NYU – Understanding US Healthcare System Ch 2


The material in this presentation is not intended
nor implied to be a substitute for professional medial or mental health advice and you should
not rely on it for that purpose. None of the information in this presentation should be
used for medical or mental diagnosis or treatment. Always consult your doctor or other healthcare
or mental health provider if you have a medical or mental health condition or if you have
questions regarding such a condition or treatment plan. You assume full responsibility for how
you choose to use this information. Before we get into the specifics of accessing medical
and mental health care let’s cover a general overview of US healthcare including some common
terms you might hear and give a basic understanding of health insurance in the U.S. The US healthcare
system offers some of the best medical care in the world, but it is complex, difficult
to navigate, and often very expensive. The US system will also likely be very different
from the healthcare system you are used to back home. The high cost of healthcare in
the United States presents a potentially serious financial risk to students. The absence of
adequate insurance coverage can result in temporary or permanent interruption of your
education; therefore NYU requires that all students registered in degree-granting programs
maintain health insurance. So let’s start by covering a few terms. Like most Americans,
you will need a private insurance plan, either through NYU or one that you purchase directly.
There is no “universal access” or “national healthcare” like many countries offer. When
you seek any medical care, the provider you choose — hospital, doctor, or clinic — will
look to you and to your insurance carrier to get paid for their services — there will
be no payment from the government. Here are a few real-life examples: Appendicitis resulting
in the need for an appendectomy (surgery in the hospital): could be around $60,000; Fractured
humerus from a bicycle accident which requires surgery: could be $47,000; Fractured clavicle
from a fall on the sidewalk: could be around $18,000. Even though NYU requires that all
students registered in degree-granting programs maintain health insurance, you should still
be prepared to pay some portion of the cost of your medical care. Cost-sharing is an important
element of the US system, so medical care is never entirely free and each time you access
the system you should expect some cost. The term premium is the amount paid to the health
insurance company to maintain your coverage. Students enrolled in a NYU-sponsored plan
will have to pay a premium just like other insurance plans. The term co-pay is a payment
defined in the insurance policy and paid by the insured person each time a medical service
is accessed. The amount of co-pay can vary depending on the insurance plan you have and
the type of location or clinician you see. For example, co-pays tend to be higher for
emergency room visits and specialist rather than out-patient clinics and general doctor
visits. The term deductible is the amount of expenses that must be paid out of pocket
before an insurer will pay any expenses. The amount can vary depending on the policy of
the plan and the premium one pays usually has an impact on how great the deductible
will be. For example, someone with a low premium payment will have a high deductible rather
than someone with a high premium payment who has a low deductible. Co-pays usually do not
count towards payments of a deductible either. Generic medications are medications sold under
a generic name; usually legal only after the patent has expired, or if no patent was issued
for the substance to begin with. Generic drugs are usually less expensive than proprietary
medications, but just as effective. Here we give you an example of Claritin, which is
an allergy mediation and on the right is its generic brand. Here’s the term network, sometimes
referred to as “in-network” this network consist of a group of doctors, hospitals and other
healthcare providers contracted to provide services to insurance companies’ customers
(that would be you) for less than their usual fees. “Out-of-network” would refer to those
who are not contracted or not in the network. An Explanation of Benefits (EOB) is a form
or document that may be sent to you by your insurance company several months after you
have received treatment that was paid by the insurance company. You should get an EOB if
you have private health insurance or when you get insurance through your employer. Your
EOB gives you information about how an insurance claim from a health provider (such as a doctor
or hospital) was paid on your behalf. Your EOB has a lot of useful information that may
help you track your healthcare expenditures and serve as a reminder of the medical services
you received during the past several years. A typical EOB has information such as: Patient
Name, Claim Number, Provider, Type of Service, Date of Service, Charge — which is the amount
your provider billed your insurance company for the service, Not Covered Amount — the
amount of money your insurance company did not pay your provider with a reason why, and
Total Patient Cost — which is the amount of money you owe as your share of the bill.
This amount depends on your health plan’s requirements, such as copay or deductible.
Also you might have received a service that is not covered by your health plan in which
case you are responsible to pay the full amount. It’s important to read your EOB carefully
and if you have questions about your EOB you can contact the Student Health Center to help
you get answers. Lets go over 4 different examples of students accessing care. One with
the NYU-sponsored Comprehensive Plan and the other with another private insurance plan
that meets NYU’s minimum requirements. Please keep in mind, these are only used to provide
examples and should not be directives for healthcare treatment. In the first example,
Pat registers for classes and is automatically charged for the NYU-sponsored Comprehensive
Plan. This is the premium payment and it shows up on Pat’s bursar bill. Pat feels sick and
remembers that all matriculated students, regardless of whether they have the NYU-sponsored
insurance, have access to the Student Health Center (SHC). Pat decides to walk into Urgent
Care at the SHC without an appointment and pays the $10 service fee. 100% of the visit
is covered since Pat went to the SHC. Pat gets treated and prescribed an oral medication
which Pat decides to get filled at the SHC Pharmacy. In the second example, Pat begins
to feel sick later in the semester. Pat decides to make an appointment at the Student Health
Center (SHC) before things get worse. Because Pat made an appointment with Primary Care,
there is no $10 service fee. Pat obtains a health assessment and gets a referral for
a Gastroenterologist (a specialist). Pat makes another appointment for the Gastroenterologist
the following day. Because Pat is being treated by a specialist now, there is a $30 visit
fee; however, 100% of the visit is covered since Pat stayed at the Student Health Center.
In this third example, we have another student by the name of Jo, who also registered for
classes and was automatically charged for the NYU-sponsored Comprehensive Plan. Jo,
however, decides to waive the plan since Jo has another private insurance plan that meets
NYU’s minimum requirements. Jo pays a monthly premium for the plan of $200 (you should notice
some of the insurance terms we discussed are bolded). Jo begins to feel sick and visits
a local clinic in the neighborhood. Jo is charged a $30 co-pay for each visit. Jo is
then diagnosed and has to receive a minor surgical procedure. The $250 bill that Jo
receives is not covered by insurance because Jo has not met the $500 deductible set by
the insurance company. Therefore, Jo has to pay the full $250 bill. Jo receives an EOB
explaining this in further detail also. In this fourth and final example, Jo falls at
night on the sidewalk. The Student Health Center is not open and Jo decides this is
a pretty serious injury and goes to the Hospital Emergency Room. Jo pays a $100 co-pay and
gets treated for a broken bone. The bill totals $1,500 and Jo will only have to pay $250 because
that was the amount left in the deductible that Jo had to meet. Therefore, the insurance
company will pay for the remaining $1,250. Jo receives an EOB explaining this in further
detail. If you need further information or have additional questions, you can contact
the NYU Student Health Center at the website nyu.edu/health or [email protected]

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