Frequently Asked Questions about Member Cost-Sharing and Claims

What is a Deductible?

A Deductible is the amount you must pay annually toward certain categories of medical expenses before insurance benefits begin. This is usually a relatively low amount compared to your overall coverage benefit.

What is a Copayment?

A Copayment is a payment which you make upfront each time you receive certain medical services. When you visit your health care provider, you pay the Copayment to the provider, and the plan covers the remaining expenses, subject to any Deductible or Coinsurance.

What is Coinsurance?

Coinsurance is the percentage of your medical expenses for which you are responsible after any applicable Copayments or Deductible has been satisfied. For example, if a SHIP Domestic student receives outpatient professional services at an “In-Network provider” for the first time, the student would be responsible for meeting the annual Deductible and 20% of the remaining charges. SHIP would cover the remaining 80% up to the plan maximum benefit.

Find an In-Network provider.

What are Out-of-Pocket Expenses?

Out-of-Pocket Expenses are the portion of medical expenses that you are responsible for. Typically this refers to the combined total of any Deductible and Coinsurance costs for which you are responsible. The Out-of-Pocket maximum is the maximum amount you are responsible for annually. In the case of SHIP, Copayments and non-covered services do not apply toward the out-of-pocket expenses.

How do I find out if a specific treatment is covered by SHIP?

Specific plan benefits can be verified by contacting the SHIP claims administrator, Wellfleet, at 1-877-657-5031. Please remember that covered services may still be subject to a deductible, coinsurance and/or copayment. All benefits are payable in accordance with the Plan Documents which can be viewed online. Plan exclusions are also detailed in the Plan Documents.

I have a question regarding a SHIP claim. What should I do?

Claims typically take up to six weeks to process. Case specific claims questions should be directed to the SHIP claims administrator, Wellfleet, at 1-877-657-5031. You can also call the SHIP office at 608-265-5232 if you have any issues or concerns and we can contact Wellfleet on your behalf.

What do I do if I receive a bill for a medical visit?

When you present your SHIP membership card to a provider, they should submit itemized medical bills to the address on the back of the card. Every bill includes universal coding to designate the procedure, diagnosis, and provider. When receiving services at a hospital, two bills are often generated. One is for the hospital charges, use of the facility, equipment and supplies, and a second is for the physician’s charges. Since it typically takes up to six weeks to process a claim, you may receive a bill or bills from the provider first. Do not pay any provider bill (except for any Copayment) unless you have already received an Explanation of Benefits from the SHIP claims administrator, Wellfleet. If you do receive any bills for any medical services, you can bring the documentation to the SHIP office. We will then fax the bills to Wellfleet for determination of patient responsibility and benefits coverage.

What is an Explanation of Benefits?

Once a claim has been reviewed and processed, the SHIP claims administrator, Wellfleet, will send you an Explanation of Benefits showing what the plan has covered, what discounts have been applied, and what your remaining financial responsibility (if any) is. This is not a bill, so do not send any balance due to Wellfleet. The provider will receive a separate notification from Wellfleet and should send you a revised bill for any remaining amount due. Please read the Guide to Understanding the Explanation of Benefits for additional information.

I have just enrolled in SHIP.  How do I fill my prescription?

After you have enrolled in SHIP, it can take up to three business days before the enrollment reflects in the system that pharmacies use.  If you do not have your physical SHIP ID card, log-in to the SHIP system to access an electronic version of your ID card.  Present your SHIP ID card to the pharmacy.  If the pharmacy is unable to electronically process your prescription at the time of dispensing, you will need to pay for the full retail cost of the prescription.  Please note that the retail cost may be significantly more than the contracted pricing that the plan would otherwise cover had the prescription been run directly through SHIP.  Reimbursement requests are based on the contracted pricing, so in some cases you may not receive any refund.  To avoid this, we recommend that if you do pay the full cost up-front – instead of seeking a reimbursement from Caremark, ask the pharmacy if they can reprocess the claim through SHIP if you return after three business days have passed. Pharmacies (including Walgreens) have this option, and it means that the pharmacy can refund you the full retail amount paid (minus any applicable member copay).  If the pharmacy is not able to re-process your prescription, a request for reimbursement can be made online at your caremark.com account under “Plan & Benefits”-“Submit a Prescription Claim”.  Caremark will review the claim request and claims will be reimbursed as if you had used SHIP at the point of service (minus any applicable member copay).