Health Insurance Basics

There are some basic insurance terms that students should know and understand, in order to best utilize their insurance benefits.

These include:

• Provider: these are the doctors, nurses, hospitals, treatment facilities and practices and that provide medical care.
• Benefits: The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid plans (like OHP), covered benefits and excluded services are defined in state program rules.
• Member: someone with insurance coverage from a particular company.
• Subscriber: If you have insurance through your parent’s, spouse’s, or registered domestic partner’s employer, the parent/spouse/ or domestic partner who is covering you as a dependent under his or her health insurance plan would be the primary subscriber, sometimes called primary enrollee.
• Explanation of Benefits (EOB): Every time services are provided, doctors and other medical professionals will submit claims to patients’ insurance companies to receive payment. The insurance company will then sent out an EOB to the member, which provides details about a claim that has been processed and explains what portion was paid to the health care provider and what portion of the payment, if any, is the patient’s responsibility. The EOB is not a bill. Generally, EOBs are sent to the primary subscriber of the insurance plan.
• Behavioral Health: term used interchangeably with mental health. Some insurers will use mental health, others will use behavioral health, to describe services.
• Pre-Authorization: depending on your insurance plan, you may need to obtain authorization—get approved—for services before starting treatment.
• Deductible: the amount you must pay before your insurance company starts to pay for covered services each year. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. This amount resets each year on January 1. After you pay your deductible, you usually pay only a co-payment or co-insurance for covered services. Your insurance company pays the rest.
• Co-payment: a fixed amount paid for covered services like doctors visits. Some insurance companies have different co-payments for different types of service or doctors. Please note that mental health providers may be considered ‘specialists’ by some plans, and could have a higher co-payment.
• ‘Out of pocket’ costs: expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and co-payments for covered services plus all costs for services that aren’t covered.
• Co-insurance: the percentage of a medical expense that you are responsible for paying. This usually applies after a deductible has been met. For example—if you have a 20% coinsurance, and the cost of services is $200, your cost would be $40.
• Claim: A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
• Premium: the amount paid for your insurance plan. This may be paid monthly, quarterly, or yearly.
• Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list. Covered medications generally fall into three categories:
  • Generic: These drugs are copies of brand-name drugs that have been on the market for a number of years and are often offered at very cheap prices.
  • Preferred: These drugs are name brand but are available to you at a price below the retail price.
  • Non-Preferred: These drugs are name brand but are not offered at a very large discount.
• Super Bill: an itemized form used by healthcare providers for reflecting rendered services. It is the main data source for creation of healthcare claim, which will be submitted to payers (insurances, funds, programs) for reimbursement.
• Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
  • ‘In Network’ provider: providers whose services are contracted with/covered by your health plan
  • ‘Out of Network’ provider: providers whose services are not contracted with your insurance plan. Some plans offer ‘out of network’ benefits, meaning that the plan will cover some of the cost of these providers. Please note that the initial payment for the full cost of services is the responsibility of the individual receiving services, and is paid at the time services are rendered. This can be a large expense. Out of network providers may offer a ‘super bill’ that can be submitted by the member for insurance reimbursement.
    
    Please note that not all plans offer this benefit.

If you have additional questions about terms not listed here, healthcare.gov provides a glossary of additional insurance and health care terms.

Benefits

Most health plans must cover certain health benefits. This includes mental health and substance use services. Your exact benefits depend on your state, insurance company, and specific insurance plan.

Most health plans generally cover these mental health and substance use services:

• Access to behavioral health providers, such as psychiatrists, and psychologists, social workers, advanced practice registered nurses, and counselors
• Treatments, such as psychotherapy, counseling, and medication
• Inpatient services, such as a hospital or emergency room visit
• Pre-existing conditions
• Preventive services, like alcohol and depression screenings are covered at no cost under most health insurance plans.

Most health plans have similar rules for coverage of mental health and substance use disorder services as for physical health. This is called “parity”, and applies to co-payments, number of visits, and pre-authorizations.

Detailed information about the benefits offered through the student health insurance plan (Pacific Source) can be found on the Student Health Insurance website.

Benefits information about other health insurance plans is not maintained by Lewis & Clark college. Please contact your insurance plan directly for benefit information. Contact information can usually be found on your insurance card. Questions about benefits that may be helpful to ask are noted below.

It is very important that students understand the specific coverage and services offered not only by their insurance company, but their specific plan.

Insurance coverage can vary greatly between plans and companies. A provider may say that they accept coverage from a particular insurance company, but they may not accept every plan from that company. Students who have coverage from the same company may have significant differences in costs and availability of providers based on their plans.

Students should contact their insurance provider directly to determine what their coverage is, and what their treatment costs will be. If a student is on someone else’s insurance plan (such as a parent, spouse, or domestic partner), they may need to talk with that person to gain access to insurance information.

It should be noted that some health insurance plans, particularly smaller, regional plans, or plans from out of state, may have very limited coverage and/or provider availability in Oregon.

There are some questions that students can ask their insurer to better understand their coverage:

• What are my behavioral (mental) health benefits for individual counseling (therapy) and/or psychiatrist appointments?
• Do I need a referral from my primary care physician for behavioral (mental) health care?
• Do I need pre-authorization in order to see a behavioral (mental) health provider?
• Do I have a deductible that needs to be paid before I can use my insurance for behavioral (mental) health services? If so, how much is it? How much of my deductible has already been met for year?
• Do I need to see a mental health professional who is on a list provided by my insurance company (in a “network”) or am I free to choose any qualified professional?
• Are there any session limits for counseling (therapy)?
• Am I able to access behavioral (mental) health services in Portland? What are my options for using my insurance coverage if in-network providers are not available locally?
• Does my plan cover tele-therapy (online therapy)?
• Does my plan offer out of network benefits? If so, what is the reimbursement rate? How long does reimbursement usually take?
• What prescription benefit does my policy offer? What are the co-pays for medications? Are there different levels of prescription coverage depending on the specific medication? Do co-payments vary depending on whether the medication is generic or name brand?

When a student utilizes health insurance coverage that is provided by someone else (usually a parent, domestic partner, or spouse), an explanation of benefits (EOB) is automatically generated (see glossary above for additional information about EOBs). The EOB is usually sent to the primary subscriber of the plan, and will detail the providers seen, and services provided.

If a student, for whatever reason, does not want the person providing their insurance to know that they’ve accessed care, the EOB can cause significant privacy concerns.

Some students may opt not to use their insurance due to these privacy concerns. In those cases, students may be able to access services from local sliding scale providers, who do not bill insurance. Sometimes, the costs of these services may be comparable to the price a student would have paid if using their insurance.

Students may also want to consider making a Confidential Communications Request (CCR). When you send your health insurance company a Confidential Communications Request (CCR), they must stop sharing your confidential health information with your health plan’s policyholder (usually a parent or spouse).

Students may also wish to review additional information about the Confidential Health Information Act and how it relates to their insurance coverage.