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Health Insurance 101

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Navigating health insurance can be challenging. With the changing landscape of US healthcare, it’s important to be as informed as you can be about your choices, what to expect, and how different plans work.

LET’S START WITH THE BASICS. WHAT IS HEALTH INSURANCE?

Health insurance is a way to pay for healthcare. It protects you from paying the full costs of medical services when you’re injured or sick. You choose a plan and agree to pay a certain rate (“premium”) each month. In return, your health insurer agrees to pay a portion of your covered medical costs.

HEALTH INSURANCE AND NYU

NYU requires that all students registered in degree-granting programs maintain health insurance. Whether enrolled in an NYU-sponsored plan or another plan (e.g. a parent’s plan), all matriculated students have access to comprehensive services at the Student Health Center. Out of pocket expenses for services vary based on a student’s insurance plan, and some services are offered at very reduced cost or no cost to the student. For information about options for NYU students, visit our Insurance and Patient Accounts page.

KEY TERMS AND DEFINITIONS YOU SHOULD KNOW

Deductible: a fixed dollar amount you pay for your covered medical services before your health plan begins to pay some or all of the costs of those services

Copay:  a fee that many insurance plans require you to pay for your covered healthcare expenses such as doctor visits, procedures and prescription drugs. Copays can range from $10 for a regular visit to $300 for emergency room visits

Coinsurance: a percentage of your covered healthcare expenses that you pay. It is often paid after you meet your annual deductible (if you have one). Your health plan pays the rest

In-network: a group of doctors, hospitals and other healthcare providers who contract with a health plan to provide care at special rates

Out-of-network: doctors, hospitals and other healthcare providers who do not have a contract with your health plan. You may pay more when you visit one of these providers

Policy: a written document that contains the terms of the contractual agreement between an insurance company and the insured person

Premium: a specified amount of money that the insurer receives in exchange for its promise to provide health insurance to an individual or a group

Reimbursement: a payment you get from your health plan for covered costs you paid to your doctor. The amount depends on the deductible, copayment or coinsurance requirements in your health plan

Preauthorization (aka precertification): some plans require you or your healthcare provider to get approval for certain medical services before agreeing to cover the service

TYPES OF PLANS

Health maintenance organization (HMO): a plan in which members choose a primary care provider (PCP) from a network. The PCP gives routine care and acts as a point person, referring members to in-network specialists as needed. With an HMO, you are typically not covered for services provided out-of-network.

Point-of-service (POS): plan members choose a PCP, but also have the freedom of seeing another in-network provider, or out-of-network provider, without a referral. However, if you choose to go out-of-network without a referral from your PCP, you will typically not be covered for those services.

Preferred provider organization (PPO): a combination of HMO and POS plans. This plan lets you see any healthcare provider without requiring a PCP or special approval. With this plan, you have some coverage for visiting an out-of-network provider, but you’ll pay less when you see doctors or hospitals in the PPO plan’s network.

Fee-for-service (FFS or non-PPO): a type of plan that allows you to use any medical provider you choose. Covered medical expenses are either paid directly by the insurance company or reimbursed to you with an insurance claim.

BEFORE YOU PICK A PLAN
  • Read the summary of benefits
  • Review a provider directory for your area
  • Know whether you have prescription drug coverage, and review the list of covered drugs
  • Know how much your copays will be for different services
  • Know if the health plan includes coverage for specialty services like vision or dental
  • Know your premium cost and out of pocket costs, including a deductible
THE PCP: YOUR PARTNER IN HEALTH

Don’t wait until you get sick to choose a Primary Care Physician. Whether your plan requires it or not, a relationship with a PCP is a good idea. Take a proactive approach to your health by having regular “well visits” and exams with an individual who knows your health history and knows you. A PCP can also refer you to a specialist, should you need one.

To find a PCP, check your  plan’s list of doctors in its network who are accepting new patients, and ask your friends or family if they have doctors they like.

PRO TIPS

Be prepared. Have a sense of how much a service may cost before getting routine, specialty or emergency care. You can find information on your plans website or the summary of benefits. Your plan may also have a customer service phone number.

Prevent problems before they start. Preventive care is usually covered at no cost to you. This means you pay nothing out of pocket for services like annual physicals and gynecological exams, vaccines and more. Take advantage of these services and stay healthy!