Health Insurance Glossary

It’s important to understand the below commonly used health insurance terms. For additional terms or more detail, please visit https://www.healthcare.gov/glossary/.

Aetna

An insurance company (refer to the definition of insurance company).

Allowed Amount

Allowed amount refers to the maximum amount of payment that your health insurance will pay for, for a service.

Claim

A request for payment that you or your health care provider submits to your insurance company. Aetna processes the claims for SHIP.

Coinsurance

The portion of expenses paid by insurance after you pay any noted deductible. You are responsible for paying the remainder.

A Plan with 80% in-network/60% out of network benefits would pay 80% of the billed charges in network and 60% out-of-network after the Plan Member has met their deductible. Therefore, the insured would be responsible to pay the remaining 20% in network and 40% out of network.

Coordination of Benefits

A practice that determines which insurance plan pays first (& subsequently) in a situation where you have more than one insurance policy. This practice is to ensure that benefits are paid on a ‘shared’ basis and that no benefits are paid in excess of the amounts charged. It is very important to respond to your insurance company when they contact you to ask whether you have additional insurance. They will often do this on the first claim of the year, or when the claim is secondary to an accident, in which case your auto insurance or homeowners insurance will be in play. If you do NOT respond to requests for other insurance information, the insurer will NOT pay your claim until they receive that information.

Copayment/Copay

A flat fee that you pay at the time of service. You will also have a $100 copay at the Emergency Department if you are not admitted to the hospital. There is no copay for office visits at the Student Health Center (SHC), but there will be charges for medications, supplies, and some procedures.

There is no copay for treatment at the Student Health Center (SHC).

Deductible

The amount you pay for covered health care services before your insurance plan starts to pay. After you pay your deductible, your insurance company pays the coinsurance and you pay the remainder. Deductibles may be reduced or eliminated for in-network providers or if proper referral procedures are followed. There is no deductible for visits to the Student Health Center (SHC).

Dependent

A person, usually a child, spouse, or partner who is covered by one’s health insurance plan. The benefits of the policy are typically the same as for the primary policyholder.

Exclusion

Specific conditions or circumstances for which your insurance company will not provide benefits.

Health Insurance

A contract that provides financial protection against the costs of medical expenses. It will typically cover a range of medical services such as doctor visits, hospital stays, and prescription drugs.

Hospitalization

Hospitalization refers to the act of being admitted into the hospital either for a medical treatment or observation. Hospitalization occurs when your medical condition cannot be adequately treated outside of the hospital.

Insurance Company (Underwriter, Carrier)

The company that assumes the risk and payment of your claims under an insurance policy. The SHIP insurance company for the 23-34 plan year is Aetna. The SHIP insurance company for the 24-35 plan year is UnitedHealthcare (UHC). Also called the Underwriter or Carrier.

Insured (Plan Member)

You are the insured as the person with the health insurance coverage. Also called a Plan Member.

In-Network

A group of doctors, hospitals, and other health care providers contracted to provide services to an insurance company’s customers at a negotiated rate. Your SHIP Provider network is a national and comprehensive network available in every state in the United States. You will pay less for using an in-network provider rather than choosing to receive care out-of-network. You may search for SHIP providers through your Aetna student account. During your search, note that mental health providers are referred to as “behavioral health” providers. Student Care Coordination can also assist with finding a provider.

Out-of-Network

A group of doctors, hospital, and other health care providers who do not offer pre-negotiated rates. Out-of-network costs will be higher.

Out of Pocket Maximum

The total amount of deductibles/coinsurance that you will be responsible for before the plan pays 100% of eligible charges. The out of pocket maximum does not include copays.

Out-patient Care

Medical services that are provided that do not require hospitalization. This includes, but is not limited to, doctor visits, medical imaging (such as an MRI), and minor surgeries.

Plan

The terms and services offered by the insurance company to pay for your health care in return for the premium you pay for that policy.

PLAN ADMINISTRATOR

A third party intermediary between the insurance buyer and the insurance company. Vanderbilt University purchases SHIP through the plan administrator Academic HealthPlans (AHP) in order to obtain the best rates and coverage for Vanderbilt students.

Plan Year

The time period your health plan provides coverage. The SHIP plan year is August 12 through August 11 of the following year.

Preauthorization

Preauthorization refers to the process of getting approval for a certain medical service or treatment from your health insurance company. It can be required for certain elective procedures and treatments so the health insurance company can ensure that it is medically necessary and covered by the insurance plan.

Premium

The amount that you pay for insurance coverage. Premium information for the current plan year can be found on AHP’s website.

Pre-existing Condition Provision

A pre-existing condition is a health condition that existed prior to your enrollment in a new plan. Examples of pre-existing conditions include pregnancy, heart disease, high blood pressure, cancer, diabetes, and asthma. Under the affordable care act, SHIP does not impose pre-existing condition provisions or exclusions.

Primary Care Physician/Provider (PCP)

The physician primarily responsible for your care, making referrals to other specialists as necessary. The Student Health Center (SHC) serves as your PCP. Referrals are required from the SHC for you to receive outside treatment.

Provider

A doctor, hospital, pharmacy, laboratory, or other facility/licensed supplier that provides health care services.

SHIP

The acronym for the Student Health Insurance Plan.

Specialist

A healthcare provider that is focused on a certain area of medicine, as opposed to being a primary care provider. These specialists can include oncologists, neurologists, and ophthalmologists. They are able to provide specialized medical care.

UnitedHealthcare (UHC)