Health Insurance Glossary
It’s important to understand the below commonly used health insurance terms. For additional terms or more detail, please visit https://www.healthcare.gov/glossary/. In addition, the Student Health Center Video “Insurance 101” is a helpful primer for understanding health insurance.
A third party intermediary between the insurance buyer and the insurance company. Vanderbilt University purchases SHIP through the insurance broker Gallagher Student Health & Special Risk in order to obtain the best rates and coverage for Vanderbilt students.
A request for payment that you or your health care provider submits to your insurance company.
Claims Company (Third Party Administrator – TPA)
The organization that processes claims and distributes payment on behalf of the insurance company. HealthSmart Benefit Solutions is the claims company responsible for processing SHIP claims. Also called the Third Party Administrator (TPA).
The portion of expenses paid by insurance after you pay any noted deductible. You are responsible for paying the remainder.
- A Plan with 80% in-network/60% out of network benefits would pay 80% of the billed charges in network and 60% out-of-network after the Plan Member has met their deductible. Therefore, the insured would be responsible to pay the remaining 20% in network and 40% out of network.
Coordination of Benefits
A practice that determines which insurance plan pays first (& subsequently) in a situation where you have more than one insurance policy. This practice is to ensure that benefits are paid on a ‘shared’ basis and that no benefits are paid in excess of the amounts charged. Please see the Gallagher Student Health & Special Risk handout titled ‘Understanding Claim Payment Provisions’ for further details. It is very important to respond to your insurance company when they contact you to ask whether you have additional insurance. They will often do this on the first claim of the year, or when the claim is secondary to an accident, in which case your auto insurance or homeowners insurance will be in play. If you do NOT respond to requests for other insurance information, the insurer will NOT pay your claim until they receive that information.
A flat fee that you pay at the time of service. You will have a copay for your prescription drugs at the pharmacy or at the Student Health Center. You will also have a $100 copay at the Emergency Department if you are not admitted to the hospital. There is no copay for office visits at the Student Health Center (SHC), but there will be charges for medications, supplies, and some procedures.
There is no copay for treatment at the Student Health Center (SHC).
The amount you pay for covered health care services before your insurance plan starts to pay. After you pay your deductible, your insurance company pays the coinsurance and you pay the remainder. Deductibles may be reduced or eliminated for in-network providers or if proper referral procedures are followed. There is no deductible for visits to the Student Health Center (SHC).
Specific conditions or circumstances for which your insurance company will not provide benefits.
Gallagher Student Health & Special Risk
An insurance broker (refer to the definition of broker, above).
Insurance Company (Underwriter, Carrier)
The company that assumes the risk and payment of your claims under an insurance policy. The SHIP insurance company is UnitedHealthcare StudentResources. Also called the Underwriter or Carrier.
Insured (Plan Member)
You are the insured as the person with the health insurance coverage. Also called a Plan Member.
A group of doctors, hospitals, and other health care providers contracted to provide services to an insurance company’s customers at a negotiated rate. Your SHIP Provider network is a national and comprehensive network available in every state in the United States. You will pay less for using an in-network provider rather than choosing to receive care out-of-network. You may search for SHIP preferred providers online or by calling 866-948-8472. During your search, note that mental health providers are referred to as “behavioral health” providers.
A group of doctors, hospital, and other health care providers who do not offer pre-negotiated rates. Out-of-network costs will be higher.
Out of Pocket Maximum
The total amount of deductibles/coinsurance that you will be responsible for before the plan pays 100% of eligible charges. The out of pocket maximum does not include copays.
The terms and services offered by the insurance company to pay for your health care in return for the premium you pay for that policy.
The time period your health plan provides coverage. The SHIP plan year is August 12, 2019 through August 11, 2020.
Pre-existing Condition Provision
A pre-existing condition is a health condition that existed prior to your enrollment in a new plan. Examples of pre-existing conditions include pregnancy, heart disease, high blood pressure, cancer, diabetes, and asthma. Under the affordable care act, SHIP does not impose pre-existing condition provisions or exclusions.
Primary Care Physician/Provider (PCP)
The physician primarily responsible for your care, making referrals to other specialists as necessary. The Student Health Center (SHC) serves as your PCP. Referrals are required from the SHC for you to receive outside treatment.
A doctor, hospital, pharmacy, laboratory, or other facility/licensed supplier that provides health care services.
The acronym for the Student Health Insurance Plan.
An insurance company (refer to the definition of insurance company, above).
*The definitions are provided as a quick reference and do not replace the official definitions as listed in your insurance brochure. Not all terms will be applicable to all insurance plans.