Understanding Health Insurance

The allowed amount is the maximum amount that the plan (Blue Cross Blue Shield) will pay for a covered service. If you use your out-of-network benefits and file for reimbursement, you will be reimbursed based on the allowed amount (minus your deductible and coinsurance) and NOT what the provider charges for the service. If your provider charged more than the plans’ allowed amount, you will be responsible for the difference between the two amounts, in addition to your deductible and/or coinsurance.

The percentage you pay for a covered health care service (30%, for example) after you’ve paid your deductible.

The amount that you must pay for (certain) covered services. Your copayment is usually a fixed dollar amount.

Services or supplies for which your health plan will pay (or “cover”) all or a portion of the cost. Most health plans do not cover all services and supplies, and it is important to be aware of any limitations and restrictions that apply to your covered services.

The amount you must pay for covered health care services before the insurance starts to pay for services. On the Student Health Insurance Plan, this only applies to out-of-network covered services.

Specific conditions or circumstances for which a health plan will not provide benefits.

Services or supplies which are appropriate and necessary for the symptoms, diagnosis, or treatment of a medical condition and which meet additional guidelines pertaining to the necessary provision of medical or mental health care. Services must be medically necessary in order to be covered.

A group of physicians, hospitals, and other health care providers who participate in a specific managed care plan. When you receive care from an in-network provider, you pay only a copayment for covered services when enrolled on the Student Health Insurance Plan.

Physicians, hospitals, and other health care providers who do not participate in your plan’s network. Services obtained from an out-of-network provider are subject to deductibles and coinsurance.

When the copayment, deductible, and coinsurance amounts you have paid in a plan year add up to the out-of-pocket maximum, the health plan will begin covering 100 percent of eligible charges for the remainder of the year. The out-of-pocket maximum does not protect you from balance billing when you have services with an out-of-network provider.

The time period your health plan provides coverage. The HUSHP plan year is August 1 – July 31.

A type of insurance product that combines in-network and out-of-network coverage. When you use in-network (or “participating”) physicians and hospitals, your costs will be lower than when you use an out-of-network provider. The Harvard Student Health Insurance Plan is a PPO plan.

A pre-existing condition is a health condition that existed prior to your application for a health insurance policy or enrollment on a new health plan. Examples of pre-existing conditions include pregnancy, heart disease, high blood pressure, cancer, diabetes, and asthma. HUSHP does not impose pre-existing condition clauses or exclusions.

A referral is an official order from a doctor or provider to transfer care for further evaluation and/or medical treatment to another medical provider.

The maximum amount a plan will pay for a covered health care service; this fee can be lower than what a physician charges and is based on a variety of criteria, including provider type and service region.