Wednesday, May 27, 2009 1:45 pm to 3:15 pm

1. Insuring Students and Funding your student health center on less than $1 a day through implementing mandatory Health Insurance Wednesday, May 27, 2009 1:45 pm to 3:15 pm

2. Panel of Presenters • Sallie Horrigan, Director of Health Services, Cardinal Stritch University • Sally LaRosa, Nurse Practitioner, Cardinal Stritch University • Kelly McCoy, Director of Student Services, Wisconsin Association of Independent Colleges and Universities

3. Objectives • Background and Need for a Mandatory Student Health Insurance Program • Initiating a Mandatory Student Health Insurance Program • Implementing a Mandatory Student Health Program • Success with a Mandatory Student Health Insurance Program

4. Cardinal Stritch University Mission Statement: To Transform Lives Through Value-Centered Education • Catholic Coeducational University located in Fox Point, WI (suburban Milwaukee) • Founded in 1937 by the sister of St. Francis of Assisi as St. Clare College • Wisconsin’s second largest independent university • Enrollment: 6242 (3060 undergraduate students and 3179 graduate students)

5. Cardinal Stritch University • About 25.3% of Stritch undergraduates are ethnic minorities: (African-American 19.9%, Hispanic 3.4%, Asian 1.3%, and Native American 0.7%). • About 10.6% of Stritch graduate students are ethnic minorities (African-American 7.8%, Hispanic 1.6%, Asian 0.9%, and Native American 0.3%). • Tuition for 2008-09 is $20,000 a year, one of the lowest of the 20 independent colleges and universities in WI. About 93% of Stritch Students receive financial aid. • On-campus housing is about $5920 a year.

6. Wisconsin Association of Independent Colleges and Universities • WAICU advances the interests and promotes the development of its members, raises public awareness about the values and purposes of independent higher education, advocates equitable public policy affecting higher education, and administers joint ventures among its members. • We currently have over 25 collaboration programs, including a student health program.

7. Motivating Factors • Cardinal Stritch recognized was a need for a mandatory student health insurance program because: • Students living in the residence hall needed access to emergency care • Eliminated the “out of network” dilemma for students • Too many students missing class due to illness and there was no provider on campus • International students left to purchase plans on their own would often had a policy with a high premium and poor coverage. International students had limited access to health care systems, sometimes going home to own country to seek health care. These needs were recognized before any actual research was completed.

8. Why Students Need Insurance • Parent’s employer plans once let dependent full time students stay on plans until age 25. Now some plans students age out as young as 19. • HMOs have become more common. Many students are out of network while attending classes, so many typical visits for students were not covered (immunizations, annual physicals, annual ob/gyn visits, cold/flu seasons visits). • Students did not want to use their parent’s insurance while seeking mental health treatment or STI/STD testing. • Many people picking larger deductible health plans or health savings accounts.

9. 20% of College Students are Uninsured

10. Minority students more likely to be uninsured

11. Why Students Need Insurance Top 5 impediments to academic performance are: • Stress • Cold/Flu/Sore Throat • Sleep Difficulties • Concern for Friend or Family • Depression or Anxiety The rate of students reporting ever being diagnosed with depression has increased 56% in the last six years, from 10% in spring 2000 to 16% in spring 2005. Source: Spring 2005 ACHA-NCHA Reference Group.

12. Why Students Need Insurance • Certain students, including part-time students, older students, students from racial and ethnic minority groups, and students from families with lower incomes, were more likely than other groups of college students to be uninsured. • Healthy Campus 2010 has a goal to have 100% of college students insured. • Nationally 30% of colleges and universities require students have health insurance. • Percentage of underinsured college students is unknown.

13. Why Institutions Need Mandatory Insurance for Students • Only way to ensure all students will have valid insurance while attending classes. • Prevents schools from “holding the bag” when someone’s policy doesn’t cover them while attending classes and decreases institution’s liability. • Generate income for the student health center, which allows health center to cover some of its expenses and diversify services. • Local provider relationships strained when students have unpaid bills.

14. Where did the plan come from? • Student Health Center Directors went to WAICU in 2003. Insurance was expensive and didn’t always cover what students needed. Could WAICU help organize a group buy for student health insurance? • Task Force Formed of several student health center directors, risk managers, dean of students. • Evaluated current student health plans on the market. • WAICU Task Force decided to build their own plan, since they didn’t like what was offered. • Wanted a student health program, not a student health insurance program, which meant finding the right partner. • Wanted a plan that would need the needs of college students and provide routine and proactive health care.

15. Problems with existing student health plans • No coverage for routine preventative care • No coverage for mental health • No coverage for immunizations • No coverage for injuries relating to drug or alcohol use or self inflicted injuries • No coverage for high risk activities students participate in, like motorcycles and rock climbing • No coverage for STI (sexually transmitted infection) testing • No coverage for treatments at the Student Health Center

16. Next Steps in Plan Development • Task Force Designed their own plan. • Treat 95% of the needs of 95% of the students at a price 100% of students could afford. • Plan would be offered on a mandatory basis. • Plan would steer students to student health services first, by offering 100% coinsurance without copays only at the student health center. Student health center only location to receive vaccines.

17. The Role of WAICU • Organized the Task Force. • Wrote Request for Proposal (RFP) and handled RFP Response. • WAICU negotiations 1 deal for all 20 private colleges and universities in WI that want to participate. • WAICU had 2 insurance agents on staff with over 40 years of experience. • With the experience and plan design, can go straight to insurance company without a broker, saving 10-15% straight away.

18. Basic Plan Design • Eligibility: all full time undergraduate students, F1 visa, nursing, and education students are automatically enrolled in the mandatory plan. Part time and accelerated students can purchase the plan voluntarily. • To meet eligibility requirements, a student must attend classes for 31 days. • 15K plan • 100% coverage in the Student Health Center • 80% coverage in network/ 60% coverage out of network • Plan has no in-network deductible and $200 out of network deductible • Plan included coverage for office visits, surgery, hospitalization, prescription drug coverage, ambulance and durable medical equipment. • $20 copay for office visits, $50 copay for ER

19. Basic Plan Design • 15K (per injury per illness) Basic Plan all students would be enrolled in. This would cover all student health center services and provide a limited amount of off campus insurance coverage. • Students without any other insurance could buy an additional 35K or 235K of insurance coverage, giving them 50K or 250K in coverage.

20. International Students • International Students needing to meet their visa requirements could automatically be enrolled in 50K of coverage and the plan had the necessary medical evacuation and repatriation benefits. • Schools need to step in and organize international student insurance because international student have enough difficult navigating US Health Care system, let alone buying an insurance plan. • Students would obtain a plan to enter the country, then drop it and hold schools liable for their medical expenses.

21. Initiating a Mandatory Student Health Insurance Program Gaining Support for a Student Health Insurance Program • Finding the Right Partners • Who will champion the cause at your institution? • Who is the decision maker? • Will you incorporate the plan into tuition or add it as a student fee?

22. Implementing a Mandatory Student Health Program • Getting the right staff: hiring an NP and office staff • Developing a Fee Schedule • Developing an Encounter Form/Charge Slip • Setting up a Billing Process • Promoting services to students at orientation • Flagging students with pre-existing medical conditions to talk to them/their parents about purchasing additional insurance • Promoting after hours Nurseline

23. Implementing a Mandatory Student Health Program Getting the right staff: medical director, nurse practioner, and office support. • Medical Director: Looked at clinic within walking distance of campus, considered affiliations with local hospital and urgent care, willing to volunteer services. • Nurse Practioner: Starting with part-time, knowledge of what is needed to “set up” the office, relationship with community and local hospital, qualifications and ability to work independently. • Office Support: general office skills, scheduling, budget, phone, ordering supplies, communication within and outside the university

24. Implementing a Mandatory Student Health Program • Managing Referrals and Off-campus Networks/Providers. • Developing relationship with off-campus medical providers (medical director, athletics) and ensure you are sending students to a location that will not charge facility charges. • Develop a relationship vendors to supply lab services and pre-packed prescriptions. • Make sure students are given expectations of the charges (ie office visit copay and 20% coinsurance for labs).

25. Developing a Fee Schedule Task Force set a fee schedule based on roughly 30% of usual and customary for Milwaukee area

26. Developing an Encounter Form

27. Developing an Encounter Form

28. Setting up a Billing Process • Figure out how you will bill the insurance carrier: spreadsheets, encounter forms, or ledger billing. • In the case of Cardinal Stritch, ledger billing is done by WAICU for all participating schools.

29. Promoting Services to Students at Orientation • Make sure incoming students are aware of the mandatory health insurance by mailings, website, and participation in orientation. • Use orientation as a chance to meet with students to make sure they have adequate insurance coverage while attending classes. • Flagging students with pre-existing medical conditions to talk to them/their parents about purchasing additional insurance. Provide them with forms and deadlines.

30. Promoting after hours Nurseline • Many insurance companies will include an after hours “Ask a Nurse” service available at a toll free number. • Make sure fliers are available in academic and residential buildings. • Make sure housing/residential staff is aware of how the nurseline works.

31. Success with a Mandatory Student Health Insurance Program • Revenue generated to student health center • Plan generates enough revenue to cover NP salary and receptionist/billing staff. • Were able to increase services: labs, prepacked prescriptions, health education. • Student Health Center was able to function more as a full functioning clinic, instead of just nurse triage.

32. Success with a Mandatory Student Health Insurance Program • Expansion of Services at the Student Health Center • NP available ¾ time • Dietician available • All vaccines (including travel) are covered • Added prepacked prescription drugs

33. Success with a Mandatory Student Health Insurance Program • Retention Rates of Students Increased from 77% to 85% after the first year and to 88% during the second year. • Student/Parent Satisfaction • Healthier Campus • Decreased institutional liability • Improved provider relations • Continuation Benefit for Insurance after graduation (1-9 months)

34. Success with a Mandatory Student Health Insurance Program • Program Revised Yearly with other WAICU SHIP Participants • Use ACHA Data to analyze increases in needs • Review utilization to drop unutilized benefits or increase benefits in a highly utilized area • Adding more coverage in areas that had been excluded (ADD/ADHD and contraceptives)

35. Success with a Mandatory Student Health Insurance Program • Program began in 2005-2006 with Cardinal Stritch as only participant. • Entering the 5th year of the program, there are 14 schools participating in Wisconsin, 1 school in DC, 2 schools in Florida, and 6 schools in North Carolina. • The larger the pool of students, the more evenly the risk is spread, which helps contain costs. • Increase in plan prices have been stable and less than medical inflation. Most increases have been for benefit enhancements.

36. Case Study: How Does the Plan Work? • Student A presents at the student health center with sore throat. Has a visit with the NP who runs a rapid strep test. Student tests positive for strep. Given a prepacked prescription of antibiotic before they leave the health center. • Student receives all treatment without having to pay a cent. • School bills insurance company for $35 office visit, $15 for rapid strep, and $10 for prescription.

37. Case Study: How Does the Plan Work? • Student falls down the stairs on a Saturday night, possible broken arm • Residence Hall Director has been trained about Student Health Insurance Program • Campus Security calls an ambulance to take the injured student to nearby emergency room • ER knows student has insurance • 80% of visit, x-rays, ambulance, durable medical equipment, and prescription covered

38. Any Questions

39. Our Contact Information • Sallie Horrigan, Director of Health Services, Cardinal Stritch University, (414)410-4096, sjhorrigan@stritch.edu • Sally LaRosa, Nurse Practitioner, Cardinal Stritch University, (414)410-4854, slarosa@stritch.edu • Kelly McCoy, Director of Student Services, Wisconsin Association of Independent Colleges and Universities, (866)924-2848, kelly.mccoy@waicu.org