insurance terms

Allowed amount

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.

Coinsurance

The portion of eligible expenses that plan members are responsible for paying, most often after reaching a deductible. An example of coinsurance could be that your health plan covers 70% of covered medical charges and you are responsible for the remaining 30 percent.

Copayment

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

Covered Services

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.

Deductible

The amount that you must pay before benefits are provided for (certain) covered services.

Exclusions

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

Medically Necessary Services

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 necessary provision of medical or mental health care. Services must be medically necessary in order to be covered.

In-Network

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.

Out-of-Network

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.

Out-of-Pocket Maximum

When the 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% of eligible charges for the remainder of the year.

Plan Year

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

Preferred Provider Organization (PPO)

A type of insurance product that combines in-network and out-of-network coverage. When you use in-network (or “participating”) physicians and hospitals, you pay only a copayment for covered services. You also have the flexibility to see out-of-network (“non-participating”) providers, but you will be responsible for a deductible and coinsurance for inpatient and outpatient covered services. The Harvard Student Health Insurance Plan is a PPO plan.

Pre-Existing Condition

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.

Referral

A referral is an official order for a transfer of care for further evaluation and/or medical treatment.

Usual and Customary Fee/Allowed Amount

The common cost of a specific medical 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.

How SHIP works with another health insurance plan

When you are enrolled in the Student Health Insurance Plan (SHIP) and another health insurance plan, the SHIP is always a secondary payer. This means that all claims are processed first through your other insurance and then processed by the SHIP. To avoid any claims issues, please notify your providers of both plans. Please contact BCBS Coordination of Benefits at (888) 799-1888 for more information.