Health Insurance

Table of Contents

Administrative Basics

Your health coverage isn’t technically run by the Graduate Employee Organization (GEO): it’s administered by University Health Services (UHS) and Cigna, and is underwritten by Consolidated Health Plans. We refer to it as a “UHS/GEO” plan in this booklet, however, for a number of reasons. First, because your ability to get the plan at an affordable-rate is entirely dependent your GEO-status. GEO’s contract with the University ensures that almost every grad employee who works for UMass-Amherst gets discounted health insurance.

There’s a reason why the university covers most of the health fee for GEO eligible employees: the hard work of graduate students through GEO since it’s inception. Before grad employees decided to unionize, many of us on campus did not have our health insurance paid for by the University. In 1991, a year after UMass grad students voted in favor of unionization, GEO won a 79% waiver of health fees for grad employees and their families after a 10-day strike. Since then, subsequent GEO contracts have gradually added benefits and new forms of coverage to our health coverage.

In past negotiations we’ve gained a Dental Plan (available only to GEO members) – making UMass-Amherst grad students some of the few grad employees in the country to receive subsidized dental care. In our negotiations for the 2004-2007 contract we lowered the cost of family health insurance, and secured full 12 month coverage for grad students.

We also refer to it as a “GEO” plan because the GEO leaderSHBP and staff is happy to assist you in answering any questions you may have about your coverage. If you have any questions, give us a call at 545-0705, or send us an an email.

(Lack of) Costs for the GEO-Eligible

Every student at UMass taking 5 or more credits is required to enroll in the Basic Health Plan offered by University Health Services (according to Massachusetts State Law, every student taking more than 5 credits must have medical insurance).

But whereas most students have to pay for the UHS health plan, GEO-eligible grad students only have to pay a small percentage of the premium. The chart below lists the relative costs of the plan to GEO-eligible and non-GEO-eligible grad students:

Individual Health Care Costs

(August 1, 2013 to July 31, 2014)

Cost of Health Plan Amount Waived by GEO Contract (95%) You Pay
Fall SHBP $1,377.50 $1,308.63 $68.87
Fall Basic $327.00 $310.65 $16.35
Spring SHBP $1,377.50 $1,308.63 $68.87
Spring Basic $327.00 $310.65 $16.35
Total for Year: $3,409.00 $3,238.56 $170.44

Eligibility

Who can get the health plan? In general, if you are working at least 10hrs/week in two semesters or 20hrs/week in one semester you get year round health coverage. However, if you are unsure it is important to pay close attention to what is specified in our contract in Article 35:

  • Graduate student employees who are employed for at least 190 hours in fall semester or previous summer, or who earn the equivalent of at least 190 hours times the campus minimum hourly rate in fall semester or previous summer, or who have full responsibility for teaching one 3-credit course section in the fall semester or previous summer will be provided with a health fee exemption of 95% of the Basic Health Fee from August 1 through January 31, and 95% of the Student Health Benefit Plan (SHBP) from August 1 through January 31, and 95% of the Student Health Benefit Plan (SHBP) from February 1 through July 31 as long as said graduate student employee is a graduate student during the following spring semester, and 90% of the Student Family Health Plan from August 1 through January 31 for those electing family health plan coverage.
  • Graduate student employees who are employed for at least 190 hours in spring semester, or who earn the equivalent of at least 190 hours times the campus minimum hourly rate in spring semester, or who have full responsibility for teaching one 3-credit course section in the spring semester, will be provided with a health fee exemption of 95% of the Basic Health Fee from February 1 through July 31, and 95% of the Student Health Benefit Plan (SHBP) from February 1 through July 31, and 95% of the Student Health Benefit Plan (SHBP) from the previous August 1 through January 31 as long as said graduate student employee was a graduate student during the previous fall semester, and 90% of the Student Family Health Plan from February 1 through July 31 for those electing family health plan coverage.
  • Determining Health Fee Exemption Eligibility From Cumulative Earnings: Graduate student employees who are employed for at least 380 hours in the one year period beginning with the first payroll date of summer and ending with the last payroll date of the spring semester, or who earn the equivalent of at least 380 hours times the campus minimum hourly rate in the one year period beginning with the first payroll date of summer and ending with the last payroll date of the spring semester, or who have full responsibility for teaching two 3-credit course sections during the one year period beginning with the first payroll date of summer and ending with the last payroll date of the spring semester, will be provided with a health fee exemption of 95% of the Basic Health Fee from August 1 through July 31, and 95% of the Student Health Benefit Plan (SHBP) from August 1 through July 31, and 90% of the Student Family Health Plan from August 1 through July 31 for those electing family health plan coverage.Summer earnings shall be applied forward within the one year period described above.
  • Determining Health Fee Exemption Eligibility From Cumulative Earnings: Graduate student employees who: are employed for at least 190 hours in the one year period beginning with the first payroll date of summer and ending with the last payroll date of the spring semester, or who earn the equivalent of at least 190 hours times the campus minimum hourly rate in the one year period beginning with the first payroll date of summer and ending with the last payroll date of the spring semester, or who have full responsibility for teaching one 3-credit course in the one year period beginning with the first payroll date of summer and ending with the last payroll date of the spring semester, will be provided with a health fee exemption of 95% of the Basic Health Fee for one six-month health coverage period, and 95% of the Student Health Benefit Plan (SHBP) from August 1 through July 31, and 90% of the Student Family Health Plan for one six-month health coverage period for those electing family health plan coverage. The one six-month health coverage period shall be the one in which the graduate student employee’s health premium costs are the highest.Summer earnings shall be applied forward within the one year period described above.
  • Graduate student employees who are academically enrolled for fewer than five (5) credits or on program fee and who are eligible for health plan fee exemptions per Section A above are not automatically enrolled for the Basic Health, SHBP, or Student Family Health Plans. The graduate student employee must enroll at University Health Services via Patient Services representatives before the end of the add/drop period of each semester to ensure no lapse in health plan coverage.

Paying for Health Insurance

  • If you’re taking more than 5 credits
    • If you’re taking more than 5 credits, you can pay for your individual Basic & SHBP right on your Bursar Bill. You may receive a bill that will say you owe the University an enormous sum of money for health insurance – but if you read the fine print, you actually don’t. Flip over your bill and on the back side you’ll see a little box marked “Check here if you are GEO Eligible” (or something to that effect). By checking that box, you instantly cancel 95% of the amount listed under health fees.
    • Just to be safe, when you go to Whitmore to pay the non-waivable fees on your Bursar’s Bill (these have traditionally been in the $200-$600 range, though the amount has been increasing due to the budget cuts), be sure to mention that you are GEO-eligible . Whatever you do, don’t pay the full amount for health insurance and wait for reimbursement – this can be a long and uncertain process. (The only time you will want to pay and get reimbursed is if you are working 20hrs/week ONLY in the spring – your health waiver will be applied retroactively and you’ll get reimbursed). If you’re receiving financial aid, be vigilant as well. Many GEO-eligible grad employees have had health insurance fees subtracted from their financial aid award without knowing it.
  • Grad student employees enrolled for less than 5 credits
    • Graduate Employees enrolled for less than 5 credits will NOT be automatically enrolled for health insurance. If you want Health Insurance, you need to go to UHS, sign-up and pay 5% of the premium. (If you’re not working enough to be “GEO-eligible” (see above) you would have to pay the whole premium).
  • If you want the Family plan
    • You can get health coverage for your spouse, same-sex domestic partner, children or other dependents you have to pay an extra fee for “the family plan”. GEO-eligible grad employees pay only 10% of the family plan premium. To purchase the family plan you must already be signed up for individual Basic and SHBP. You must go to UHS to sign up and pay the fee.
  • If you want to pay through Payroll Deduction
    • All grad student employees are allowed to pay for their health insurance costs through payroll-deduction. Ask UHS specifically for a payroll deduction form when you sign-up for coverage.

Basic vs. Student Health Benefit Plan (SHBP)

“Basic” and “Student Health Benefit Plan” (SHBP) are terms UHS uses to denote categories of coverage. In a nutshell, Basic coverage includes the cost of general practitioners, mental health physicians, and some services for things like physical therapists that are not covered by your primary insurance. For a list of other services, please visit the UHS website at www.umass.edu/uhs.

The Student Health Benefit Plan (SHBP) covers catastrophic emergencies, prescriptions, hospitalizations, and specialty and outside referrals. For those of you who’ve been around for a while, SHBP used to be called the Student Health Benefit Plan (SHBP), and before that, “Supplemental Insurance.” If you read UHS’s literature about coverage SHBP is also classified as your “Primary Insurance” if you have no other insurance.

UHS has several on-site specialty clinics that require a referral from a primary care doctor at UHS. These clinics include services from Northampton Ob/GYN Associates, Hampshire Orthopedics, Northampton Surgical Associates and Valley Acupuncture. Your primary (SHBP) insurance will be billed and acupuncture is available on a fee-for-service basis.

 

Family Health Insurance

Costs: August 1, 2013 to July 31, 2014

Cost of Health Plan Amount Waived by GEO Contract (90%) You Pay
Fall SHBP $4,377.50 $3,939.75 $437.75
Fall Basic $1,418.00 $1,276.20 $141.80
Spring SHBP $4,377.50 $3,939.75 $437.75
Spring Basic $1,418.00 $1,276.20 $141.80
Total for Year: $11,591.00 $10,431.90 $1,159.10

To pay for the family plan, go to UHS before the add/drop period of the semester you want your family to be enrolled. You can either pay by check or make arrangements for the amount to be deducted from your paycheck. Please note that “payroll deduction” and a “payment plan” are two separate things. You must ask specifically for “payroll deduction” if you would like your health premium to come directly from your paycheck.

Who is Family?

Your spouse or same-sex domestic partner and all of your dependents can be enrolled in the family plan at the rates listed above. There is no price difference between enrolling 2 kids, 4 kids, or just your partner alone. The Family Plan does not cover aunts, uncles, grandparents, etc. — nor does it currently cover opposite sex domestic partners.

Enrollment

For GEO-eligible individuals taking 5 or more credits, enrollment in the individual health plan is automatic. There are exceptions, however.

Enrollment is not automatic for the family plan . If you are interested in enrolling in the family plan, you must bring a check to UHS before the add/drop period of every semester you wish to be enrolled.

Also, if you are on program fee, or are taking less than 5 hours of course credits, you must enroll in person at UHS before the add/drop session each semester. This is very important. Every year, many grad students who are eligible for health coverage don’t get it because they don’t realize they have to go to UHS in person.

Coverage Dates

Fall Coverage Dates: August 1, 2013 to January 19, 2014

Spring Coverage Dates: January 20, 2014 to July 31, 2014

Does your coverage end when you graduate?

  • Fall semester graduates – coverage ends January 1
  • May graduates – coverage ends July 31
  • September Graduates – regular coverage ends July 31, but you may apply at Health Services for supplemental coverage until Aug. 31
  • February Graduates – coverage ends January 19

For graduates, there are some options you can look for:

Summer Coverage and Earnings

Summer Coverage is now included in your fall & spring health coverage.

Earnings in the summer can be “banked” forward an counted towards your GEO-eligible status for the next academic year.

Traveling

Many grad students go out of the state or to their home countries for the summer and wonder whether they are covered. If you’re on SHBP over the summer, you will still receive its benefits (i.e., emergency care, prescriptions, referrals) wherever you go in the world.

If you have a chronic health condition or you know you’ll need to see a doctor for office visits over the summer, be sure to get a referral from UHS before you leave, as this will reduce the amount of your co-payment.

If your physician is outside of the United States , they will most definitely be Non-Preferred. Likewise, if they’re in the U.S. but out of Massachusetts , they are probably Non-Preferred.

If You Have Other Insurance…

If you read the info bulletins put out by UHS, you’ll quite often see the phrase “This service will be billed to your primary insurance first.” If you are covered by another insurance plan at the same time you’re covered by our health plan, UHS refers to your other health coverage as your Primary Insurance. A lot of procedures will be billed to your other insurance plan first, with UHS picking up the tab for many services that fall through the cracks. UHS recently adopted this policy as a result of the cuts to the state budget, and in doing so has been able to save a lot of money without compromising the extensive range of services it offers.

Copayments / “Appendix A”

Prescription copayments are $15 for generic medications, $30 for name-brand medications, and no copay for birth control as of August 1, 2012.  If you have paid more than $10 for birth control before August 1, contact GEO at geo@external.umass.edu.

The GEO contract refers to a 1991 document called Appendix A, which refers to the co-pay schedule.  Appendix A refers to the following co-pay schedule:

  1. Pharmacy Benefit: Birth control pills, $10.00 per cycle.  Each prescription of all other formulary items (including insulin) will be at wholesale cost for up to one month supply, minimum $5.00, maximum $50.00 per prescription.  Non-formulary prescriptions at cost plus handling charge.
  2. Surgical Specialists Visits at UHS: $10.00 per visit co-payment, including orthopedics, general surgery, and gynecology specialists.  Exclusions: consults regarding termination of pregnancy, and pre- and post- natal coverage remain fully covered.
  3. Visits between 9:00PM and 8:00AM the next morning: $10.00 per visit co-payment.
  4. Visits after noon on Saturday and all day on Sunday, until 8:ooAM on Monday morning: $10.00 per visit co-payment.
  5. Allergy Clinic Visit: $10.00 co-payment per visit.  Allergy Testing: Full fee-for-service charges for visit and test materials. (Cost of test materials not covered by SHBP).
  6. Electrocardiograms(routine, non-diagnostic): $10.00 per exam.
  7. Colposcopy: $25.00 co-payment per exam.
  8. Sigmoidoscopy: $25.00 co-payment per exam.
  9. Diabetic Supplies: Covered at 50% of costs.
  10. Physical Examinations (routine, non-diagnostic): $25.00 per exam, plus any necessary laboratory exams.

Maximum Copayments

According to Article 35(g) of the GEO contract, no one should make more than $250 in co-payments per year. Members have to keep track of their co-payments themselves, however, because UHS does not automatically stop charging co-pays once this limit is reached. Anyone who thinks they may have paid more than $250 in co-payments over an academic year should contact the GEO office immediately. There is a $35 for emergency room fee.

  1. To request co-payment reimbursement you will need to present documentation from the health care facility/pharmacy reflecting the service rendered, date of purchase and cost. To verify that you have paid more than $250, please contact Consolidated Health Plans at (877) 657-5027.
  2. If you have exceeded the $250 in co-payments:
    1. Fill out a GEO co-pay reimbursement form and a W-9 form (both available at UHS or in the GEO office).
    2. Present proof of purchase, which includes a statement from the facility/pharmacy reflecting the prescription(s), date(s) of purchase and the cost.
    3. Present proof of payment, which can be either a cancelled check or credit card statement or a paid receipt from the facility/pharmacy (reprinted receipts are acceptable).

All the above documentation must be submitted to University Health Services, Financial Services Division – Room 369C.

Please contact the GEO office if you have any questions about the procedure or the forms and documentation required.

Family and Medical Leave

Under Article 44 of GEO’s contract, grad employees may take up to 12 weeks per year of unpaid Family and Medical Leave. To be eligible, you must have been employed in a position covered by the GEO contract for at least 4 months prior to the start of the leave.

Leave may be granted to grad employees for:

  • the birth of a child and care for the newborn
  • the placement of a child with a grad employee for adoption or foster care
  • the care of a spouse, parent, grandchild, grandparent, domestic partner, or child with a serious medical condition
  • a serious health condition of your own that makes you unable to perform your job (Article 44 of the GEO contract defines “serious health condition”)

During leave, you receive the same health benefits you would have received had you continued to work. You do not receive your stipend, however. Once you return, you are also guaranteed your former position or an equivalent position with the same stipend and benefits.

To be granted Family or Medical Leave, you must submit a leave application to your immediate supervisor, who will forward it to the Graduate School . If the leave is for your own medical condition, you must submit a medical certification form explaining the need to leave. This form can be obtained from the Graduate School and must be filled out by the health care provider.

University Health Services

The main facility. University Health Services is a progressive, state of the art medical facility offering single-payer coverage to the campus community. It is staffed by board certified physicians, nurse practitioners, physician assistants and a variety of support staff. It is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

In its main building on campus one can visit general practitioners, allergists and physical therapists, get X-Rays, blood work, eye exams and pharmaceuticals, purchase eye glass frames and over the counter drugs, etc. UHS physicians can also refer you to any one of a wide range of specialists. While you can get urgent care treatment at UHS (i.e., you can see a doctor for sicknesses and minor injuries that can’t wait for an appointment), UHS is not an emergency facility.

Appointments and Waiting Rooms: Using UHS

Like most medical facilities in the U.S. , UHS is by-appointment only. Call the appointment line at 577-5101 and someone will schedule you with the doctor, nurse practitioner or physician assistant appropriate to your needs.

Urgent care is the exception to the appointment-only rule — one may simply come to the Urgent Care clinic and sit in the waiting room. You can also call ahead to make an appointment at 577-5101. If you simply want to talk to a triage nurse about your illness or injury, you can do that as well – just dial 577-5229.

Clinic hours are from 8:30 am to 5 pm, Monday thru Friday. The Urgent Care clinic is open 24 hours a day during the semester. Click here for directions to UHS.

Outside Referrals

Although there are many medical professionals available in-house at UHS, you have access to plenty of other health providers off-campus as well. CHP/Cigna maintains a long list of doctors in Western Massachusetts whose services are covered under your health plan. The main guideline for seeing off-campus providers is this: to see a provider off campus, you should first be referred by someone at UHS.

Preferred and Non-Preferred Providers

Cigna maintains a list of health care facilities and personnel called the “Network of Participating Providers.” A “Preferred Provider” is a doctor or other professional in this network and covered under the UHS health plan — services rendered by a Preferred Provider are generally covered at 85%. Non-preferred providers are generally covered by our plan at 75%, after a $200 deductible. Needless to say, it’s better to stick with someone on the Participating Provider list.

The Network of Participating Providers is both local and national in scope (but primarily local). To see the complete list of providers and to check if a particular doctor is on it, visit Cigna’s website.

Emergencies

So long as you are covered under SHBP, medical emergencies are covered at 100% of the “negotiated” or “reasonable” charge, after you pay a $35 co-pay. You don’t need to be referred by UHS to the emergency room you’re taken to, nor does the hospital you are using have to be part of the Preferred Network.

If you have a medical emergency such as heart attack symptoms, loss of consciousness, severe difficulty in breathing, seizure, or spinal or neck injury, dial 911 and a local ambulance will take you to the nearest hospital (the ambulance will not take you to UHS). Ambulance rides are covered at 100% if you receive the ride from the American Medical Response or the Amherst Fire Department, all other ambulance rides are covered at 80% of the reasonable charge.

SHBP will NOT cover any non-emergency use of the emergency room. Please go to UHS for all preventative and routine care.

The Urgent Care unit in UHS’ main building is a clinic, not an emergency room. For serious emergencies, go to an area hospital such as Cooley-Dickinson in Northampton . Important: only go to UHS Urgent Care if you have a non-emergency illness or condition that simply can’t wait for the normal appointment procedure as urgent care office visits are not covered by the Basic plan!

The patient, the patient’s representative, physician or hospital must contact Cigna Claims within 1 business day following admission and notify them of your visit to the emergency room. The number is 1-866-494-2111.

Non-Emergency Inpatient Hospitalization

SHBP also covers non-emergency inpatient hospitalization. If your provider is part of the Participating Provider Network, is referred by UHS, and is approved by the Pre-Certification procedure outlined below, SHBP can cover 85% of the cost of an overnight stay, intensive care unit expenses, miscellaneous hospital expenses, surgical expenses (including anesthesiology), and physician hospital visits.

For Non-Preferred providers referred by UHS, coverage for the above is generally 75% of the Reasonable and Customary Charge.

Prescriptions

Prescription copayments are $15 for generic medications, $30 for name-brand medications, and no copay for birth control as of August 1, 2012.  If you have paid more than $10 for birth control before August 1, contact GEO at geo@external.umass.edu.

OB/GYN and Contraception

Staff from Hampshire OB/GYN Associates (HOGA) come to UHS several days a week and their services are billed to the Student Health Benefit Plan. Contraception services are also available through General Medicine. Some birth control pills are available from the UHS pharmacy at a reduced “clinic” price.

Pregnancy

Pregnancy is covered under SHBP like most medical conditions – that is to say, hospitalization and delivery costs are covered so long as the provider is part of the Participating Provider Network. You can see a certified midwife or OB/GYN without a referral for pre-natal care. Pre-natal classes are not currently covered by SHBP.

For info on maternity leave, see Family and Medical Leave.

Mental Health

Mental Health is also covered under the Basic plan for six visits per semester. Mental Health Services, located in 127 Hills North, has a staff of psychologists, social workers and psychiatrists to provide crisis intervention and short-term psychotherapy to individuals, families and groups (family and couples counseling is also available). Basic also covers referrals by UHS to other therapists in the area.

Six visits per semester are fully covered by the Basic plan. To request services, call 545-2337, Monday through Friday between 8am and 5pm, and a senior clinician will help match you to the service appropriate to your needs.

Twenty-four hour emergency mental health is available every day of the year. For mental health emergencies, call 545-2337 between 8am and 5pm on weekdays and ask for an “on-all” clinician. After 5pm and on weekends and holidays, call 577-5000 or come directly to UHS.

Optical

At UHS’ Eye Care Services you can get complete optometry examinations, choose from a wide selection of eyeglass frames, buy contact lenses and more. Optical services are not covered by the Basic Health Plan and thus require additional fees. Those insured under the Basic plan, however, can get most optical services done at UHS at well below the average market cost. A complete optometry examination, for example, is only $20 for those on our plan. Eyeglass frames by designers such as Gucci, Giorgio Armani, and Calvin Klein are also available at UHS at a cheaper rate than just about anywhere else you’d find them.

Emergency optometric care for eye diseases and disorders is covered by the Basic Health plan. Call Eye Care Services at 577-5244 for details.

Allergy Treatment

Allergy injections are given by appointment (serum is not included) and billed to your primary insurance (SHBP for most GEO members). Only certain allergy serums are covered by SHBP; call Cigna to find out if yours is covered. Allergy testing with a preferred doctor is covered at 85% of the negotiated charge.

Physical Therapy

UHS also has a Physical Therapy Department which is located on the ground floor and is staffed with physical therapists specializing in the treatment and evaluation of orthopedic as well as sports-related injuries. Pulmonary function testing is also available. Routine services are also covered under the Basic Plan, but they require a referral first.

Appendix

Glossary

Basic Plan

This includes office visits at UHS including Physical Therapy, allergy shots, mental health, radiology, and lab work. All grad students taking five ore more credits are required to get Basic.

Student Health Benefit Plan (SHBP)

This covers catastrophic emergencies, prescriptions, specialty referrals and non-emergency hospitalizations. Most GEO-eligible grad employees receive SHBP over the entire academic year, including the summer

Primary Insurance
If you are covered by another insurance plan at the same time you’re covered by our health plan, UHS refers to your other health coverage as your Primary insurance
Preferred Provider
Cigna maintains a list of health care facilities and personnel called the “Participating Provider Network.” A “Preferred Provider” is a doctor or other professional covered under the Cigna plan — services rendered by a Preferred Provider are generally covered at 85%.
Non-Preferred Provider
A Non-Preferred Provider is a facility or health care professional not part of the “Network of Participating Providers.” With the exception of emergency room care, services rendered by a Non-Preferred provider are generally covered at between 75%.
Reasonable and Customary Charge (R&C). Consolidated Health Plans defines this as the following:
“Reasonable & Customary (R&C) charges are guidelines developed by an independent source and used by insurance companies to help assure that the fees providers are charging for services are reasonable for their geographic area. Consolidated Health Plans utilizes the 80th percentile of R&C for most of our plans.”

Phone Numbers

UHS General: 577-5000

UHS Main Appointment Line: 577-5101

Billing: 577-5256

Health Plan Information: 577-5192

Urgent Care Clinic (8am-5pm): 577-5229

Urgent Care Clinic (after hours): 577-5000

Family Practice: 577-5312

Ob/Gyn Specialty: 577-5150

Mental Health Services: 545-2337

Mental Health, after hours urgent: 577-5000

Eye Care Services: 577-5244

Physical Therapy: 577-5158

Pediatrics: 577-5311

Internal Medicine: 577-5313

Pharmacy Prescription/Refill: 577-5066

Pharmacist: 577-5031

For Further Information…

For further information on the Health Plan not answered by UHS or GEO, call Cigna at 1-866-494-2111 or visit their website: https://www.mycignaforhealth.com.

You can also can Consolidated Health Plans at 877-657-5027, or visit https://consolidatedhealthplan.com/group/173/home.