Insurance Terms Definitions:
Copay: The copay is a flat dollar amount that must be paid every time you (or your spouse or child) visits a doctor or has a service by a medical provider. This amount is different than your deductible or coinsurance amount. The most commonly used copay for most patients is the office visit copay, which is $10 per doctor visit for IU grad students. Each time you go to the doctor anywhere except the IU Health Center, you must pay a $10 copay. Copays also apply for various other services (e.g., there is a $200 copay for inpatient hospital admissions, a $50 copay for emergency room visits and various copays for prescriptions filled outside the IU Health Center). Check our benefits brochure (available online) for more specific information.
Coinsurance: The percentage of the medical charges that the patient is required to pay after insurance pays. This is separate from the copay and deductible and is typically calculated as a percentage. Coinsurance will not typically apply for services rendered by preferred providers. For non-preferred providers, you will typically be responsible for approximately 40% of the charges, in addition to the copay and deductible.
Deductible: Your deductible is the amount you must pay to your doctor before the insurance will start making payments to them. Our deductible is $100 for a preferred provider and $500 for a non-preferred provider, therefore you can pay up to $600 in deductible payments each year (however, you will only pay $100 if you use only preferred providers). The amount the insurance tells you that you must pay under your deductible each year should never exceed these amounts. If it does, the insurance has made an error and needs to be contacted. The deductible does not apply, under any circumstances, to services rendered at the IU Health Center.
Your deductible will reset every year (as of now, on or around August 15 th ), so that you will be responsible for the first $100 (or $500) of your medical expenses outside the Health Center each year. This applies even if you have been seeing the same doctor for years – you will still have to pay the first $100 (or $500) at the beginning of each year before your insurance will start to pay claims. Student insurance generally resets around August 15.
Preferred/Non-Preferred Providers: Preferred providers are those who have signed agreements with Aetna to accept special negotiated rates for their services. It is to your benefit to use a preferred provider whenever possible, because the costs to you will be much lower. Both the deductible and the coinsurance amount you will be required to pay are much lower for preferred providers:
|
Charge |
Negotiated Charge |
Insurance Pays |
Patient Pays |
Preferred Provider |
$1000 |
$880 |
$770 |
$110 ($10 copay and $100 deductible) |
Non-Preferred Provider |
$1000 |
N/A (full charge is billed) |
$294 |
$706 ($10 copay, $500 deductible, plus 40% of remaining charge) |
Explanation of Benefits (EOB): The detailed statement you will get from Chickering following each claim submission. It will tell you how much was charged, how much the insurance in paying, and how much you must pay via copay, deductible, and coinsurance.
Negotiated Charge: The amount that preferred providers have agreed to accept as full payment for their services when treating Chickering patients. For example, a doctor may charge $100 for an office visit. However, if they are preferred providers, they will have agreed to accept a lower amount (i.e., $78), as full payment. If you are seeing a preferred provider, you may not be billed by your doctor for the $22 difference, regardless of what your insurance pays.
Reasonable Charge: This discounted amount applies to non-preferred providers, and it is an amount determined by Aetna/Chickering without any input from the provider. Providers do not typically accept “reasonable charges” as full payment for their services. The reasonable charge is calculated from typical charges in the doctor's geographic area and the charges the insurance determines are appropriate for the services rendered. However, the patient is often still responsible for the difference between the amount charged and the “reasonable” charge as determined by the insurance. So, if a doctor charges $100 and Chickering determines that $78 is a “reasonable charge” and limits its payments to that amount, the patient may still be responsible for the $22 difference between the charge and the reasonable amount.
Claim: The itemized bill submitted to Chickering on your behalf. It lists your identifying information, along with a detailed statement of the services rendered and the charges incurred, along with the provider's name and address.
FAQs:
How do I contact Chickering? The insurance website is www.chickering.com – you can access our plan brochure, find a doctor, or check claim status online. The toll-free number is 1-877-437-6512, and is found on the front of your insurance ID card. If you are calling about a rejection or problem with an insurance payment, you need to ask for the claims department. If you are calling to find out if a service will be covered or to find a doctor in your network, you should ask for the benefits department. Insurance companies make many mistakes in processing claims and calculating payments, so if you feel they have made a mistake you should always call before paying a bill. If you don't get a satisfactory answer on your first call, call back – you'll probably get a different representative. For us poor graduate students, it is very important to stay up on your insurance claims and call on anything that seems out of the ordinary. Don't assume that they've done everything right.
I went to the doctor several months ago and they submitted a claim to our insurance, but I haven't heard anything from Chickering. What should I do? At this point you should make sure that the insurance has received the claim. A common problem with insurances is that they mysteriously “lose” several claims every month. If two months or so has passed with no payment or rejection from the insurance, you should log onto the Chickering website to check the claim status via the online system, or call the insurance to see if they have received the bill. It is important that you keep up with the claims you submit, because our insurance has a 90-day filing deadline. If the insurance doesn't receive the bill for the first time within 90 days (even if it's their fault for “not receiving” a bill you sent in), they will reject it as being beyond the filing deadline and it is very hard to get them to pay at that point. If they claim to have lost or never received the claim, ask the doctor's office to resend or fax the claim, checking the address to which they are sending the claim and patient ID number. If you are submitting the claim yourself, you can go back to the Health Center and request a reprint of your bill from the cashier and mail or fax it in yourself (the Health Center does not bill our insurance directly).
Does our insurance cover contraceptives? Our insurance does cover oral contraceptives, but not contraceptive injections (i.e., Depo-Provera). However, you must fill your oral contraception prescriptions at the IU Health Center Pharmacy to get them covered. If you fill a contraception prescription at any other pharmacy, you will have to pay the full charge ( not just the copay, but the entire cost of the prescription). If you fill it at the IU pharmacy, Chickering pays 100% of the charge. (NOTE: Your prescription does not have to be from an IU doctor). In order to get your prescription covered, you need to pay for it at the Health Center (or bill it to your bursar account), and then ask for a receipt from the cashier. Mail the receipt with a copy of the label on the outside of the prescription bag to the Chickering address on the back of the card, and you should expect a reimbursement check from Chickering in approximately one month.
Does our insurance cover prescriptions from doctors outside the Health Center ? Yes. You can take a prescription from an outside doctor to the IU pharmacy to be filled, and Chickering will pay 100% of the charges. You must submit the bill on your own as detailed in the previous question. If you prefer another pharmacy and are filling any prescription besides oral contraceptives and a few others detailed in our plan brochure, you will be responsible only for the prescription copay ($10 for generics, $20 for name-brand drugs), and the pharmacy will send the claim to Chickering for you.
What if I get a rejection saying that my insurance coverage is not in effect? Your insurance takes effect on August 15 th before your first semester at IU, and is continuously in effect until you leave the program, unless you request to end your coverage prior to leaving the program. Anytime you receive a rejection stating that your coverage is not in effect, you need to call the insurance. Occasionally this will happen around the middle of August of each year, as our insurance “resets” for the next year and the benefits are altered slightly or our group number is changed. However, once you enter the IU program your insurance will be in effect every day until you leave the program.
What if I get a rejection saying that a service done at the Health Center was not a covered benefit? Basically all services rendered at the Health Center are covered by Chickering, unless specified in our plan brochure. If you receive a rejection stating a service is not a covered benefit, it may be because of a coding issue. When providers bill for services, they will use a procedure and diagnosis code to indicate the services they performed and why you sought treatment. Sometimes the insurance will not pay for a service because the diagnosis code (the reason you were seeking treatment) was incorrect. A common example is with women's annual gynecological exams. Chickering will pay for one exam per year done at the Health Center , but the doctor must use the correct diagnosis code (an annual exam diagnosis code, not a code for contraceptive management, which is a semi-common mistake that occurs). If a claim is billed with the wrong diagnosis code and you receive an insurance rejection, you need to contact your doctor to see if they will change the diagnosis code that was used. At the IU Health Center, you need to call 855-3865 and ask for the billing department to change the diagnosis code.
I have to have a minor surgical procedure, and my surgeon wants me to have it at an outpatient surgery center. Will this cause any problems? Under our plan, any surgical procedure must be performed at Bloomington Hospital (or another local hospital, such as Dunn Memorial in Bedford). While some surgeons prefer to use outpatient surgery centers to save on time and costs (such as the Bloomington Surgery Center on West 2 nd Street or Southern Indiana Surgical Center on Tapp Road), these facilities are not in-network under our plan. Even if you have a procedure at one of those facilities using an in-network provider, it will be paid at the out-of-network rate because the facility would be out-of-network.
So what can I do? Let your surgeon know that outpatient surgery centers are not covered under our insurance, and s/he should be more than willing to perform the surgery at Bloomington Hospital. If your doctor insists on using a surgery center, seek a second opinion.
NOTE: These comparisons are purely hypothetical. Your specific claims will vary based on the types of services you had, the specific medical problem you were having, and several other factors. But in general, the amount of you have to pay will be markedly lower for preferred providers.