Recent changes to out-of-network coverage

What’s Happening?

In the Spring of 2019, a number of changes were made to the Student Health Plan, which covers all graduate students and many family members of graduate students. Two of these positive changes for which graduate students have been advocating for years are: increased in-network care, and better coverage of expenses for pregnancy and childbirth.

Unfortunately, administrators decided to pay for these increases to coverage by decreasing coverage for care from providers who are out-of-network with Aetna from 80% to 70%. This means that starting this September, we will all pay half again as much for out-of-network care. These changes might be relatively minor for something like a routine office visit, but for a surgery or other procedure, the difference in cost could easily be in the thousands of dollars. 

The Dean of Student Life has established a Health Plan Assistance Program to offset some of these increased costs for graduate students. This fund is different from the Medical Expense Assistance Program. It is administered through the Graduate School, not the Student Health Plan.  


What Do We Know About The Health Plan Assistance Program?

  • It is a reimbursement program. Graduate students will have to pay the increased costs, file for Aetna reimbursement, then file again for reimbursement from the Graduate School.
  • The Graduate School is not currently guaranteeing that all graduate students will be able to get reimbursement from the HPAP. Lisa Schreyer, Associate Dean for Student Life, administers the program and has confirmed that she anticipates that some applications will not be approved.
  • The HPAP can be used by any graduate student who needs assistance with increased out-of-network costs, not only (as its website suggests) by graduate students in absentia
  • Approval for the program requires an application:
    • A letter explaining “why you cannot reasonably access care from an in-network provider”
    • receipts from your provider
    • explanations of benefits
    • an itemized spreadsheet summarizing costs for treatment unfolding over multiple weeks
  • If your application is approved and you have ongoing expenses, you will need to submit receipts, explanations of benefits, and an updated spreadsheet to Lisa Schreyer each month for continued reimbursement.
  • These applications can be filed now for ongoing care from an existing provider. You do not need to wait; you can file your application using past bills and it will be reviewed immediately.
  • Turnaround time on these applications is expected to be about a week.

No formal eligibility requirements or definitions of what meets the standard of “unable to reasonably access in-network care” are available to graduate students.

  • You may also be asked to provide an explanation of why you were “unable to reasonably access in-network care” at the time you established care—even if out-of-network and in-network care were covered at the same rate at that time!
  • Review of applications is conducted by Lisa Schreyer and her team in the Student Life department. Applications are not directly reviewed by healthcare providers. Lisa consults with Counseling Services and Health Center staff as she sees fit. 
  • It will reimburse costs to 80% of coverage if an application is approved. Direct deposit will be used for reimbursement if you have it set up; if not, you will receive a check.


What do we not know about the Health Plan Assistance Program?

  • We do not know what criteria—informal or formal—are being used to determine whether an application meets eligibility requirements
  • We do not know when healthcare providers are consulted in reviewing applications 
  • We do not know what information about diagnoses or treatment are being shared with other deans, including departmental Deans of Graduate Study
  • We do not yet know how many applications or what kinds of applications are being turned down for funding.


Who Does this Affect?

These changes affect anyone who needs to see a provider out of network. This includes those of us who have already established care with primary care providers, specialists, or therapists out of network. It also includes anyone who lives or does research in an area with few providers who are in-network with Aetna. It also includes anyone who newly needs care from someone with a specialization or expertise only available out-of-network.  


What Can You Do?

First, make sure you know whether your established care providers are in-network or out-of-network with Aetna. Because the rates of coverage for in- and out-of-network care were previously the same, you may not know the answer to this question. It’s a good idea to call all of your providers to find out. Make sure you know what your past and present Aetna reimbursement rates are, too, as you’ll need that information to file claims with the Graduate School. 

Second, make sure you’re in touch with other graduate students!

  • Staying in touch will be helpful as you compile your dossier of materials and file your application for assistance from the HPAP. PGSU has templates available that you can use to create your application materials and can also connect you with other graduate students who are applying or have applied to the program.  
  • Because so little has been formally shared about these changes, it’s vital that we share what we’re learning with each other to keep each other updated about how our healthcare coverage is changing.


What Are PGSU’s Goals On This Issue?

  • To support all graduate students in securing the coverage for out-of-network care we need
  • To secure a commitment from Lisa Schreyer’s office to cover graduate students’ out-of-network care at the 80% rate during this Aetna contract
  • To secure a commitment from the University to return parity to in-network and out-of-network care coverage in the next Student Health Plan contract with Aetna
  • To ensure that graduate students are decision-makers in our own healthcare in the future