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Urgent Care Reimbursement

from WHOI Dean Jim Yoder (effective 9/1/06; updated 4/20/07)

This policy is for JP students based at WHOI and are covered under the MIT health insurance plan and need Urgent Care, and do not want to, or are unable to, travel to the MIT medical facility. The intent of this plan is to match the benefit of the MIT Plan and the accessibility of the MIT medical facility for JP students with Urgen Care needs who are based at WHOI and live nearby.

Urgent Care has an official definition within your MIT student health plan which you should review. Urgent Care is different from emergency care, and it also is different from routine health care. The plan described below only refers to Urgent Care; other types of treatment are NOT covered. If it's an emergency (bleeding, broken bones, very high fever, etc.), go the nearest hospital or call 911! Your MIT plan should cover emergency treatment.

In brief, here is a summary of the details for Urgent Care:

The plan applies only to WHOI-based JP students who either live on the Cape to be near their WHOI advisor, or who have a WHOI advisor and spend most of their working hours at WHOI. The Joint Program Office has a list of students who we believe meet this criteria. You may want to check with the office to be sure we consider you in the "WHOI-based" category, as we will provide a list of eligble persons to the administrator of the plan. You should also notify Marsha Gomes and Ronni Schwartz if your home base changes during the year. This plan does NOT apply to JP students who are based at MIT, since you have access to the MIT medical facility. Furthermore, if you are based at MIT and get sick while you are visiting WHOI, you are NOT covered. In the latter case, you should get treatment at the MIT medical facility. The plan also does not apply to any family members; only to the JP student.

The benefit is capped at $500 per year.

If you are one of the eligible students, and you believe you have developed a medical situation that falls under Urgent Care as defined by your MIT medical plan, here are the steps you need to take. It sounds complicated, in part because we are not sure of how various local clinics or doctors will react when you present your MIT card for Urgent Care, nor how the MIT medical facility will react when you request permission to be treated locally. Thus, we have to describe the possibilities and the options as we see them based on very little experience and very little information. I am sure we will encounter situations we have not anticipated, so we'll have to refine the program as we gain experience.

1. Call the MIT medical facility to explain your medical condition and ask permission to be treated locally. MIT may authorize local treatment, or they may insist that you drive to Boston to be treated at the MIT facility. Always call MIT first!
2. After calling MIT, and if you choose to be treated locally, go to your doctor or to a local clinic (see below). Present your MIT insurance card (even if MIT told you that you would have to drive to their facility and thus will likely deny the claim) at wherever you are seeking treatment. If they accept your MIT card, you will likely avoid immediate significant out-of-pocket expenses, although you will likely have a co-pay.
3. It is likely, although not guaranteed, that your doctor or clinic will accept your MIT card and bill MIT (perhaps minus a co-payment) for the cost of your visit. It’s possible that MIT will pay this bill, in which case nothing more needs to be done.
It is more likely, however, that MIT will reject the bill, and it will eventually come back to you. At that point, you can submit the rejected bill, along with some sort of proof that MIT rejected your claim to Benefit Strategies with a completed form. If Benefit Strategies (WHOI’s third party billing service) determines that your condition qualified as Urgent Care, they will pay the bill (up to the annual maximum) or reimburse you for your out-of-pocket expenses (up to $500/year).
4. It is also possible that your doctor or clinic will not accept your MIT insurance card and will want you to pay the bill. If that happens, either submit the bill or receipt (if you had to pay on the spot) to the MIT medical facility and ask them to pay it (or reimburse you). If MIT pays, great! If they reject your claim, send proof of the rejection plus your receipt or the bill to Benefit Strategies. If Benefit Strategies determines that your condition qualified as Urgent Care, they will pay the bill (up to the annual maximum).
5. It’s also possible that MIT will pay some, but not all, of the costs for Urgent Care treatment at local doctors or clinics. In those cases, you could submit a claim to Benefits Strategies for costs not covered by MIT. These claims will be reviewed, and if they would have been covered in full if you utlized the MIT's urgent care facility, they will be reimbursed to you up to the $500 limit. [Note: There was a recent case where MIT paid for some but not all the costs. Health Benefits reimbursed the student for those costs not covered by MIT.]
6. If you are on the MIT plan and incur medical expenses during official travel, this is an issue to take up with the MIT plan, not the WHOI supplemental plan.

This is the first time WHOI has tried something like this, so I am sure we are going to encounter some problems (in fact, we already have). There is also the possibility that the plan will prove too expenseive or too cumbersome or too something, and we might have to drop it. So, be patient and try to help us fine-tune the plan. We'll try to work through the issues as they arise.

Here is some information on local clinics (NO endorsement implied). I'd be interested in hearing about any experiences you may have at any of these places, or if you have found a local doctor or practice that will take walk-in or same-day appointment patients.
1. Falmouth Hospital - Falmouth Hospital will provide urgent care treatment on a walk-in basis, BUT they charge emergency room rates. In other words, it's very expensive. On the other hand, one can envision the situation in which a JP student believes they have an emergency, but the hospital considers it urgent care. If MIT eventually rejects your claim, then submit proof of the rejection plus the bill to Benefit Strategies. If you believe you have an emergency, always go the hospital or call 911!
2. There is a walk-clinic on Teaticket Highway in Falmouth. Their number is 508-540-6790 and their hours are M-F 8am-4pm, closed 12noon-1:30pm for lunch.