By: Yumna Hussain ’25
Students and their families often feel overwhelmed attempting to navigate a highly complex health care system. Students frequently raise important questions regarding access to care and insurance coverage on campus, in the Easton community, and at home.
Here are things to know about access to care and insurance coverage during the academic year and at home. Lafayette students do not need to show medical insurance to see providers at Bailey Health Center. However, if further treatment or evaluation is needed in certain circumstances, insurance may be utilized. For example, a provider may recommend diagnostic tests including lab work and imaging. For any diagnostic testing performed outside the health center, medical insurance will be needed.
It is helpful to know the “lingo” used in the health care system, especially insurance terminology. Here are terms to know, according to the Glossary of Health Coverage.
Appeal: A request that your health insurer review a decision that denies a benefit or payment.
Claim: A request for a benefit made by you or your health care provider to your health plan for items/services you think are covered.
Coinsurance: Your share of the cost of a covered health care service, calculated as a percentage of the allowed amount for the service. You generally pay coinsurance plus any deductibles you owe.
Deductible: An amount you could owe during a coverage period for covered health care services before your plan begins to pay. An overall deductible applies to all, or almost all, covered items and services.
Copayment: A fixed amount you pay for a covered health care service usually when you receive service.
Access to health care in the community is more complicated, but having an understanding of the process before you need these services is critical. It’s important to do your homework ahead of time. Here are some important tips to consider:
- Understand your coverage:
- Review your insurance policy thoroughly to understand what is covered and what is not. Pay attention to copayments, deductibles, and any limitations on coverage.
- When you register for an insurance plan, your policy documents outline the terms and conditions, coverage limits, and exclusions. This can be helpful in understanding what services are available to you.
- Your insurance ID has essential information such as your policy number, preferred provider organization, health maintenance organization, and so on, which will help you navigate your plan.
2. Network providers:
- Identify the health care providers, hospitals, and clinics that are in your insurance network. Visiting in-network providers can significantly reduce your out-of-pocket costs.
- Depending on your plan, you can find a directory of in-network providers on the insurance company’s website helping you know which provider will reduce costs.
3. Primary care physician (PCP):
- Choose a primary care physician if required by your plan. Your PCP can be your first point of contact for routine care and referrals to specialists.
- Many insurance companies will have tools online to help you find your in-network PCPs based on your location and other preferences.
- If this is still confusing, you can reach out to your insurance provider’s customer service (number is available on your insurance ID), and they can assist you through the process.
- Make sure to also seek recommendations from family, friends, and co-workers for suggestions on PCPs they trust as it would be invaluable for your doctor-patient relationship.
- Some other things to consider when choosing your PCP are:
- Location
- Office hours
- Specialties, based on your medical need.
4. Know your benefits:
- Familiarize yourself with the preventive services covered by your plan, such as vaccinations and screenings. Many insurance plans cover preventive care at no additional cost to you. Review your preventive service guidelines provided by your insurance company.
- Some health insurance plans have wellness programs. These provide additional benefits such as discounts on gym memberships or other resources for managing chronic conditions.
- Some common checkups covered by insurance include mammograms, colonoscopies, and cholesterol screenings.
- If your plan includes prescription drug coverage, understand the formulary (list of covered medications) and any copayments or coinsurance for your prescriptions.
- Know the procedures and costs associated with emergency room visits and urgent care centers. In nonemergency situations, using urgent care facilities can be more cost effective.
5. Keep records:
- Maintain a record of all your medical expenses, including bills, receipts, and explanations of benefits (EOBs), from your insurance company. This documentation can be helpful for any disputes or tax-related purposes.
6. Ask questions:
- If you have any doubts or concerns about your coverage, don’t hesitate to contact your insurance provider’s customer service. Ask questions about coverage, claims, and procedures to ensure you have a clear understanding.
7. Appeals process:
- Familiarize yourself with the appeals process in case your insurance claim is denied. If you believe a service should be covered, you have the right to appeal the decision.
Remember that each insurance plan is unique, so it’s essential to be proactive in managing your health care and understanding the specifics of your coverage. If you’re ever unsure about something, don’t hesitate to reach out to your insurance provider for clarification.
Sources:
Glossary of Health Coverage and Medical Terms:
https://www.healthcare.gov/sbc-glossary/
University of Florida’s Site for Student Understanding and Navigation of Insurance Policies: https://shcc.ufl.edu/fees-and-insurance/understanding-your-insurance/
Lafayette College Site for Health Insurance: https://www.universityhealthplans.com/letters/letter.cgi?group_id=16
CMS GOV – Navigating Your Health Insurance:
https://www.cms.gov/priorities/health-equity/c2c/navigate-your-coverage
JDRF– Terminology to help understand your insurance:
https://www.jdrf.org/t1d-resources/living-with-t1d/insurance/common-health-insurance-terms/