STATE UNIVERSITY SYSTEM
STUDENT HEALTH INSURANCE
TASK FORCE
FINDINGS AND RECOMMENDATIONS
February 2010
STATE UNIVERSITY SYSTEM
STUDENT HEALTH INSURANCE TASK FORCE
FINDINGS AND RECOMMENDATIONS
Table of Contents
I. Introduction and Overview ........................................................................................1
II. 2007 SUS Student Health Insurance Task Force ...................................................2
III. 2009-10 SUS Student Health Insurance Task Force ............................................3
A. Introduction ............................................................................................................3
B. Task Force Charge ..................................................................................................3
C. Task Force Membership ........................................................................................3
D. Student Health Insurance: Issues and Trends ...................................................4
1. SUS Perspectives on Student Health Care ....................................................4
2. National Perspective .........................................................................................6
3. Insurance Carriers Perspective .......................................................................8
4. ACHA Standards / Best Practices ................................................................10
E. Student Health Insurance: Programs and Impact...........................................12
1. Programs and Policies ....................................................................................13
2. National Update ..............................................................................................13
3. Student Health and Retention .......................................................................15
4. Financial Issues................................................................................................16
5. Student Classifications: Undergraduates, Graduates, Internationals ....17
F. Student Health Insurance: Delivery Options ..................................................18
1. Campus-based Programs ................................................................................18
2. State System Programs ....................................................................................27
3. Consortia ...........................................................................................................27
4. Reimbursement and Billing for Services ......................................................30
G. Conclusions and Recommendations .................................................................34
DRAFT
Student Health Insurance in the State University System:
Findings and Recommendations
I. Introduction and Overview
The State University System (SUS) consists of ten public universities and one public liberal
arts college, each with a distinctive mission, collectively dedicated to serving the needs of
a diverse state through excellence in teaching, research, and public service. There are over
300,000 students currently enrolled in the SUS, including over 12,000 international students
and 57,000 graduate students.
College students represent a diverse and distinctive population with individual and
specific health needs, risks, and behaviors. While college students are generally a
healthy population, they have health care needs that, if left unaddressed, can adversely
impact their academic success. Students’ academic matriculation and persistence
toward completion of a degree is directly correlated with their health status, health
behaviors, access to health care, and ability to pay for adequate health care and
affordable health insurance.
National student health trends are confirming an increasingly complex set of student
health issues that include chronic and/or disabling conditions. There has been an
increase in the number of college students with depression, attention deficit disorders,
obesity, diabetes, sexually transmitted infections, and generalized anxiety disorders that
require complex, expensive, and time-consuming treatment. In light of these trends,
colleges and universities are now prioritizing student health issues, working to
eliminate barriers to obtaining health care, and creating comprehensive services and
programs that advance student health and well-being.
Florida SUS student health and counseling centers provide diagnostic, treatment, and
prevention services designed to maintain and enhance their students’ physical,
emotional, and social health and well-being. The SUS student health centers do an
excellent job providing basic clinical and health educational services that are costeffective and meet the specific needs of their student population while serving the
mission of the university. Increasingly, the student health centers are providing
educational out-reach programs and services to students on a broad array of healthy
lifestyle issues that promote student engagement, student learning, and responsibility
for one’s health and well-being. Student health centers, however, cannot meet the
demands or the clinical need for specialty care, ambulances, hospitalization and
surgery, or long term chronic care.
As the value and impact of sufficient health insurance coverage for students becomes
increasingly understood and substantiated, greater numbers of states and institutions
are requiring students to have an adequate level of insurance. Florida’s state
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universities either sponsor or endorse one of a variety of student health insurance plans,
and specific insurance policies and programs are designed by each institution to meet
the needs of its students. Student health insurance trends and policy and program
options will be reviewed in this report.
II. 2007 SUS Student Health Insurance Task Force
The Board of Governors (BOG) Student Affairs Committee convened a SUS Student
Health Insurance Task Force in early 2007 to gather and analyze data on issues and
trends relating to options for the delivery of student health insurance programs. The
Task Force examined the impact of various types of health insurance policies and
programs and analyzed the merits and disadvantages of voluntary programs as
compared to mandatory programs. Florida State University provided a review of the
development of a mandatory insurance policy that led to approval and enactment of the
policy by the FSU Board of Trustees.
The 2007 Task Force offered the following preliminary recommendations to the Student
Affairs Committee:
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Develop a long-term, comprehensive strategy that provides support for
economically disadvantaged students.
Ensure that SUS institutions remain competitive in their ability to recruit highquality graduate students by including a subsidy specifically designated for
student health insurance.
Require each university to implement a mandatory student health insurance
program with a hard waiver option.
Encourage universities to seek out consortia, networks, or purchasing
partnerships to secure the best health insurance plan(s) based on their student
enrollments, residential populations, specific student demographic data,
geographical locations, and available on-campus services.
Require each university’s plan to comply with the Standards for Student Health
Insurance Benefits Programs, published by the American College Health
Association.
Adopt a BOG regulation that requires all international students in the SUS to
have health insurance before registering or enrolling in university classes.
Develop an SUS Operations Task Force to develop strategic action plans,
financial plans, and implementation guidelines to carry out the approved
recommendations.
The Committee directed the Task Force to continue to collect information on reasons
why students leave universities due to health and/or health insurance related issues,
student insurance programs in other states, and the impact that uninsured college
students have on the communities in which they live.
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III. 2009-10 SUS Student Health Insurance Task Force
A.
Introduction
The SUS Student Health Insurance Task Force was re-convened by the BOG Student
Affairs Committee in the summer of 2009. This action followed considerable legislative
activity in early 2009 in which numerous inquiries were made to the state universities
regarding student health insurance policies and procedures. Legislative bills were filed
mandating university billing procedures and systems for student insurance claims.
During this period, the BOG Student Affairs Committee received updated information
from university student health center directors on student health insurance policies and
programs, as well as professional analyses of proposed legislation. Committee chair
Ann Duncan requested a more detailed examination of current issues and trends from a
system-wide perspective and requested study by a SUS Task Force, based upon the
charge below.
B.
C.
Task Force Charge
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Provide an update on student health insurance issues and trends, nationally and
in Florida.
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Examine the various types of student health insurance programs, including
mandatory health insurance, available to Florida State University System
students. Analyze the impact of these insurance options on student health and
well-being, the cost of attendance, financial aid, and student fees.
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Identify and target areas where efficiencies might be gained in the provision of
health insurance to SUS students, such as consortia arrangements and
reimbursement options for medical and counseling services.
Task Force Membership
Doreen Perez, Co-Chair - Director, Student Health Services
University of North Florida
Lesley Sacher, Co-Chair - Director, Student Health Center
Florida State University
John Barnes – President, Florida Student Association
Student Member, Board of Governors. University of North Florida
Sherry Benton - Director, Counseling Center. University of Florida
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Charles Brown - Vice President for Student Affairs. Florida Atlantic University
Youndy Cook - Associate General Counsel. University of Central Florida
Darryl Marshall - Director, Financial Aid. Florida State University
Ralph Wilcox -Executive Vice President and Provost. University of South Florida
D.
Student Health Insurance: Issues and Trends
Colleges and universities offer health insurance plans to students because they have an
interest in maintaining the health of their students and helping them achieve their
educational objectives. These plans can also help students avoid high medical bills. To
offer a health insurance plan, institutions either contract with an insurance carrier or
fund their own plans. Unlike enrollees of employer-sponsored, group plans, those
enrolled in student insurance plans typically pay the full premium for coverage.
While some students may be covered under parent plans, they are often “out of
network” while on campus. This exposes them to higher deductibles and co-insurance
rates and penalties for certain providers and results in much higher out-of-pocket
expenses. Students underinsured in this way may defer needed care “until they get
home,” creating increased risks of illness.
To make decisions about the plan’s eligibility criteria, benefits, and premiums,
universities typically convene a student health insurance committee, which generally
includes institution administrators, student health center administrators, student
representatives, and parent representatives. These committees decide how the student
insurance plan will coordinate with the institution’s student health center. College and
university student health centers vary greatly in the services they provide – some offer
limited services with one nurse and others offer comprehensive services from multiple
specialists.
1. SUS Perspectives on Student Health Care
The State University System is committed to providing quality academic degree
programs and student services that will move students through its universities to
degree completion in an efficient and cost effective way. Healthy students more easily
succeed in completion of the process than unhealthy students and quality health care is
integral to general student health and well-being. The following chart depicts a life
cycle of medical and mental health care components as critical determinants of a
university student's academic success.
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The SUS Task Force surveyed selected SUS academic and student affairs front-line
professionals to gain perspective on the critical nature of student health care
services. The focus of this inquiry was on student access to quality health care in the
SUS and positive outcomes gained from these interactions. The following points
summarize the survey responses:
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Health care issues for state university students are increasingly more
complex, often requiring specialty care services and referrals.
The issue of student mental health is an increasing concern for health care
professionals due to the increasing number of serious mental health incidents
on our campuses.
State university health care services provide a comprehensive program of
high quality medical services, counseling and mental health services,
wellness education, and campus recreation.
State university student health centers are staffed with qualified, licensed
professionals and are convenient for students. All services are cost effective.
Educational health and wellness materials are available free to all students.
Student access to quality health care has direct impact on ‘student success’ as
measured through retention, class attendance and grades, time to graduation,
leadership and community engagement, and the indebtedness at the time of
graduation. Access to quality health care also impacts health education of the
students and public health of the campus and the surrounding community.
Students are able to learn personal responsibility and self-reliance for good
physical and mental health in order to develop and maintain healthy lifestyle
behaviors.
Further, students learn the life skills necessary to navigate the health care
system and utilize and manage their health insurance benefits.
All students should be provided access to health insurance, as students with
adequate health insurance have greater likelihood of being academically
successful and maintaining a healthy lifestyle.
2. National Perspective
a) The 2008 United States Government Accountability Office Report, Health
Insurance Most College Students Are Covered Through Employer Sponsored
Plans, and Some Colleges and States are Taking Steps to Increase Coverage
http://www.gao.gov/new.items/d08389.pdf) stated the following:
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Based on a generalized random sample size of 340 institutions nationwide,
62 percent of four-year private colleges and 22 percent of four-year public
colleges required full-time college students to have health insurance for
the 2007-2008 academic year. In addition, another five percent of colleges
nationwide required some students to have health insurance according to
their housing and areas of major.
The United States Census Bureau’s 2007 Social and Economic Supplements to
the Current Population Survey (CPS) stated 80 percent of 18 to 23 year old
college students in 2006 had health insurance coverage through employer
sponsored plans, other group or individual plans, student health
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insurance plans and public health options such as Medicaid and State
Children’s Health Insurance Programs.
CPS data also showed that 1.7 million college students (20 percent) did not
have health insurance in 2006, which resulted in $120,000,000 to
$255,000,000 in uncompensated health care costs.
Minority students were more likely to be in the uninsured students group.
See table below.
2006 Uninsured College Students by Race
White
15%
Asian
26%
Black
29%
Hispanic
38%
b) The Analysis and Policy Recommendations for Providing Health Insurance
and Health Care Services for the College Student Population published by
the Lookout Mountain Group (June 2009,
http://www.hbc-slba.com/LMG/LMG_abstract_3.5.pdf) reports “an estimated four
million college students without health insurance may represent the single
largest, cohesive group of uninsured Americans, between 25 and 30 percent
of college students attending four-year and graduate degree granting
institutions. Further, based on an ACHA 2007 survey, approximately 20 to 30
percent of college students attending four-year and graduate degree granting
institutions that currently have health insurance are underinsured to the
extent that in many instances, coverage is so minimal that students are
effectively uninsured.”
c) The United States Congress enacted Michelle’s Law, named after the late
Michelle Morse, effective October 9, 2009.
http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=110_cong_bills&docid=f:h2851enr.txt.pdf).
This legislation allows college students to take up to a one year medical leave
without losing their health insurance. Michelle was a full time college
student at Plymouth State University when she was diagnosed with colon
cancer. Her doctors advised her to take a medical leave while undergoing
chemotherapy, but she could not because if she did not maintain her student
status, she would lose her family's health insurance when she needed it most.
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Many students face a similar dilemma of having to choose to receive health
care or continue their education.
3. Insurance Carrier Perspectives
The SUS Task Force contacted six national insurance companies/brokers in July
2009 who currently provide student health insurance plans to universities in the
Southeast United States. Those contacted were asked to respond to five questions
pertaining to health insurance issues for postsecondary students in order to gain a
national/regional perspective. The six companies contacted were: Academic
Healthplan, Aetna, Blue Cross Blue Shield, Collegiate Risk, Pearce & Pearce, Inc.,
and United Healthcare. Summaries of their responses to five questions follow:
a) Identify trends nationally, regionally, and within Florida for the provision
of health insurance to university students.
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Nationally, health insurance products are evolving into more
comprehensive health plans, more institutions of higher education are
mandating that students have coverage, and the marketplace of providers
is consolidating.
Most Florida public universities offer voluntary health insurance plans.
Most Florida private institutions have a hard waiver policy in which a
student must either purchase health insurance or show proof of existing,
comparable coverage.
To address the increasing incidence of uninsured individuals, states,
university systems, and individual institutions are exploring the
implementation of hard waiver programs. Institutions with hard waivers
are able to lower rates and offer more comprehensive coverage.
Many student health centers are exploring ways to generate revenue,
including third party billing systems.
Institutions are offering more comprehensive coverage plans with
incentives to seek care through the student health center and in-network
providers.
b) Identify pros and cons of a consortium arrangement of universities and
state your opinion on consortia.
Pros
 Administrative economies of scale exist relating to pricing and benefits
due to combined purchasing power.
 Ability to spread risk across a broader pool of participants results in lower
premiums and broader coverage.
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With a hard waiver as a base, consortiums allow plan and rate flexibility
among the schools in the consortium.
Smaller universities benefit from the expanded risk pool.
Challenges
 Agreement of participants.
 A long-term commitment to a plan design that will meet the distinctive
needs of each institution.
 Accommodating the distinctive institutional health care services offered at
various institutions within the buying consortium.
c) Would your company be interested in a consortium for purchasing student
health insurance that maintained a voluntary status within a state
university system?
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With a voluntary program, it is difficult to maintain affordable coverage
due to an adverse selection situation where only students who are sick
purchase the coverage.
Some of the respondents felt that only one plan design should be offered,
and that all institutions must be committed to participate with only the
selected program.
Institutions would need to evaluate a number of individual carriers to
identify the best plan.
A consortium with a mandatory (hard waiver) program would be most
beneficial for institutions and their students.
Prediction: a national mandate that everyone has health insurance is
imminent.
d) What is your opinion on student health centers implementing a billing
system for insurance providers, including billing for office visits?
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There is recognition of the increasing need to diversify revenue streams
and to accommodate all students.
Many institutions are exploring billing their third party providers and
most Florida schools bill their university sponsored student health
insurance provider for charges inside the student health center.
Student health centers are encouraged to participate as an in-network
provider and bill for all services.
For a billing system to be effective, it is felt that a hard waiver enrollment
system must be maintained, as third party billing can only be effective and
affordable if a significant portion of the students are insured.
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e) What components, policies, or procedures of a university student health
insurance program will decrease costs, increase benefits, and provide for
greater efficiencies within Florida?
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A student coverage requirement is the best vehicle to reduce the number
of uninsured students, spread risk, and maintain benefits at reasonable
costs.
An initial way to decrease costs is to administer some form of a waiver,
which will reduce costs and can increase benefits.
For greater efficiency, student health centers should participate as innetwork providers.
All student plans should promote the utilization of the student health
center and should focus on the strengths of the center.
Comprehensive educational programs for students on student health
insurance, wellness, and healthy lifestyles are recommended.
4. ACHA Standards for Student Health Insurance/Benefits Programs and Best
Practices
The American College Health Association (ACHA) has instituted standards to guide
colleges and universities in the establishment of appropriate, credible student health
insurance/benefits program http://www.acha.org/info_resources/stu_health_ins.pdf.
The ACHA has recommended that all colleges and universities require that students
demonstrate adequate health insurance coverage or adequate financial resources to pay
for expected and unexpected medical expenses as a condition of enrollment.
Standard I
As a condition of enrollment, the college or university requires students to provide
evidence that they have adequate health insurance coverage.
Standard II
The college or university recognizes that students rely upon its student health
insurance/benefit program for their primary source of health insurance protection. An
adequate and appropriate scope of coverage is provided, including, but not limited to:
 Coverage for preventive health services.
 Coverage for catastrophic illness or injury.
 Coverage for prescription medications, including coverage for psychotropic
medications.
 Minimization, or ideally elimination, of pre-existing condition
exclusions/waiting periods.
 Coverage for dependents of covered students including children, spouses, and
domestic partners.
 Continuity of coverage up to plan limits for students requiring a medically
necessary leave of absence.
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 Continuity of coverage for previously insured students in plan renewals or with
new carriers (i.e., no gain/no loss provision), subject to RFP provisions and final
negotiations.
 Program benefits, limitations, exclusions, special provisions, and definitions are
reviewed to assure they are consistent with common practices of the group
health insurance field and/or there is a compelling reason for the college or
university to have a provision that is unique for its SHIBP.
 The program encourages use of campus health and counseling services, where
doing so provides cost effective and high quality care for students.
Standard III
The college or university acknowledges it has a fiduciary responsibility to manage
student health insurance/benefits programs in the best interests of students covered by
the programs.
Standard IV
The student health insurance/benefits program is annually reviewed to assure it is in
full compliance with all applicable federal and state statutes and regulations.
Standard V
Student consumers, student health program staff, and other internal or external experts,
as appropriate, are involved with the selection, monitoring, and evaluation of the
student health insurance/benefits program.
Standard VI
The student health insurance/benefits program is reviewed annually to ensure the
program: (a) meets the needs of covered individuals; (b) provides desired benefits at the
least possible cost; and (c) returns as much of the premium or fund contributions as
possible to covered individuals in the form of benefits. Reserve funds may also be
maintained to assure short- and long-term financial viability for the program.
Standard VII
Commercial insurance carriers, agents, brokers, and all others providing services to the
student health insurance/benefits program are required to provide a full description of
estimated claims, reserve estimates, administrative expenses, and all other fees. The
student health insurance/benefits program is audited periodically and the results are
provided to appropriate university or college officials and student consumers. Each
year, a summary financial report for the program is published and made available to
student consumers and campus officials responsible for management of the student
insurance/benefits program.
Standard VIII
The selection of vendors for the student health insurance/benefits program adheres to
institutional and/or applicable governmental requirements relative to competitive
vendor selection processes.
Standard IX
Agents, brokers, consultants, and program managers do not have relationships that
could be construed to be a real or potential conflict of interest. Agreements with
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consultants or brokers are fully disclosed and clearly define the services to be
performed and the compensation to be received.
Standard X
The student health insurance/benefit program is available to all eligible students
regardless of age; gender identity, including transgender; marital status; psychological/
physical/learning disability; race/ethnicity; religious, spiritual or cultural identity; sex;
sexual orientation; socioeconomic status; veteran status. (March 2008)
E.
Student Health Insurance: Programs and Impact
Colleges and universities have sponsored or endorsed student health insurance plans
for decades, with policies designed for the specific college campus. Many student
health insurance plans provide comprehensive coverage, fully complying with the
standards for college health insurance plans endorsed by the American College Health
Association. These programs provide primary coverage and counseling benefits,
catastrophic coverage, prescription drug benefits, and many have no pre-existing
condition exclusions.
1. Programs and Policies
A description of the various student health insurance policies and programs appears
below.
 Voluntary – Students have the option of purchasing the institution’s health
insurance plan, but are not required to show any proof of insurance to the
institution.
 Soft Waiver – Students are required to purchase the institution’s health insurance
plan, or have health insurance coverage comparable to the institution’s plan.
Students who claim to have comparable coverage can waive the college plan, and
are not required to provide evidence of comparable coverage.
 Hard Waiver – Students are required to purchase the institution’s plan or have
health insurance coverage comparable to the institution’s plan. Students who
claim to have comparable coverage must provide evidence of this coverage.
 Mandatory – All students are required to purchase the institution’s student
health insurance plan regardless of outside insurance coverage. There is no
ability to waive the institution’s plan.
Insurance can be viewed as the distribution of risk over a pool of healthy and unhealthy
purchasers. Prior to the 1990s, most student health insurance plans were voluntary for
domestic students. However, over the last 15 years, the premiums of such voluntary
plans have increased tremendously and the benefits have decreased, much faster than
the national average for commercial, employer-based plans. This trend in student
health insurance programs is due largely to adverse selection, as typically only those
students with existing medical problems, and/or students who believe they will need
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the insurance, actually enroll in the plan. Adverse selection pools provide a significant
challenge to insurance planning.
The self-selection of students with high utilization tends to increase the loss ratio for the
insurance carrier, which ultimately makes such insurance plans less economically
feasible to underwrite. When premiums are calculated for the subsequent policy year,
they must be increased to compensate for the excess utilization from the previous year.
Ultimately, the plan pays claims in excess of the amount at which the insurance
company can make a reasonable profit (sometimes in excess of the total premium
collected). Increased premiums exacerbate the out migration of healthy plan members
and cause the plan to be populated to an even greater extent only by those in need of
expensive medical care.
Increasingly, states, state postsecondary systems, and individual institutions are
considering health insurance requirements and alternative student health insurance
plans and coverage policies in an effort to reduce policy premiums and increase
coverage benefits. Primary factors that must be considered include:
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The health and well-being of enrolled students;
The high cost of providing services;
The number of students who do not have health insurance;
The costs to institutions of providing medical services to uninsured students;
The increasing need and demand for expanded mental health services;
The potential impact of more fees on student recruitment and retention;
The potential negative reaction from students, parents, and authorities.
Some states and higher education governing boards have implemented health
insurance requirements for college students. States are finding that a mandatory
requirement for insurance for all students serves to replenish the insured pools with
healthy candidates, resulting in lowered utilization, healthier pools, and improved
policy coverage for those who already have insurance. A number of states and
institutions that have implemented a mandatory student health insurance program
have been able to make significant additional wellness and mental health services part
of their programs. These policy decisions are attempting to address the rapid growth in
the need and demand for comprehensive and critical counseling and mental health
services for today’s college students.
2. National Update
According to a 2007 Maryland Health Care Commission report by the Commonwealth
Fund, about 38 percent of U.S. public universities and 79 percent of private universities
and colleges require students to have health insurance as a condition of enrollment.
While several states have considered legislation to mandate health insurance coverage
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for college students, only a few states have acted. Six states (California, Idaho, Illinois,
Massachusetts, Montana, and New Jersey) have a state legislative mandate that fulltime undergraduate students who are U.S. citizens must have health insurance in order
to enroll.
a. The SUS Task Force conducted a telephone survey in June 2009 of university
governing bodies in all 50 states to ascertain which states had a mandatory
health insurance policy for students in it university system. Due to differences
in governance that exist, responsibility for health insurance oversight was
difficult to ascertain. When possible, additional information was retrieved via
internet searches.
At the time of the survey, the governing bodies of 14 states (28%) had a
mandatory health insurance requirement for full time college students, 20 states
(40%) had universities within the state university system that had a mandatory
insurance requirement, but the requirement was not yet statewide, and 16 states
(32%) did not have universities with a mandatory health insurance requirement.
June 2009
b. In 1968, New Jersey passed the following statute requiring health insurance for
full-time college and university students:
N.J.S. 18A: 62-15. Health insurance coverage required for full-time students at
institutions of higher education. a. Every student enrolled as a full-time student at a
public or private institution of higher education in this State shall maintain health
insurance coverage which provides basic hospital benefits. The coverage shall be
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maintained throughout the period of the student’s enrollment. b. Every student enrolled
as a full-time student shall present evidence of the health insurance coverage required by
subsection a. of this section to the institution at least annually, in a manner prescribed by
the institution.
d. The Idaho State Board of Education instituted the following policy and
procedure in 2003:
III.P.16 Mandatory Student Health Insurance
Every full-fee paying student (as defined by each institution) attending classes in
Idaho shall be covered by health insurance. Students shall purchase health
insurance offered through the institution, or may instead, at the discretion of each
institution, present evidence of health insurance coverage that is at least
substantially equivalent to the health insurance coverage offered through the
institution. Students without evidence of health insurance coverage shall be
ineligible to enroll at the institution.
3. Student Health and Retention
Student retention and academic success are top priorities of universities, their
institution leadership, faculty, staff, and students. Much of the research on why
students are not successful and leave, however, does not provide classifying reasons
and fewer yet investigate health as a factor. A few studies have identified the positive
associations between academic success, health behaviors, and status, and indicate that
health-related problems affecting academic success and retention are many and varied.
These include smoking, alcohol use, health-related quality of life, social support, and
maladaptive coping strategies.
It is generally understood that healthy students are more successful students. Students
in good health can take advantage of educational opportunities better than those who
avoid or delay healthcare because of being uninsured or under-insured. Untreated or
under-treated illness may render students too ill to continue or may limit their learning
ability while enrolled.
Colleges and universities have an increasing interest in providing for and promoting
adequate health insurance for students in order to ensure their continued participation
as students and to protect the university’s investment in recruitment and retention of
those students. Student health insurance plans coordinate care with the campus health
service and the local community providers to ensure access to the best medical care, as
not all student health issues can be resolved at campus health centers. Referrals to offcampus or specialty providers are often needed and usually incur a high cost for the
student. Growing bills for health care may place educational costs out of reach for some
students or serve as a strong distraction from the learning environment.
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4. Financial Issues
College-age adults are generally healthy and are commonly at a lower income earning
stage of their life. For students, the likelihood of major medical expenses seems remote
and the benefit of health insurance is not readily apparent. College students face
challenges in obtaining health insurance. Students may not have access through an
employer and, as they get older, they may lose dependent coverage obtained through a
parent’s plan; although there is discussion with the current pending health care reform
legislation that the age for inclusion in parental health insurance policies may be
increased to 27 years old for students.
Going without health insurance coverage can have significant short and long-term
implications. The uninsured are far less likely than those with coverage to have a
regular source of care, which compromises access to needed medical services,
particularly preventive care. Inadequate health insurance coverage leaves college
students and their families at risk for high out-of-pocket costs in the event of serious
illness or injury. An uninsured student is often not prepared to handle the financial
burden of an accident or illness and may be faced with one of four choices: withdraw
from their planned education in order to work and gather income to cover the medical
expenses, seek public assistance, borrow to cover the expenses, or simply default on
fees for medical care. The cost of this uninsured care may be passed on to state and
federal payers, such as Medicaid or as uncompensated care to be paid by the citizens of
the local communities. According to the 2008 GAO Report, the 2005 Medical Expenditure
Panel Survey from the Department of Health and Human Services (MEPS) analysis stated
that 18 percent of uninsured college students incurred uncompensated care in 2005.
This report acknowledges that the $120 million to $255 million of uncompensated care
incurred by uninsured college students for non-injury related medical care is
understated and was primarily for visits to office based providers and hospital
emergency rooms.
State university student health centers report seeing various types of students who
withdraw from the institution because of unmanageable medical bills. Due to the lack
of health insurance that would cover medical bills, these students are unable to pay
their education bills. Further, there are international students who take a leave of
absence from their program of study to return home for surgery or other expensive
medical procedures. Often, a university is able to provide temporary measures, shortterm loans or other programs, to help these students, but many of these students end up
dropping out of the university because they cannot pay unexpected medical bills.
The approach an institution uses to cover the health insurance premium can affect
affordability. Most universities that require health insurance fold the insurance
premiums into the institution’s overall cost of attendance (COA). This approach
enables students to receive financial aid to pay for their health insurance premiums.
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COA expenses qualify for financial assistance from scholarships, work studies, federal
aid and student loans. Students may find health insurance coverage more affordable if
health care coverage is included as a component of COA.
As colleges and universities are increasingly requiring some form of health insurance
for their students, many universities are looking into ways to help students afford
adequate health insurance coverage by broadening the school’s definition of cost of
attendance. In general, the COA covers tuition, room and board, transportation, books
and miscellaneous expenses. The average COA estimates that are calculated by
individual universities within a state system, however, vary considerably, even within
the same region. Costs for full-time and part-time students are not calculated
consistently around the U.S. More importantly, these estimated costs also vary based
on policy decisions made by the universities.
Colleges and universities compete for students based on the cost of attendance, and
there has been concern that implementing a health insurance coverage requirement
would become a disadvantage in attracting students. Public institutions are particularly
concerned about adding a new fee because public colleges have lower annual tuition
than private colleges and the addition of an insurance premium to student fees results
in a larger percentage increase in the cost of attendance (COA). However, there has
been no research to substantiate these concerns.
5. Student Classifications: Undergraduates, Graduates, Internationals
The Florida SUS System currently enrolls over 300,000 students, including
approximately 234,000 undergraduate and 57,000 graduate students. Approximately 37
percent are ethnic minorities and 57 percent are females. The SUS enrolls over 12,000
international students, a majority of them being graduate students. The SUS awards
approximately 70,000 degrees annually, including nearly 18,000 graduate degrees.
Student Classification Issues
Graduate Students
Talented graduate students are the foundation of much of the State universities’
cutting-edge research and they provide valuable, competent assistance to faculty in
teaching laboratory skills and beginning undergraduate courses. Their supervised
teaching also provides them with valuable experience as they prepare to become the
next generation of faculty for our state and national higher education systems.
Outstanding graduate students can actually help the universities lure top faculty.
There will be an increased need for incentive packages for graduate students as the
State University System strives to produce more graduates, in general, and specifically
more graduates in targeted areas, particularly given that students in many of the
targeted areas are offered such competitive incentive packages at peer institutions.
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Graduate assistants, teaching assistants, and research assistants tend to choose
universities that provide health insurance as a benefit as they are no longer eligible to
receive health insurance benefits through their parents due to age or enrollment
restrictions. As previous task force research demonstrated, this policy exists in states
surrounding Florida and in other parts of the United States. Currently, the University
of Florida, University of Central Florida, and Florida A & M University pay 100 percent
of the graduate student teaching assistants’ health insurance premiums.
Many Florida educators believe that the graduate student population requires
immediate attention regarding health insurance as a fully covered benefit for graduate
assistants and teaching assistants. Florida must ensure that it remains a viable
competitor for superior, advanced master’s level and doctoral level students who attract
and maintain research dollars.
Domestic Undergraduate Students
According to the 2008 United States Government Accountability Office Report, Health
Insurance Most College Students Are Covered Through Employer Sponsored Plans, and Some
Colleges and States are Taking Steps to Increase Coverage, 80 percent of 18 to 23 year old
students currently have health insurance coverage through their parents. The 20
percent who are not insured are more likely to be minorities and cannot receive
financial aid to purchase health insurance unless health insurance is mandatory.
International Students
This population has a mandatory health insurance requirement in place for
international students with a visa status of F1,2 and J1, 2, but does not have the local innetwork providers requirement, which can result in effectively being uninsured if there
are not providers in the local area.
Veterans
Student veterans can access health care through Veterans Administration (VA) clinics.
Recent changes in veteran benefits will allow the VA to contract with student health
centers to provide care to veteran scholars.
Part-Time Students
This population is usually exempt from a mandatory health insurance requirement if
they are enrolled in six hours or fewer per semester.
F.
Student Health Insurance: Delivery Options
1. Campus-based Programs
In recent years, large insurance companies such as United Health Care, Blue Cross Blue
Shield and Aetna have entered the student health insurance market to establish a
market hold, and most of the small independent companies have either left Florida or
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gone out of business. These large insurance companies understand the world of
insurance and the coverage needs of students and a number of company representatives
have indicated that student health policies can be reasonably priced with good benefits
if students are required to show proof of insurance.
Each Florida state university currently provides some health insurance coverage to its
domestic students on a voluntary basis except for Florida State University which has
required proof of insurance as a requirement of attendance for new incoming students
since the fall 2007 semester. All schools require proof of insurance as an admissions
requirement for international students. There are various brokers and insurance
companies representing the 11 state universities. At the present time, no university
goes out to bid with another university. The front end (bidding) is a time consuming
process handled by different departments in each university, resulting in a duplication
of negotiations across the 11 schools in the SUS.
Insurance Premiums
Florida SUS students are offered health insurance coverage at varying price points. For
the 2008-09 academic year, university sponsored domestic health insurance plan costs
have ranged from $4.94 to $20.27 per $1,000 of coverage. This is due to the student
population in general, followed by the number of policies purchased and frequency of
policy utilization specifically. The following chart contains the current student health
insurance premiums as reported by each university’s student health center (SHC)
director or designee.
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Coverage Benefits
Maximum benefits are also uneven across the SUS, ranging from $50,000 to $250,000.
As an example, a student who attends and purchases the university sponsored health
insurance plan at Florida Agricultural and Mechanical University (FAMU) has a plan
with a higher premium per dollar of coverage and significantly lower benefits than the
student who purchases the university sponsored plan at the University of Florida (UF).
This is due to the distribution of risk factor that insurance underwriters use to
determine the population to be covered, how many policies will be purchased, and how
often claims will be filed.
Due to the inconsistencies in health insurance coverage throughout the SUS, students
have different financial responsibilities for medical care depending upon which
university they attend. Additionally, students who have existing health insurance
through their parents or other sources may have plans where the coverage does not
meet the average SUS plan. Those students may experience financial hardships due to
the lack of adequate coverage. Examples of fees students would be responsible to pay
according to the 2008-09 health insurance policy available through the university the
student is attending are listed below.
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Note: Calculations were made according to each university’s student health insurance plan
assuming the student went to an in-network provider for maximum coverage and that the
student had not received services year-to-date so that the annual deductible applied.
 Scenerio #1: A domestic student must have an emergency appendectomy and a
24 hour hospital admission. The total “in-network negotiated rate” hospital bill
is $20,000 ($4,000 was surgeon’s fee). The amount a student would be
responsible to pay ranges from $1,180 to $17,000 according to the individual
university’s health plan or $20,000 if the student does not have any health
insurance.
Example: FAU (($20,000 bill - $400 deductible) x 80% = $15,680 paid by
insurance company).
University
FAMU
FAU
FGCU
FIU
FSU
UCF
UF
UFShands
UNF
USF
UWF
No Ins
Coverage In-Network
Hospital =80% ($1,000/day max); surgeon
=80% ($2,000 max)
$400 deductible; hospital & surgeon = 80%
$150 deductible; $150 copay; hospital &
surgeon=80%
$100 deductible; hospital & surgeon=80%
$100 deductible; hospital & surgeon=80%
$300 deductible; hospital & surgeon=80%
$200 deductible; hospital & surgeon=80%
to $10,000, then 100%
$200 deductible; hospital & surgeon=90%
to $10,000, then 100%
$100 deductible; hospital & surgeon=80%
$300 deductible; hospital & surgeon=80%
$100 deductible; hospital =90%
($1,600/day max); surgeon =90% ($5,000
max)
No insurance Coverage
Insurance
Student
Pays
Responsibility
$3,000
$17,000
$15,680
$4,320
$15,760
$4,240
$15,920
$15,920
$15,760
$4,080
$4,080
$4,240
$17,840
$2,160
$18,820
$1,180
$15,920
$15,760
$4,080
$4,240
$5,200
$14,800
$20,000
 Scenerio #2: A domestic student fractures an ankle skateboarding across
campus. After being seen at the student health center, the student is sent to an
orthopedist for casting and follow up visits. The total “in-network negotiated
rate” for the casting and orthopedic follow up is $950. The amount a student
would be responsible to pay ranges from $ 40 to $462 according to the individual
university’s health plan or $950 if the student does not have any health
insurance.
Example: UCF (($950 bill - $200 deductible) x 80% = $600 paid by insurance
company).
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University
FAMU
FAU
FGCU
FIU
FSU
UCF
UF
UNF
USF
UWF
No Ins
Coverage In-Network
80% ($1,500 maximum)
$20 copay; presume 2 visits
$150 deductible; $25 copay, presume 2
visits
$100 deductible; $40 copay for specialists,
presume 2 visits
$100 deductible; $10 copay, 80% covered,
presume 2 visits
$200 deductible; 80% covered
$100 deductible; $25 copay for specialists,
presume 2 visits
$100 deductible; $40 copay for specialists,
presume 2 visits
$300 deductible; $20 copay, 80% covered,
presume 2 visits
$100 deductible; 90% covered
No insurance Coverage
Insurance
Student
Pays
Responsibility
$166
$784
$40
$930
$200
$750
$770
$180
$664
$286
$600
$800
$350
$150
$770
$180
$488
$462
$765
$185
$950
Loss Ratios
Insurance companies look at an institution’s loss ratio history to determine policy
prices. A loss ratio is the difference between the premiums paid to an insurance
company by the policyholders and the claims paid out by the insurance company on
behalf of the policyholders (claims paid divided by the premiums received). For the
universities in the SUS, the policyholder is the student who purchased the health
insurance plan. For example, if the insurance company collects $100,000 in premiums
and pays out $60,000 in claims, then the loss ratio is 60%. Insurance companies
calculate the loss ratio for each university by calculating all the premiums received from
all the policyholders and all the claims paid out on the behalf of all the policyholders.
The higher the loss ratio, the less profit the insurance company realized which impacts
policy prices for the next negotiated time period. Increased numbers of policyholders
decreases the insurance company’s financial risk and usually the loss ratio. Loss ratios
of 75% or less are preferred by the health insurance companies.
Loss ratios were requested from the SHC Directors for those universities in the SUS for
the 2006-07 and 2007-08 academic years. Loss ratios were requested from all 11 schools
in the Florida SUS; seven universities responded with their loss ratios as shown on the
Loss Ratio Chart below.
Note: for those schools who showed separate loss ratios according to student age, those ratios
were averaged together for one total loss ratio.
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Loss Ratio 06-07
Loss Ratios
Loss Ratio 07-08
200.0%
199.0%
182.0%
180.0%
160.0%
140.0%
126.0%
120.0%
80.0%
95.0%
92.0%
100.0%
89.0%
75.0%
60.0%
60.0%
71.0%
65.5%
50.6%
76.0%
71.0%
48.2%
40.0%
20.0%
0.0%
FAU
FGCU
FSU
UCF
UF
UNF
USF
Policy premiums for those same seven universities are shown for the 2006-07, 2007-08,
and 2008-09 academic years.
Note: For those schools with multiple premium prices according to patient age, the cost for
those students under the age of 26 years was utilized for equitable comparisons.
Policy Premiums
$1,800
$1,600
$1,400
$1,200
$1,000
$800
$600
$400
$200
$0
FAU
FGCU
FSU
UCF
UF
UNF
USF
Insurance Premium 06-07
$1,004
$1,347
$1,449
$1,834
$1,375
$883
$1,196
Insurance Premium 08-09
$1,182
$1,554
$1,404
$1,236
$1,350
$976
$1,364
Insurance Premium 09-10
$1,222
$1,222
$1,250
$1,384
$1,391
$1,105
$1,539
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The Florida State University Student Health Insurance Program
o Florida State University (FSU) began phasing in mandatory health insurance for
full-time students in fall semester 2007. Newly enrolled students were required
to either purchase the student health insurance plan or verify existing coverage
via an online waiver program. Each new academic year, another incoming
group of students has had to meet the mandatory health insurance requirement,
which has resulted in increased enrollees in the student health insurance plan.
o Health insurance purchase is eligible for inclusion in “cost of attendance” for
financial aid consideration.
o Informational videos for parents and students are posted on the health center
website.
o Online tutorials are posted on the health center website for purchasing the
student health insurance or waiving insurance by entering current insurance
information.
o Registration is blocked until insurance purchased or waived. The block is
automatically lifted electronically upon completion.
FSU Health Insurance Premiums
o Since the implementation of mandatory health insurance, the number of policies
sold has increased resulting in a premium decrease. The loss ratio for the 20062007 academic year, prior to mandatory health insurance, was 110%.
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Annual Insurance Premium at FSU
$1,500
$1,300
$1,449
$1,440
$1,404
$1,250
$1,100
$900
$929
$700
$500
2006-2007
2007-2008
2008-2009
2009-2010 option 2009-2010 option
1
2
Maximum Health Insurance Benefits at FSU
$300,000
$250,000
$250,000
$250,000
$250,000
$200,000
$150,000
$100,000
$100,000
$50,000
$30,000
$0
2006-2007
2007-2008
2008-2009
2009-2010
option 1
2009-2010
option 2
o Students over the age of 24 years old have experienced an even greater reduction
in premiums.
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Changes in Benefits & Premiums at FSU From 2006-07 to 2009-10
2009-10
17-24 Year Old Students
2009-10 Basic
Comprehensive
Percentage Benefit Change
833.30%
333.30%
Percentage Premium Change
-13.7%
-35.9%
25-34 Year Old Students
Percentage Benefit Change
Percentage Premium Change
35 Years & Older Students
Percentage Benefit Change
Percentage Premium Change
2009-10
Comprehensive
833.3%
-28.2%
2009-10
Comprehensive
833.3%
-43.4%
2009-10 Basic
333.3%
-46.6%
2009-10 Basic
333.3%
-57.9%
2. State System Programs
A review of recent state action shows that New Jersey and Massachusetts require
student health insurance coverage for its public university students. In many states,
including California, Florida, Idaho, Illinois, Maryland, Minnesota, and Montana, there
are public institutions that require insurance coverage. Currently, a number of states
are conducting state-level reviews of student health insurance coverage requirements,
including Florida, Maryland, Maine, New Mexico, New York, Oregon, Pennsylvania,
Texas, South Carolina and Utah. The North Carolina Board of Governors recently made
the decision to implement mandatory health insurance with a hard waiver for state
university students effective the 2010-11 academic year.
It is reported in the 2008 United States Government Accountability Office (GAO)
Report, Health Insurance Most College Students Are Covered Through Employer
Sponsored Plans, and Some Colleges and States are Taking Steps to Increase
Coverage, that during the course of the GAO research, 37 student health insurance
purchasing consortiums comprised of over 500 colleges were identified for the 20072008 academic year.
3. Consortia
Colleges and universities increasingly are jointly purchasing health insurance through
consortia and these partnerships are able to increase the availability of health insurance
for college students and the number of students who are insured. Consortia are groups
of colleges and/or universities that join together to participate in and pool resources for
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a common goal, such as purchasing. Consortia can provide institutions of all sizes and
levels of complexity with a method to purchase health insurance and offer it to their
students when the individual institution may otherwise be unable to do so. Consortia
and/or purchasing partnerships are currently found in the following states: Arizona,
Georgia, Kansas, Massachusetts, Minnesota, Montana, North Carolina, South Carolina,
North Dakota, South Dakota, and Tennessee.
Consortia Activity in the US Southeast States
The SUS Task Force researched student health insurance policies, programs, and
purchasing arrangements in selected southeastern states. Georgia, South Carolina,
North Carolina and Tennessee have some or all of their state universities participating
in student health insurance buying groups or consortiums.
a) Georgia
 A buying group began with the University of Georgia and Georgia Tech
voluntarily working together to form a student health insurance
purchasing group.
 At a later time, the issue went to the Board of Regents and the buying
group was expanded to include research institutions and medical schools.
 Five years ago, the Georgia Board of Regents instituted mandatory health
insurance for 50 categories of students at all Georgia colleges and
universities and set minimum insurance requirements.
 The mandatory insurance program is a hard waiver system where a
student must either show comparable health insurance coverage or
purchase the student health insurance plan offered by the institution.
 Pearce & Pearce, the insurance broker, verifies all hard waiver insurance
policies twice per academic year. The student is only required to enter the
hard waiver information once per academic year. The cost for Pearce &
Pearce to verify the insurance policies is built into the premium price so
that the academic institutions do not bear an additional cost for the
service.
 Verification of insurance in a hard waiver system is critical for program
success and ensures all students have current health insurance coverage
with local in-network providers in the region where the student attends
school.
 Georgia has had success with their consortium due to the flexibility of the
colleges and universities who participate in the program.
 Georgia has had three plans for the participating schools to choose from
and each school selects the plan they would like to offer at their individual
school.
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b) South Carolina
 The University of South Carolina and Clemson started a voluntary
purchasing group four years ago.
 A total of seven schools have joined the voluntary purchasing group to
date.
 Each school designs the limits and options desired for that individual
school’s student health insurance plan.
 The South Carolina State Budget Control Office facilitates and negotiates
the insurance plan bid process.
 For the 2010-11 academic year, South Carolina is proposing mandatory
insurance for all state universities to broaden the risk pool, increase
benefits, and decrease premiums.
 South Carolina has had one insurance plan for all schools participating in
the purchasing group.
c) North Carolina
 Six years ago, seven institutions formed a voluntary purchasing coalition;
some schools implemented a hard waiver system and some did not.
 All students who were enrolled for six or more hours had to purchase
insurance or enter their insurance information into a hard waiver system
showing the student had existing comparable health insurance coverage.
 The first year, seven institutions participated. By the fourth year, 13
institutions participated.
 Most recently, five different plans have been offered and each institution
may select the plan they would prefer to offer at their individual campus.
 There has not been an increase in the student health insurance premiums
in five years while benefits have increased.
 Until recently, the University of North Carolina at Chapel Hill and North
Carolina State University have not participated in the purchasing
coalition.
 Effective fall 2010, the State University System Governing Board has
approved that all 16 North Carolina institutions will institute a mandatory
health insurance requirement with a hard waiver system.
 The Request for Proposal is currently in process. With the new
mandatory health insurance policy for all state universities and the size of
the buying group, it is expected that a $1,000,000 policy can be written for
an approximate annual premium of $700. An additional expectation is
that the new plan will have intercollegiate sports coverage of $3,000 with
an option to purchase up to $7,500 in coverage.
 An example of the success of implementing a hard waiver system exists
with the University of North Carolina at Charlotte (23,000 students).
When student health insurance was voluntary, 300 policies were
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purchased. When student health insurance became mandatory with a
hard waiver verification system, 6,000 policies were purchased. A larger
volume of plans sold reduced the overall risk and allowed for a better
plan at a lower premium.
d) Tennessee
 The Tennessee Board of Regents has recently formed a buying group with
28 schools in the state.
 Student health insurance will still be voluntary with the exception of
international students, and a hard waiver will not be required.
 The first year will offer limited benefits and higher premiums due to the
voluntary participation status for students, which results in a decreased
risk pool, higher premiums and lower benefits.
Consortia or purchasing partnership plans can provide useful models to capture
efficiencies with a state postsecondary system. With a state system level consortium or
with a consortium of selected institutions, students in the SUS could purchase increased
health insurance coverage at a reduced premium if health insurance packages were
negotiated statewide with the increased purchasing power of a large buying group.
Most plans allow students to transfer within the system and maintain their health
insurance without interruption. Further, students would have the benefit of being part
of a large purchasing group so that the student that attends the university with 10,000
students has the same health insurance available as the student attending the university
with 45,000 students.
4. Reimbursement and Billing for Services
A variety of policies and procedures are in place among the state universities to conduct
billing of insurance companies for services rendered. Below are summaries of
procedures at selected universities:
Florida Atlantic University
For students with FAU health insurance, an Excel spreadsheet containing the student’s
identification information, date of services, diagnosis/ICD-9 coding, CPT coding, and
charges is generated from the Clinic’s PyraMED Medical Software System. This
spreadsheet is stripped of student ID numbers/SSN and the insured member’s
insurance ID number is substituted. The secured website for United Healthcare
Insurance is accessed and the above spreadsheet is uploaded. The uploaded
spreadsheet is then checked by United Healthcare Insurance for accuracy in ICD-9 and
CPT coding. If this passes scrutiny, the member insurance ID numbers and
demographic information (name, date of birth) are checked for accuracy. If all checks
are error free, a message is returned that “all claims have been successfully uploaded”.
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Any charges, including insurance co-pays and rejected claims, are direct-billed to the
student’s university financial account as a generic health services charge.
Approximately 7-10 business days later, a check and Explanation of Benefits (EOB) are
received from United Healthcare Insurance outlining which claims were paid or denied
along with an explanation for denial (if applicable). No charges are assessed for
counseling center visits and services.
For students without health insurance, any fee for service charges incurred are directbilled to the student’s university financial account as a generic health services charge.
Students with other medical insurance may choose to submit a claim for reimbursement
to their insurance company. NOTE: Many do not file a claim because the charges
assessed for their clinic visit are less than the standard office visit co-pay charge
dictated by their insurance carrier.
Florida State University
The Front End Process: Students are told to bring their insurance card for each visit to
the health center. When the student arrives for an appointment, the clerk scans an
image of the insurance card into the Medicat system (the practice management and
electronic medical records system). The scanned image will not populate or update the
insurance screen, so the clerk also manually adds the student’s insurance information.
The clerk then asks whether the student would like fees, if any, associated with their
appointment to be billed to their insurance. Depending on the response, the clerk will
mark the visit in the Medicat system accordingly. At the conclusion of the
appointment, the clinician will have selected various codes which may result in charges
that will appear on the student’s ticket. The ticket is a detail of the medical procedures
performed that have associated fees. After the student’s claim has been processed by
the insurance company, any charges due become the responsibility of the student (copays, deductibles, co-insurance) on their University account.
The Back-end Process: Tickets associated with insurance by the clerks are reviewed by
Billing Office staff. Their review includes checking the completeness and accuracy of
the insurance information, reviewing the medical procedure coding applied during the
student’s visit to ensure it is complete, accurate and that expected relationships between
the codes exist. During review, if the Billing Office staff notices any errors or missing
data, it is their responsibility to either make appropriate corrections or to forward to the
responsible staff member for resolution. Once the claims are reviewed, the Medicat
system is used to generate an electronic billing file for submission to our third-party
insurance claims processor. The third party processor performs their own edits, then
forwards the claims to the appropriate insurance company.
After the respective insurance companies have reviewed their claims, an Explanation of
Benefits (EOB) and, ideally, a check are sent to the health center. Using the EOB, which
detail amounts paid and not paid (including explanations), the information returned by
the insurance company is recorded in the Medicat system. Unpaid claims may be
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placed on the student’s university account. This is done through an automated upload
process.
The importance of the review process cannot be minimized. Accurate (clean) claims
improve cash flow. Returned claims must be corrected and resubmitted. Each time a
claim is handled, costs occur. The Billing Office conducts regular training with nurses
and clinicians to address common coding errors, communicate changes, and questions.
University of Central Florida
Patients are asked when they make their appointment if they have insurance. If so, they
complete an authorization form and their insurance card is copied. The information is
loaded into the electronic practice management system (PyraMED) and the insurance
data is electronically linked to the appointment.
When the provider enters the procedure and diagnostic codes, the system automatically
assigns the associated charges to a pending insurance file. Then, the billing specialist
selects various accounts or carriers to be billed and electronically bills all charges.
Three employees in the insurance department are cross-trained to perform all the billing
functions. The health center normally bills once or twice per week, but can do it daily if
needed. The RealMED automated clearing house has been used for all billing for the
past three years. However, the health center has been electronically billing insurance
for ten years.
University of Florida
The UF Student Health Care Center uses a complete electronic practice management
system called PyraMED that includes scheduling, electronic medical records, and
billing functions. UF SHCC currently uses a "bulk billing" process to submit claims to
the university sponsored student insurance companies. Essentially, information is
imported into an Excel spreadsheet from the billing module of PyraMED and sent to the
company by uploading the file to a secure web server. The company then verifies
coverage, ensures that the maximum benefits have not been reached, and makes
payment on one check as opposed to adjudicating each individual claim based on
diagnosis and service provided. Any charges that are denied are then transferred to the
student’s university bank account.
If the student is not insured or owes the coinsurance on a service provided, these
charges can either be paid at the UF SHCC cashier on the same day of service or the
charges will be transferred to the student’s university bank account. If the student does
not pay the fees on the university account, holds will be placed on activities like
registering for classes or picking up football tickets.
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Should a student be insured by a private insurer and want to submit a claim for
reimbursement, he/she can come to UF SHCC insurance office to receive a copy of the
paper claim form (CMS-1500). The health center will mail the form for them however,
the insurance company is instructed to pay the student directly. Should the insurance
company pay the health center instead, the center will either credit the student’s
account or refund them via check if they have already paid the charge.
University of North Florida
The UNF Student Health Services (SHS) uses ledger billing for students with the Blue
Cross/Blue Shield student insurance policy. At the beginning of each semester,
Collegiate Risk Management sends SHS a check for an estimated amount to pay for
covered services. Each time a student receives a service, the amount is deducted on the
ledger. If patient services exceed the amount in the ledger, a request is made for
additional funds to cover the remainder of the semester. The students do not pay any
money out of pocket under the ledger billing system. Students are only responsible for
their co-pay for prescriptions.
University of South Florida
The USF SHS implemented third party billing in October 2008 through collaborative
agreements with USF Health (USFH) and University Medical Services Assoc (UMSA).
Below is an excerpt from the Intra-University Agreement between SHS and USFH.
The USF Practice plan has the sole authority to bill, collect and account for payment
from a student patient’s payer for charged services in the USF Student Health Services
facility. The Practice Plan is not authorized or responsible to collect any office visit copayments or deductible amounts related directly from USF students for charged
services provided in the Health Services facility. This waiver of payment or co-payment
and deductible amount does not apply to any other services provided at USF or any
other location.
Therefore, the health fee only eliminates the out of pocket expenses for an office visit
but not for any other service rendered by USF-SHS. For insured patients, the office visit
co-pay is automatically waived. Furthermore, if there is a co-insurance or if a
deductible is applied to the office visit charge, it is waived as well. However, any other
services rendered applied to the deductible or co-insurance will be the patient’s
responsibility.
The decision by a college or university to implement a billing system for insurance
charges often represents a change in both philosophy and process for its student health
center in that it may include a number of discrete components including: contracting
with commercial vendors, credentialing physicians, customer service, and revising
procedures that capture insurance information, collect monies, automate processes for
information management, and conduct audits. Billing of insurance claims can be
complex for some, but also simply an additional process for institutions that have been
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working with voluntary institutional insurance programs. Additionally, institutions
with medical centers serving the local and campus community are already experienced
in such systems.
When health insurance policies are mandated, institutions are often able to retain the
flexibility to determine the most effective and efficient way of billing insurance
companies. What works for one institution might not work for others. Research on
student health insurance billing systems found that billing becomes a natural and
logical outcome of implementation of a mandatory policy, and billing system
partnerships and consortiums can provide efficiencies of operation and services.
G.
Conclusions and Recommendations
Student health insurance is a significant U.S. health care issue, is at the forefront of the
national debate on health care reform, and has become a critical point of deliberation in
the U.S. Congress during the task force’s period of activity. At the time of the writing of
this report, federal legislation has yet to be passed and continues to be considered in
both houses of Congress. The State University System Student Health Insurance Task
Force has continued to monitor this national debate, however, and to analyze proposed
legislation as it relates to student health insurance issues.
The 2010 report represents an examination of the complex issues of student health
insurance by a SUS Task Force with a broad representation of university constituencies.
Conclusions were reached and recommendations were developed following a review of
the current national health care reform deliberations, an update of other state and state
system policies and purchasing plans, and an examination of existing SUS insurance
policies and programs.
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CONCLUSIONS
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Health Insurance for University Students
Health insurance is now a critical factor in the delivery of student health care on
university campuses as there is correlation between students’ health and wellbeing and their academic matriculation and persistence toward degree
completion. The following factors apply:
o Trend toward more complex health issues with an increased need for
higher level of medical care: emergencies, acute illness, hospitalization,
surgery, chronic/long term care.
o Recognition of a direct financial impact of unexpected accidents or major
illness.
o Availability of more competitive insurance plans with improved
affordability for students and enhanced benefits.
o Growing demand for more comprehensive mental heath and counseling
services, with increasingly critical issues affecting students.
Student health insurance plans offered by colleges and universities are
customized to reflect the institution’s priorities in making insurance premiums
affordable for their students while providing coverage that meets distinctive
student and campus needs.
University students without adequate health insurance defer necessary
preventive, medical, and mental health care, and assume extraordinary health
and financial risks at a time when health care and finances are closely tied to
their potential for academic success.
There is a significant financial impact on local Florida communities for nonreimbursed health care for uninsured and underinsured college students.
State University System Student Health Care
Each of the 11 institutions in the State University System has a unique student
population, based on its history, size, geographic location, academic program
offerings, complexity, and technological sophistication. Accordingly, each
campus has unique health care needs that may extend beyond the basic, primary
care services.
The distinctiveness of each state university dictates the health care services
provided by that institution. These services range from student health centers
with comprehensive and extended services at the large universities to clinics
with limited services at the smaller institutions.
Each state university offers its own student health insurance plan to its enrolled
students with distinctive coverage benefits and price points. Due to
inconsistencies in coverage throughout the SUS, students have different
financial responsibilities for medical care depending upon what university they
attend.
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In the three year, phased-in implementation of a mandatory student health
insurance program, Florida State University has:
o Increased its student health plan participation by 416 percent;
o Reduced its student premium by 14 percent for the comprehensive plan and
36 percent for the basic plan; and
o Increased benefits by 833 percent for the comprehensive plan and 333 percent
for the basic plan.
Student Health Insurance: Delivery Options
A number of states and higher education governing boards have implemented
health insurance requirements for college students.
There are insurance cost efficiencies that can be gained by a system-wide plan for
health insurance. State system plans are priced based on utilization and can
provide targeted coverage and benefits.
As universities are increasingly requiring some form of health insurance for their
students, many institutions are exploring ways to help students afford adequate
health insurance coverage by broadening the institution’s definition of cost of
attendance (COA).
From an analysis of existing state and state system policies, the following
potential advantages have been identified for a mandatory policy of student
health insurance coverage as a condition of enrollment:
o Reduces the state’s uninsured and uncompensated health care costs by
requiring that all students have health insurance to help pay for covered
medical services;
o Provides more affordable coverage by adding healthier individuals to the
institution’s existing student health insurance pool, thereby spreading the
risk and lowering premiums;
o Increases student retention rates and reduce medical debt by creating a
financial safety net for students in the event of major illness or injury;
o Improves access to broader health services, by extending coverage to include
more specialty services in both medical and behavioral health.
Healthy students are more successful in completion of their education pursuits than
unhealthy students and quality health care is integral to general student health and
well-being. The System of Care Life Cycle below shows the direct relationship between
quality health care, health insurance and healthy students. At each step of the Life
Cycle where a student needs health care services, health insurance coverage, billing,
and reimbursement are part of the process. The SUS Task Force believes that the
provision of comprehensive, cost effective health insurance coverage is integral to
maintaining healthy, academically successful students in the SUS.
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RECOMMENDATIONS
1. The Board of Governors should authorize the establishment of one or more
State University System Purchasing Consortium(s) for student health
insurance to ensure that the System will be able to efficiently respond to
pending federal legislation that addresses health care and insurance coverage.
2. The Board of Governors should direct the SUS Council for Student Affairs, in
collaboration with the SUS Health Center Directors, to convene a Work Group
that includes representation by students and appropriate student affairs units
to:
 Develop an action plan for the provision of student health insurance in
the State University System that will:
o meet the insurance needs of all student constituents according
to the guidelines set by the American College Health
Association,
o provide for the efficient transition of SUS institutions into a
consortium, and
o include a process that will enable state colleges and
independent postsecondary institutions to participate in a SUS
Purchasing Consortium.
 Recommend an Invitation to Negotiate (ITN) process for the
procurement of a student health insurance program for the State
University System that will be responsive to new federal law upon
enactment and will comply with the state purchasing process.
3. Each state university should continue to individually determine its
participation in a structured billing system for student health insurance claims
pending the establishment of a SUS purchasing consortium(s) and
accompanying recommendations of the SUS Work Group.
4. The Board of Governors should include in its 2011-12 Legislative Budget
Request support for full health insurance coverage for state university
graduate assistants, teaching assistants, and research assistants.
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