Insurance Literacy
Understanding your insurance plan helps to manage healthcare costs and avoid unexpected expenses. To start, we recommend you review the SHIP’s Medical Plan Coverage Table.
When evaluating an insurance plan, being familiar with the following terms will also be helpful:
In-Network and Out-of-Network
- In-Network providers (doctors) or facilities (laboratories, urgent care centers, hospitals, or imaging centers) participate in your insurance plan network. The most cost effective way to seek care is to see healthcare providers that are in-network. If you have the CMU SHIP and see an in-network provider, there is no deductible.
- Out-of-Network providers do not participate in your insurance plan network. If you have the CMU medical SHIP and see an out-of-network provider, the plan will cover 80% of the cost of the service after you meet your deductible. The dental plan has different coinsurance rates.
Copays
Copays are a one-time payment at the time of service and can range depending on the service being provided. For the CMU SHIP, most copays are $0-$25. Some services have a higher copay, such as advanced imaging ($40), emergency room visits ($125), and hospital admissions ($150). You must pay the copay once for each visit where it is applicable. Prescriptions also incur a copay, but copays depend on the type of medication and frequency of refill.
Deductible
A deductible is the amount of money you pay for health care services before your insurance plan starts to pay covered expenses. It is important to review insurance plans so you are aware if there is a deductible or not. Once the deductible is met, the plan will start covering benefits as outlined in the policy.
The CMU medical SHIP has no deductible for in-network care, but there is a deductible for out-of-network care. The dental SHIP has a deductible for both in-network and out-of-network care.
Coinsurance
Coinsurance is a portion of healthcare charges that the member is responsible to pay, usually after a deductible has been met. There is no coinsurance for in-network care with the CMU medical SHIP. For out-of-network care with the CMU SHIP, you would be responsible for 20% of covered charges, after paying the deductible amount. Coinsurance rates vary depending on the plan and the service, so you must review plan(s) carefully.
Explanation of Benefits (EOB)
EOBs show the total charges for your visit and which portion of charges the health insurance plan will cover. EOBs are not bills. EOBs help you understand how much your health plan covers, and what you can expect to pay when you get a bill from your provider.
- Students can access their EOBs in the claims section of their Highmark portal.
PPO vs HMO Plans
THE CMU SHIP is a Highmark Blue Cross Blue Shield PPO plan.
- A PPO (Preferred Provider Organization) medical plan provides healthcare coverage through a network of providers, and you pay less if you use providers and hospitals within the plan's network. However, you can go outside of the network for an additional cost (see coinsurance).
- An HMO (Health Maintenance Organization) plan provides healthcare coverage through a network of providers, but you are generally limited to seeing providers within the HMO network for covered services, with limited or no coverage for out-of-network care (except for emergencies). HMO networks are generally limited to the area where the person lived at the time of their enrollment.