Additional exclusions and limitations can be found in your plan brochure. As a reminder, SHIP does not cover everything. Please check with the claims administrator Relation Insurance Administrators (RIA) before you have a procedure to make sure it is covered or for specific benefit questions at (877) SHIP OVERVIEW / 6

7 How to Access Care In the event of a life-threatening emergency, go directly to the nearest Emergency Room (ER) or call 911. If you access the ER for non-emergencies be prepared for the following: Long wait times: triage is used to decide who is most urgently in need of medical care. Higher Costs: ERs charge much more than doctor s offices and urgent care centers. $150 copay for ER visits: this is only waived if you are admitted. You will not be covered for ER expenses for minor conditions. That means you will pay out of your own pocket for non-emergency use of the ER. If you need to treatment for a severe but non-life-threatening condition and you cannot wait for a scheduled appointment, it is highly recommended that you to an Urgent Care Center. It will save you time and money. SHIP OVERVIEW / 7

8 How to Access Care For general medical care, it is highly recommended that you go to the Student Health Center (SHC) first. They can treat many conditions or refer you to another doctor or specialist, if necessary. The deductible does not apply at the SHC. If the SHC is closed or if it can t provide the treatment you need, you should seek outside medical treatment. Again, you are not required to use a PPO provider, but choosing a doctor/hospital that is part of the Cigna PPO network will save you more than going to a non-ppo provider. For a complete listing of the PPO doctor or hospital facilities in your area, visit or call (800) We recommend that you ask the doctor or medical facility to confirm that they are still part of the Cigna network before scheduling an appointment. SHIP OVERVIEW / 8

9 Paying for Healthcare After your visit, the provider will send a bill to the insurance company for the charges. The insurance company will review the provider s statement and determine the payment for each itemized procedure. The provider will receive payment from the insurance company and then bill you for any amount not covered by the insurance. In some circumstances, such as when using a non-ppo provider, you may be required to pay in full upfront. When this is the case, submit a claim for reimbursement by sending all medical bills, your referral (if applicable), and either a copy of your health insurance ID card or a completed claim form to RIA. Once the claim is received and processed, RIA will reimburse you for the amount the insurance is responsible for paying. Claims are usually processed in 7-10 business days. Download a claim form from and mail or fax the completed form with all bills and receipts for medical treatment to: Relation Insurance Administrators P.O. Box 6040 Agoura Hills, CA Fax: (818) SHIP OVERVIEW / 9

10 Paying for Healthcare The completed claim, including all hospital and medical bills, must be submitted for payment within 90 days after the date loss occurs, or as soon thereafter as is reasonably possible. Once the claim is received and processed, RIA will reimburse you for the amount the insurance is responsible for paying. Claims are usually processed in 7-10 business days. If you have questions about the status of your claim, please call RIA at (877) Always keep a copy of all documents submitted for claims. If you don t pay for the services and charges that the insurance company doesn t cover, your credit might be affected. For this reason, it is highly recommended that you always confirm with RIA that a claim was submitted after receiving medical treatment. Again, you are ultimately responsible for any charges not covered by the insurance. SHIP OVERVIEW / 10

11 Filling your Prescriptions Prescriptions must be filled at an Express Scripts Network pharmacy or they will not be covered. To fill a prescription, visit any Express Scripts in-network pharmacy, including CVS, Rite Aid, Walgreens, and Walmart, present your ID card, and pay your portion of the cost. To locate an Express Scripts pharmacy, visit or call (800) We recommend asking for the generic form of the drug, if available; generic versions are the most cost-effective. SHIP OVERVIEW / 11

12 Treatment Outside of California or the U.S. Cigna and Express Scripts network providers are available throughout the U.S. You can always find a complete listing of the PPO doctor or hospital facilities in your area by visiting the network websites. Any medical treatment received outside California but within the U.S. will be paid at 100% of covered charges for PPO services, 60% of reasonable and customary expenses for non-ppo services. Medical treatment received outside the U.S. is covered at 60% of reasonable and customary expenses. SHIP OVERVIEW / 12

13 Recap In an emergency call 911! In all other instances, visit the SHC whenever possible, go to an Urgent Care center, or schedule an appointment with a doctor. You don t have to go to a Cigna PPO provider, but you will save money if you do. Once you find a provider, we recommend that you confirm that they are in-network before you schedule an appointment. Always go to an Express Scripts pharmacy for prescriptions. Always confirm with RIA that a claim was submitted after receiving medical treatment outside of the SHC. If you have claims or benefits questions call (877) If you have questions regarding eligibility, enrollment, waivers, or plan materials call (800) SHIP OVERVIEW / 13

14 SHIP OVERVIEW / 14 Thank You!