4 ways to understand and optimize your student health insurance plan

Claims data can provide a wealth of knowledge—if you know where to look. To start, be sure to keep your eye on these four data points that can help identify costly problems or student trends that need addressing.

Determine whether atypical large claims are derailing your plan.

Review the section of your claims reports that shows the large-dollar claims (i.e., the large-dollar claim diagnosis); then delve deeper to see if those claims are being considered as part of a normal trend or if they are unusual. Trends, and any large claims resulting from them, will typically be factored into your insurance rate going forward, but atypical, nonrecurring large insurance charges—such as an acute condition resulting in a lengthy inpatient stay or a complex surgery—should be separated and pooled with your carrier’s portfolio of other large claims.

If you discover a large atypical claim, be sure you understand how this event is affecting your claims experience. Ask your broker or carrier if that charge is being removed from the completion factor or how it is being discounted from the experience. Large claims can and do happen, but they shouldn’t upset an otherwise stable insurance plan.

Are students seeking care where you want them to?

Because network providers are typically more cost-effective for both the insured student and the plan, in-network care, as opposed to out-of-network care, is the preferred option. A close analysis of your claims report can reveal how many student health care services are being provided in network.

Find the section of your claims reports that identifies the total allocation for in-network versus out-of-network services. Because large claims amounts can have an outsized effect, allocation data alone doesn’t tell the whole story. To get a more complete picture, you can examine allocation amounts in conjunction with the specific numbers of in-network and out-of-network claims.

Perhaps you will find that 85 percent of payment allocations are in network, but only 50 percent of all total claims are filed in network—revealing that many students are accessing out-of-network care. Armed with this data, you can compare current student activity to your school’s goals and can evaluate whether or not there is a need for marketing-communications campaigns to help drive student behavior. Messages to students about the value of seeking care with network providers—in both digital and real-world locations where they typically look for information—can be very effective.

Is the student health center being accessed enough?

A health care center can be a vital part of your student health plan and have a significant effect on costs, so you’ll likely want to try to optimize usage and leverage your student health center as a cost-effective care provider.

Claims data can help you as you seek to answer questions, such as the following:

  • How many students are going to the student health center for care?
  • How often are they going?
  • What services are they seeking most frequently?
  • Because students are filing claims for similar services with other providers, are there certain services offered by the student health center that are being underutilized?

Your campus may have other specific questions about student health center usage that an in-depth claims data analysis can help you understand. To increase awareness of health care options on campus, you might consider developing a marketing campaign geared towards students that evaluates how and where students access information about the student health center (especially online), conducting information sessions in collaboration with residence halls, and/or using targeted messaging to address a specific problem revealed by your claims data analysis.

Identify excessive emergency room use.

Your claims report can also reveal if your students are making too many trips to the emergency room—a common problem, especially within international student populations who are unfamiliar with alternative health care options. An average ER visit can often lead to claims exceeding $2,000, proving costly for both students and health plans.

Consult with your broker or carrier to determine how your school’s emergency room claim amounts compare to claims from other providers during the same period. Emergency room claims data from previous years or, if available, other schools, can also provide a valuable frame of reference. Check to ensure you understand what practices your plan’s claims administrator has in place to obtain proper discounts, adjudicate claims that may arise from nonemergency care, and remove unreasonable charges (whether or not they are emergency room claims).

One way to address high emergency room usage is to implement an effective training program to educate students on how, when, and where they should access care. It may be useful to emphasize to students their potential cost savings (e.g., reduced coinsurance payments and/or no balance billing) if they access care at the student health center or, if treatment is needed before they can see their primary care provider, at an urgent care center.

Understanding how your school’s student health plan is being accessed throughout the policy year can provide valuable insight about the health of your student health plan and your campus. These tips will help you get started, but they also only scratch the surface of what can be learned from claims data—there are a myriad of possible factors to consider once a claims report hits your desk.

A regular claims data review can serve as a student health plan barometer, helping identify any trouble areas that must be addressed. Also, while insurance carrier underwriters use many different analysis tools to project your insurance program’s cost, claims data review can be used to help you anticipate and prepare for any potential plan increases that may result the following year. Additionally, consistent review before your annual policy renewal date can help pinpoint activities, utilization behaviors, or trends that will influence important decisions about your plan, such as the changing of a benefit offering or the incorporation of a different network.

You may also be able to use claims data to help diagnose specific campus needs, such as an increased emphasis on wellness, greater mental health assistance, or more education on how students can consider cost when obtaining care. Uncovering behaviors that drive up plan costs is key to making the data-informed decisions that can help you better manage your student health plan and better focus on the well-being of your students. Whether you review your claims activity monthly, quarterly, or by semester, the process can allow you to see how the year is progressing and consider year-over-year performance.

Diving into data analysis may seem daunting, but there is good news—you are not alone. Your broker, consultant, or health plan provider can be a valuable partner in the process by regularly reviewing claims data with you and providing analysis on what that data means for your program. Scheduling a claims data review will help you more fully evaluate the intricacies of your institution’s student health care plan and feel more confident that you are managing your plan strategically and sustainably.


About the Authors


Michael Babore is Executive Vice President of Consulting Services for Relation Insurance Services’ Education Solutions practice. Connect with Michael at (310) 566-2061 or [email protected]



Neil Majors is President of Relation Insurance Services’ Education Solutions practice. He can be reached on LinkedIn, via email at [email protected], or via phone (310) 566-2051.



This article originally appeared on the University Business website here. To learn more about Relation Education Solutions and our custom insurance solutions and services, click here.


Date: Tuesday, February 23 2016
Time: 10am PST
Who Should Attend: Forward thinking Sr HR and Financial Professionals in the Technology Industry
Duration: 60 minutes
Captive Launch Date: January 1 2017

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By Michael Babore, Executive Vice President, Ascension Collegiate Solutions

I have worked in the student insurance marketplace for over 15 years. With the implementation of the Affordable Care Act (ACA), the past three years have been the most challenging for our clients and the marketplace in general.

The first challenge was understanding how the ACA would affect student health insurance plans (SHIPS). SHIPs aren’t like employer plans, and also aren’t like other types of individual plans, so we worked hard with our underwriting partners to understand the new regulations and make the necessary policy adjustments.

But that was only the first step. Next came implementing plans with expanded benefits and higher premiums. For some colleges and universities that had historically offered low-cost, limited-benefit plans that suited a young and healthy population, the higher costs associated with ACA-compliant plans was shocking. At the same time, the state insurance Exchanges came online, offering an option previously unavailable to college-age students. There was also a strong push by the Exchanges to get younger people on these plans with targeted marketing campaigns.

However, now that we have a clearer view of the ACA in terms of the both its regulations as well as what kinds of plans are being offered through the Exchanges, we have a lot more information to help determine what is the best option for students at higher education institutions.

Let’s take a closer look at the Exchanges versus SHIPs.


  1. Affordability

    – Plans are generally affordable and priced based on health history as well as income. This seems like an advantage for the “young and healthies” that typically make up college populations. However, students that access the Exchanges for an affordable option often just select the cheapest Bronze option, a High Deductible Health Plan. From the student’s perspective, they are covered and can forget about it. The reality is that the student will still have to satisfy a large deductible ($6,600 for most Bronze plans). Too many students do not understand this, and find themselves paying out-of-pocket for day-to-day accidents or illnesses. Many, if not most, students don’t have the money required to satisfy the first $6,600 of their medical expenses, which could result in students having to decide whether to pay for their education or pay for medical treatment. Since 98% of all medical claims are under $5,000[1], this puts the responsibility of paying for their healthcare squarely on the student’s shoulders.

  1. Subsidies

    – The subsidies offered to people in certain income brackets may sound appealing to students, as they perceive that subsidized Exchange plans are more affordable than the student health plan offered by their school. However, a recent study by the Kaiser Family Foundation that focused on IRS penalties in 2014 found that over 50% of individuals who accepted a subsidy for health insurance were not eligible for the amount they received[2]. We hear frequently that students are going to the Exchanges and answering the income questions accurately from their perspective, only to find out that mom and dad are claiming the student as a dependent on their tax return. Since subsidies are based on the total household income, families will be required to pay back the subsidy a student received in error. In this instance, what originally seemed to be a great value to the student has turned into a tax burden for their family.

  1. International Students

    – Not only can the Exchanges be confusing for international students, but this population is not eligible for subsidies or Medicaid, since those are for U.S. Citizens or permanent residents only. Without guidance from foreign student advisors or insurance professionals, these students are unassumingly accepting subsidies without fully understanding the ramifications for doing so. In the past year our firm has seen a large increase of international students being deported for violating the terms of their visa.

  2. PPO Networks

    – While Exchange plans have access to national PPO networks, the networks affiliated with Exchange plans are often limited networks, especially in non-metro areas. What’s happening is that national PPO networks will offer a much smaller network carve-out to Exchange plans. We’ve heard reports (and seen first-hand) of signs in doctor’s waiting rooms saying they don’t participate in the Exchange PPO network. The result is that students are left with few choices of in-network providers near campus, and end up paying the higher out-of-network prices – including coinsurance, deductible, and out-of-pocket max – for services they need.


  1. SHIPs help the school’s bottom line.

    Our consultants have reported that many colleges and universities no longer see the value of providing a comprehensive health insurance plan to their students. The simple truth is that requiring students to have a health insurance plan is in the best interest of the college or university; keeping students healthy and enrolled has a significant impact on the school’s bottom line.

  1. SHIPs are usually the best deal for students.

    Many think the Exchanges are good enough for their students. However, as I pointed out earlier, Exchange plans often include really high deductibles which may be financially overwhelming to a student trying to pay for college. SHIPs, on the other hand, generally have low deductibles, coinsurance, and copays. That means a student enrolled in a SHIP can get the care they need right away, without the need to pay for all expenses out-of-pocket until they meet a (generally unattainable) deductible.

  1. Health Center Tie-In (and Buy-In).

    A lot of students are going off-campus to seek medical care, rather than utilizing the on-campus health center. SHIPs can coordinate with student health centers, which can help bring more students in and increase revenue for the campus, as well as keeps insurance costs down for students. It’s a win-win.

  1. SHIP premiums are competitive

    Sometimes we hear that SHIP premiums are high compared with Exchange premiums. However, a lot of the low-priced plans on the Exchanges have high deductibles and limited networks (therefore a lot of the charges are being paid at the out-of-network prices). The reality is that, if you are making an apples-to-apples comparison, SHIPs are often less expensive than Exchange plans or than students being insured as dependent on a parent’s plan. Since SHIPs now offer full coverage (rather than limited benefits with low benefit maximums that they did in the past), SHIPs are more expensive than they used to be; however, the value of SHIPs has increased as well.

The bottom line is that a quality insurance plan can cover the costs of high medical expenses that could otherwise prevent a student from continuing his or her education. It’s important to consider all the ramifications to students of sending them off to the Exchanges. For many students, the Exchange reality is very high out-of-pocket expenses, few in-network doctors, and not much coverage in the absence of extreme illness or injury. SHIPs might not be the answer for every campus, but I truly believe that in most cases, they can offer students and schools a much better option.


Michael Babore has worked with colleges and universities since 2000, developing roadmaps for successful student health insurance programs. His goal is to deliver the service each and every client requires. Prior to joining the Ascension team, he worked as the Head of Sales for HTH Worldwide in their international student insurance division. Michael is a member of NAFSA,ACHA, URMIA, NAICU and the FORUM. He is a regular presenter at many industry-related events and has traveled to 22 countries in his career. For more information, contact Michael at 310-255-2061 or [email protected].

[1] Claims data based on breakdown of claims for students insured through Ascension for the 2013-2014 and 2014-2015 academic years.

[2] Cox, Cynthia, et al. “Repayments and Refunds: Estimating the Effects of 2014 Premium Tax Credit Reconciliation,” March 24, 2015. Kaiser Family Foundation. Web. <http://kff.org/health-reform/issue-brief/repayments-and-refunds-estimating-the-effects-of-2014-premium-tax-credit-reconciliation/>