Student Health and Expatriate Plans FAQ
Last Updated 02/26/2019
- How is "student health insurance coverage" defined in the final rule?
- Student health insurance coverage is defined as a type of individual market health insurance coverage offered to students and their dependents under a written agreement between an institution of higher education and an issuer.
- To whom can student health insurance be offered?
- Student health insurance coverage may be issued to students enrolled in an institution of higher learning and their dependents. The coverage cannot be offered to individuals other than students and their dependents.
- Can student health insurance coverage be underwritten based on health status?
- No, issuers may not condition eligibility based on health status.
- Does student health coverage have to cover the Essential Health Benefits (EHB)?
- Yes. Nothing in the regulation exempts student health plans from the EHB requirements.
- Will student health plans be sold through the Marketplace?
- No, institutions of higher learning will continue to market student health plans in the traditional way. Issuers of student health plans are not required to offer a choice of plans. Neither the student health plan issuer nor the educational institution has to offer multiple plans / multiple metal levels.
- Are student health plans required to meet actuarial value metal levels?
Effective for policy years after July 1, 2016, student health plans are no longer required to fall within the de minimus ranges for specified actuarial metal levels (i.e. platinum, gold, silver, bronze). However, the plan must provide at least 60% actuarial value and disclose in the plan documents that the plan meets or exceeds the next lowest standard actuarial plan level. For example, if a plan has an 86% actuarial value, the plan documents must state that it meets or exceeds a “gold” metal of coverage.
- Are student health plan issuers required to file CMS templates in binder filings?
No, student health plans are not sold on the Marketplace, therefore, issuers of these plans are not required to file binders that include state or federal data templates. However, we will need to confirm the plan provides at least 60% actuarial value as demonstrated by the submission of Actuarial Value Calculator screenshots. The Unified Rate Review Template (URRT) should not be used for student health plans.
- Are there restrictions on how student health plans are rated?
- Student health plans can be rated based on their own experience or the experience of another relevant credible source. This also extends to subgroups within the school, such as domestic and international, undergraduate and graduate, etc., as long as these pools are not discriminatory based on health status. Premiums at the individual family or member level are subject to the Federal market rules for the individual market. Community rating is allowed with family tiers, as long as it is done uniformly. Dependents 21 or older, including spouses, must be rated the same as the student. Dependents under the age of 21 must be charged a uniform rate, but in no case at a level higher than the student or adult dependents and dependent premium must be capped at 3 times the student premium. Rating may also be performed on a per member basis, but the corresponding rates must follow the Federal age curve and the tobacco surcharge must be no greater than 50%. No other adjustments to rates are permitted (e.g. health status).
- Is student health insurance considered to be short-term, limited duration coverage?
- No, short-term limited duration coverage is not considered student health plan coverage. Short-term limited duration coverage cannot exceed a coverage period of more than 180 days and is not renewable after that term, it also does not provide coverage for preexisting conditions. Student health plans are designed to provide coverage that a student could have through the same health insurance issuer for one or more years during the course of his or her undergraduate or graduate education.
- Can student health insurance impose dollar limits on essential health benefits?
- No, dollar limits on essential health benefits in student health plans have not been permitted since January 1, 2014.
- Must student health insurance plans provide preventive services?
Yes, student health insurance plans must provide preventive services with no cost-sharing as required under PHS Act section 2713 and the implementing regulations.
- What other individual market protections apply to student coverage?
Along with no lifetime or annual limits and coverage for preventive services, student health plan issuers are prohibited from rescinding coverage, must allow dependents under the age of 26 to remain on their parents' health plan, and are subject to the patients' bill of rights.
- Which provisions of the PHS Act do not apply to student health plans?
- The exemptions for the PHS Act include requirements for guaranteed availability (guarantee issue) of coverage and the guaranteed renewability requirements.
- Can issuers of student health insurance plans enter into agreements with providers at student health centers?
- Yes, PHSA section 2713 and the implementing regulation do not prevent student health insurance coverage from coordinating with student centers to ensure the provision of preventive services. An issuer can arrange for a student health center to serve as its in-network provider provided that the centers have sufficient provider capacity and range of services available to support the designation as an "in-network provider."
- Can a student health plan be considered "grandfathered" coverage?
- Grandfathered status is determined by the coverage in which each individual student was enrolled on March 23, 2010; any coverage in which an individual student is newly-enrolled after March 23, 2010 is non-grandfathered.
- Are issuers of student health plans subject to the federal rate review process?
Student health plans effective on or after July 1, 2018 are no longer subject to the federal rate review process as described in 45 CFR 154.
- Are issuers of student health plans subject to the Medical Loss Ratio (MLR) standards?
- Yes, however, an amendment to 45 CFR Part 158 provides that the experience for student coverage is to be reported separately from other individual market coverage, with national aggregation of student health insurance coverage data rather than on a state-by-state basis, and credibility adjustments are permitted in the student health insurance market.
- Will student coverage MLR reporting be on a plan year basis or a calendar year basis?
- MLR reporting for student health plan coverage has been required on a calendar year basis since January 1, 2013.
- Are students eligible for MLR rebates?
Yes, rebates will be distributed directly to the student in the same manner as rebates for other individual market coverage.
- Are student administrative health fees considered cost-sharing under the regulation?
- No, student administrative health fees are not considered cost-sharing.
The answers provided are not meant to be a substitute for legal advice.