Executive Summary

Executive Summary

In Texas, young adults aged 18 to 24 have the highest risk of being uninsured of any age group. A significant proportion of people in this age group are enrolled in Texas colleges and universities. National data shows that young adults attending college are more likely to have insurance than those who do not attend college; however, college students are disproportionately at risk of lacking insurance coverage when compared to the population in general.

When considering how to reduce the high insured rates of young adults, college students deserve special attention. This population alone has access to student health insurance plans that are generally offered through colleges to students. Student health insurance plans are insurance products offered by commercial carriers that have contracted with colleges to make coverage available to some or all of their students. Student health insurance plans, which are separate from accident-only policies, are offered by most colleges in addition to routine medical services that may be provided at a reduced cost through a health center on campus.

This unique vehicle through which students can obtain coverage could be one way that coverage is expanded in this population. Before efforts to expand this market may be considered, more information is needed about the relatively unexamined subjects of uninsured Texas college students and school-sponsored, student health insurance. From June 2004 though April 2005, the Texas Department of Insurance (TDI) conducted an in-depth examination of uninsured college students in Texas and college-sponsored, student health insurance in the state. The goals of the study were to: (1) develop a clear understanding of student health insurance in the state today, (2) identify the issues and opportunities related to insuring college students through school-sponsored plans, and (3) identify public policy options that could expand health insurance coverage to uninsured Texas college students through school-sponsored, student health insurance plans. Research for this project was funded in part by a federal State Planning Grant awarded to TDI to examine options for expanding health insurance.

Surveys

To collect data on uninsured college students and student health insurance. TDI conducted four surveys, each intended to evaluate the topic from a different perspective. The surveys included:

1. A survey of most student health insurance policies sold through Texas colleges and universities. TDI catalogued plan components from student health insurance plans offered at 65 Texas colleges and universities during the 2004-2005 academic year.
2. A survey of current Texas college students. TDI surveyed over 2,500 college students on nine campuses across the state in February and March of 2005. In addition to collecting demographic information, the survey asked students whether or not they had insurance coverage and through what means they obtained coverage or why they lacked coverage.
3. A survey of Texas college and university administrators. From August to November 2004, TDI surveyed Texas colleges to determine how many offer a student health insurance plan to students. This survey also collected data on the extent of college-level requirements that some or all students have health insurance coverage as a condition of enrollment.
4. A survey of insurance carriers writing student health insurance in Texas during the 2004-2005 academic year. This survey collected data on the experience in the student health insurance market and the number of lives covered by these plans.

Data Highlights

Student Health Insurance Policies in Texas

· The average cost for student-only coverage in a student health insurance plan in Texas ranges from $718 to $786 per school year.

· Student health insurance policies tend to have limited benefits and multiple exclusions when compared to employer-sponsored coverage.

· About one-half of policies offered in Texas extend eligibility to any registered student, but the other half extend eligibility to only those students registered in a minimum number of hours. Minimum hour requirements for eligibility ranged from 3 to 12 hours, but a minimum of 6 hours was the most frequent cutoff for which students were eligible for the plan.

· Most policies offer limited catastrophic coverage. The most frequent catastrophic coverage limit was $50,000 per accident or illness.

· Three-fourths of Texas policies offer some prescription coverage, but most cap coverage per year. The average prescription coverage limit was around $500 per year.

· Two-thirds of policies offer some coverage for inpatient and outpatient mental health, but most limit this coverage. Common limitations to inpatient mental health coverage include $3,000 per year and 30 days per year. A common limitation placed on outpatient mental health care is coverage for $50 per visit up to a maximum of $500 per year.

· Policies generally exclude pre-existing conditions for the first 12 months if the student lacked prior coverage.

· More than one-half of policies contain exclusions for routine exams and preventative care, injuries obtained while under the influence of alcohol or drugs, injuries resulting from “high risk” activities such as skydiving or bungee jumping, injuries from fighting except when in self defense, self-inflicted injuries including attempted suicide, elective abortions, and organ transplants.

Insurance Coverage and Current Texas College Students

• An estimated 36 percent of students attending public colleges are uninsured and 23 percent of students attending private colleges are uninsured.

• In general, students with the highest risk of being uninsured include non-traditional aged students, single parents, Hispanic students, students not in good health, students not required to have coverage by their college, students whose education is primarily financed by the military, and students in their senior year.

• In general, students with the greatest chance of having insurance coverage include those whose education is primarily financed by their parents, those required to have insurance by their college, PhD. students, students who work full-time, and married students with no dependent children.

• Seventy-eight percent of surveyed college students said that health insurance coverage is very important, 20 percent said it is somewhat important, and only two percent reported thinking that coverage is not important.

• About one-half of all students surveyed indicate a willingness to pay up to $50 each month for coverage; however, only 38 percent of uninsured students would pay more than $50 a month for coverage.

• Thirty percent of uninsured students lacked coverage for more than three years, and 30 percent of uninsured students had lacked coverage for less than one year.

• Seventy-one percent of uninsured students said they lacked coverage because it was too expensive.

• Fifty-four percent of uninsured students said they did not buy the school-sponsored student health insurance plan because it was too expensive, and 36 percent reported not knowing about the plan.

Plans Offered by Texas Colleges

• Sixty-three percent of Texas colleges reported offering a student health insurance plan.

• Health-related institutions and public universities are more likely to offer a student health insurance plan than private colleges or junior colleges.

• No college reported difficulty finding a carrier that would provide coverage to their students.

Coverage Requirements for Students

• Few colleges in Texas require all students to have insurance coverage as a condition of enrollment, but that trend is growing nationwide.

• 12 percent of Texas colleges reported requiring all students to have coverage, 61 percent require certain students to have coverage and 27 percent do not require coverage for any student.

• Of the 12 colleges that reported requiring all students to have health insurance coverage, seven are health-related institutions, and the other five are private colleges.

• Almost all public universities in Texas only require international students to have health insurance coverage. Coverage is voluntary for all other students.

Plan Enrollment Rates

• In general, enrollment in student health insurance plans in Texas is relatively low. The average enrollment rate in fall 2003 was 11 percent of the student body and the median enrollment rate was just six percent of the student body.

• Enrollment rates are highest at health-related institutions. Enrollment rates at private colleges are higher than those at public colleges.

• The median enrollment rates at colleges which require students to have coverage is 29 percent.

• The ability to pay for coverage as part of tuition and fees and the requirement that students must accept or reject coverage during registration are both linked to higher plan enrollment rates.

• Enrollment in plans drops over the summer. In 2003 and 2004, enrollment dropped 12 to 15 percent from the spring semester to the summer semester. The decline is due in part to an insurer provision that requires students to be enrolled in summer classes to purchase coverage at the beginning of the summer term.

Student Health Insurance Market

• At least ten carriers wrote student health insurance during the 2004-2005 academic year. Of these, five have been in the Texas student health insurance market two years or less, and four have been in for ten years or more. Nine of ten carriers in the Texas market indicated they were considering expanding business.

• Total student health insurance premiums written in 2003 for the seven companies writing were $22,200,000. Total claims paid were $19,500,000.

• In 2003, the market was relatively concentrated in two companies. The largest accounted for 59 percent of written premiums, and the second largest carrier wrote 22 percent of total premiums.

• Insurers reported covering 56,000 lives in student health insurance plans at any time in 2003, and they covered 37,500 lives on September 15, 2004.

Conclusions and Policy Options

School-sponsored, student health insurance plans provide insurance coverage for tens of thousands of college students in Texas, and they could potentially provide access to coverage for hundreds of thousands of Texas college students that are currently uninsured. These plans have both benefits and limitations, which make it debatable whether expanding the student health insurance market would be a good way to provide coverage to more college students.

Students can benefit from school-sponsored plans that are designed to integrate with health services offered on campus, and students in less than perfect health can greatly benefit from the prohibition of medical underwriting in these plans. From an enrollee’s perspective, the limitations of these plans may include affordability issues, relatively low benefit levels compared to employment-based group plans, multiple exclusions, limited eligibility for part-time students, and limited accessibility over the summer.

If an expansion of the student health insurance market is deemed desirable, options exist at both the college-level and state-level to expand coverage to uninsured college students through student health insurance plans. More students could be encouraged to take advantage of coverage through these plans by policies that address more effective plan promotion, increasing accessibility and affordability of coverage, increasing the size of insured pools, adjusting coverages, increasing communication between colleges and providing more education to students on the value of health insurance protection. Crafting public policies that expand coverage to uninsured college students and achieve an appropriate balance of affordability, adequacy and accessibility for student health insurance plans will prove challenging but could result in benefits to students, colleges and the State of Texas.

Introduction

In 2001, the Texas Department of Insurance (TDI) was awarded a State Planning Grant from the Health Resources and Services Administration of the U.S. Department of Health and Human Services to collect data on the uninsured population in Texas and evaluate options for expanding health insurance coverage. With this funding, TDI did extensive research on the uninsured population in Texas and the small employer health insurance market in Texas. Several changes subsequently enacted during the 2003 Texas legislative session were aimed at making health insurance more affordable and accessible for uninsured Texans.

In 2003, TDI was awarded supplemental grant funds to extend its research on methods to expand health insurance coverage. The additional funding was used to evaluate the effectiveness of policies implemented in 2003, as well as to expand research into areas of opportunity identified under the original grant.[1] One such area that became a focus of research under the supplemental grant was the uninsured college population and college-sponsored, student health insurance. Prior to this study, little information had been compiled on student health insurance in Texas. It was unclear how many colleges offered such coverage to students, how many students were enrolled, which students were required to have health insurance coverage as a condition of enrollment, and how many carriers wrote this coverage in the state. As part of this project, TDI gathered information from Texas colleges and universities, insurers who write student health insurance, and current college students. The ultimate goals were to: (1) develop a clear understanding of student health insurance in the state today, (2) identify the issues and opportunities related to insuring college students through school-sponsored plans, and (3) identify public policy options that would expand health insurance coverage to uninsured Texas college students through school-sponsored student health insurance plans.

The following report summarizes the research, findings, and policy options generated under TDI’s year-long investigation into the circumstances under which Texas college students have access to and use health insurance coverage available through colleges and universities. Chapter 1 provides statistics showing the extent of uninsurance among young adults in Texas in general and among the college student population specifically. An overview is also provided on how college students access health insurance and how that differs from the population in general. The chapter discusses reasons why young adults and college students traditionally have high uninsured rates and why health insurance coverage is important to this population.

Chapter 2 defines student health insurance plan coverage and explains how it differs from other health insurance products. An overview of the plans that are currently offered through colleges and universities in Texas is provided. This chapter also discusses the growing trend for states and colleges to mandate insurance coverage for students and discusses the different forms such mandates can take.

Chapter 3 discusses the results of a survey of more than 2,500 Texas college students from nine colleges and universities across the state. College students were asked about their attitudes toward health insurance and their own health insurance coverage or lack thereof. This chapter provides insight into the racial/ethnic, gender, and age dimensions of current Texas college students that are uninsured and discusses their reasons for lacking health insurance coverage.

Chapter 4 presents findings from a statewide survey of colleges and universities about student health insurance plans offered through colleges to students. This chapter provides data on how many colleges make such plans available and how that differs between four-year public universities, private colleges, junior colleges, and medical schools/health-related institutions. This chapter also provides information on how many colleges have policies requiring some or all students to have health insurance coverage and which students are subject to those requirements.

Chapter 5 provides the enrollment rates in school-sponsored health insurance at Texas colleges and looks at the differences between student health insurance plans with relatively high enrollment and those with low enrollment. Various factors that may lead to higher enrollment in student health insurance plans are discussed.

Chapter 6 presents findings from a survey of carriers that write student health insurance coverage in Texas. This chapter discusses the experience in the market as well as market concentration. An overview of benefits and exclusions offered in approved policy forms is also provided.

Finally, Chapter 7 discusses the limitations and benefits of student health insurance that were identified over the course of TDI’s research. Based on ideas and data discussed in the previous six chapters, this chapter provides a list of policy options intended to expand health insurance coverage to more Texas college students through student health insurance plans.

Notes

Chapter 1. Health Insurance Coverage among Young Adults and the College Student Population

Young adults aged 18 to 24 are in the age range at the highest risk of being uninsured in Texas, and the college student population in Texas exhibits high uninsured rates. Full-time college students are more likely to have health insurance than part-time students or young adults who do not enter college; however, even full-time college students are disproportionately at risk of being uninsured.[2] Generally, this population is thought of as young and healthy, so the consequences of uninsurance among young adults and college students may not seem severe. Health insurance coverage is an important factor, however, to help individuals in this population maintain their health and avoid financial hardships. This chapter discusses the extent of uninsurance among the young adult and college student populations and the reasons why these populations disproportionately lack coverage. Data is provided on how college students access insurance and the extent to which college requirements for coverage vary among schools.

Uninsured Young Adults

The Uninsured Young Adult Population in Texas

Texas has the highest uninsured rate in the nation. In 2003, one-quarter of all Texans, or 5.37 million people, lacked health insurance coverage compared to the national uninsured rate of 15.6 percent.[3] Rates of uninsurance vary dramatically by age. Table 1.1 shows the Texas uninsured population and rates by age in 2002. The age group with the highest risk of being uninsured is young adults ages 18 to 24 years old. In 2002, 42.5 percent of Texans in this age group, or approximately 955,000 young adults, lacked health insurance, and the numbers are increasing. In one year, the rate of uninsurance for 18 to 24 year olds in Texas increased nearly 10 percent from the 38.7 percent uninsured in 2001 to 42.5 percent. Uninsured young adults ages 18 to 24 constituted more than 17 percent of the total uninsured population in Texas in 2002. The 25- to 34-year-old age group also shows high rates of uninsurance. In 2002, 37 percent of this age group lacked health insurance coverage, and uninsured 25 to 34 year olds accounted for 22 percent of the total uninsured population in Texas.[4]

Factors Leading to Uninsurance in Young Adults

Multiple factors explain why 18 to 24 year olds are particularly susceptible to being uninsured. The life transitions experienced by young adults both leave this age group vulnerable to losing insurance coverage and cause them to have unstable insurance coverage.[5] Children covered by public insurance often lose their eligibility when they reach adulthood. Children covered under the Children’s Health Insurance Program (CHIP) in Texas lose eligibility when they turn 19, and eligibility criteria for Medicaid coverage becomes much more stringent when enrollees turn 19.[6]

Table 1.1
Texas Uninsured Population and Rates by Age, 2002

Age Range	Number Uninsured	Percent Uninsured within Age Group	Percent of Total Uninsured Population
0 – 6	480,163	19.65%	8.64%
7 – 17	872,044	24.19%	15.70%
18 – 24	955,337	42.48%	17.20%
25 – 34	1,222,205	37.10%	22.00%
35 – 44	953,315	30.15%	17.16%
45 – 64	1,031,520	22.19%	18.57%
65 and over	41,014	1.93%	0.74%
Total	5,555,598	25.81%	100.0%

Source: Texas Department of Insurance, Working Together for a Healthy Texas: Interim Report of the Texas State Planning Grant (Austin, Tex., September 30, 2004), p. 13. Online. Available: http://www.tdi.state.tx.us/general/pdf/spgint04.pdf. Accessed: March 7, 2005. Data from the March 2003 Current Population Survey. Analysis by Texas Health and Human Services Commission.

Young adults in many states risk losing coverage through their parents on their 18th or 19th birthday unless they are enrolled in college full-time. A 2004 national survey of employer-sponsored health plans found that nearly 60 percent stop covering 18- or 19-year-old dependents who are not enrolled in college.[7] Texas law, however, requires fully-insured group and individual health plans to allow parents to continue coverage of unmarried dependents until they turn 25, regardless of school or work status.[8] (Note: This provision does not apply to self-funded group plans exempt from state regulation under ERISA.) Prior to the passage of this provision in 2001,[9] Texas law allowed plans to terminate coverage for children at age 19 if not attending school, or age 23 if the dependent was in college.[10]

Young adults are also less likely to have access to employer-sponsored health insurance than older adults. This is especially true of young adults that do not go to college. Often, when young adults join the labor force, they work in jobs that are the least likely to offer health insurance coverage. Even young adults that can access insurance through their employers may not be able to afford the required premiums, and they remain at risk of unstable coverage because younger workers tend to change jobs more frequently than older workers.[11]

Health Insurance and College Students

The Uninsured College Population

Nationally in 2002, 19 percent of full-time college students were uninsured,[12] which was nearly 4 percentage points higher than the national uninsured rate.[13] Also, in 1999, 29 percent of part-time college students lacked insurance.[14] Among young adults that graduated from high school from 1996 to 2000 and enrolled in college, 23 percent lacked health insurance at some point during their freshman year in college.[15] Estimates of the total uninsured rate among all college students range from 25 percent to 33 percent.[16]

How College Students Access Insurance

The majority of non-elderly Americans obtain health insurance coverage through an employer. Nationally in 2003, 62 percent of the non-elderly had employer-sponsored health insurance coverage. Most college students are able to access insurance in two ways many other adults cannot. First, many college students can remain covered by a parent’s employer-sponsored health insurance. Second, most colleges and universities make student health insurance plans available to their students. This school-sponsored coverage provides a unique vehicle through which college students can access health insurance coverage. One-quarter of students are covered under either school-sponsored plans, an individual plan or a public health plan, including private individual plans, school-sponsored student health insurance, and public health insurance.[17] Almost one-half of full-time college students have employer-sponsored insurance coverage as a dependent, and an additional 7 percent have employer-sponsored insurance from their own employment.

Benefits of Health Insurance for College Students

In general, college students tend to be relatively healthy, yet health insurance can provide many benefits to this population. Insurance coverage can help students meet their health care needs, especially when such care involves services not available on campus. For example, students may access primary care for the treatment of common infectious illnesses[18] and sexually transmitted diseases.[19] Regular preventive care is important to students, especially female students, for whom annual Pap smears are recommended once they reach age 18.[20] Mental health care is increasingly important for college students. A study by the American College Health Association found that almost one-half of college students had trouble functioning at some point in college due to feelings of depression. In addition, stress, eating disorders, drug and alcohol abuse, and thoughts of suicide are all conditions for which college students frequently need access to mental health care.[21]

Health insurance protects students and their families from high medical costs associated with serious injuries or illnesses. Though generally healthy, traditional-aged college students need access to acute care. In 2002, the leading cause of death among 15 to 24 year olds was unintentional injury.[22] As seen in Table 1.2, young adults ages 18 to 24 are much more likely to have injury-related emergency room visits than older adults or children. From 2001 to 2002, 14 percent of all injury-related emergency room visits were made by 18 to 24 year olds.[23]

Table 1.2
Injury-Related Emergency Room Visits per 10,000 Persons
by Age and Gender, 2001-2002

	Male	Female
Under 18 years	1,635	1,180
18-24 years	2,317	1,635
25-44 years	1,775	1,311
45-64 years	1,036	974
65 years and over	1,193	1,369
All ages	1,556	1,239

Source: National Center for Health Statistics, Health United States 2004 (Hyattsville, Md.: NCHS, 2004), Table 84. Online. Available: http://www.cdc.gov/nchs/data/hus/hus04.pdf. Accessed: March 8, 2005.

Students that lack health insurance coverage may have difficulty accessing necessary care. A survey of uninsured young adults ages 19 to 29 found that they were more than twice as likely as insured young adults to say that they “would wait as long as possible to seek care when sick.”[24] Additionally, 56 percent of uninsured young adults reported foregoing needed health care because of costs, compared to 33 percent of young adults with insurance coverage.[25] Keeping continuous coverage during college will also help students access care after they graduate. Assuming a graduate maintained continuous insurance coverage in the year prior to graduation and takes a job that offers health insurance without a break in coverage of more than 63 days, he or she will not have any pre-existing conditions excluded during the first year of job-based coverage.

Finally, health insurance coverage during college will help teach students about health insurance and its value. College years often serve as a transition from dependence to independence, and a time when students begin to take on adult responsibilities. During their college years, students are likely to assume a more direct role in seeking and paying for medical care, and in doing so, will be made aware of the high costs of medical care and prescription drugs. Having and using insurance coverage during this time will give students a better understanding of and appreciation for the importance of coverage, and may increase the likelihood that they will continue to remain insured upon entering the job market.

Health Insurance Coverage Requirements for College Students

There is a growing trend at colleges and universities nationwide to require all college students or full-time college students to have health insurance coverage. Most colleges do not specifically require participation in the school-sponsored plan, but they make such coverage available to students who do not have insurance through their parents or some other means. [26] The American College Health Association, an advocacy and education organization for college and university health programs, recommends that colleges require their students to provide proof of health insurance coverage as a condition of enrollment.[27] For the most part, colleges in Texas do not require coverage for all students. Coverage requirements in Texas will be discussed in depth in Chapter 4. This section defines the different types of insurance requirements, identifies populations to which these requirements apply, and discusses reasons for insurance coverage requirements.

Types of Student Health Insurance Requirements

Student health insurance requirements range from fully voluntary to fully mandatory. A fully voluntary plan does not require any student to have coverage, and any student who wants coverage purchases it directly from the carrier. A forced answer system is next on the continuum. Under this system, students are still not required to have coverage, but they are required to either accept or reject insurance before school registration can be completed. If a student accepts coverage or fails to reject it, premiums are added to the tuition and fee bill.[28]

Under mandatory systems, some or all students are required to have coverage as a condition of enrollment. Often, mandatory systems let students waive school-sponsored coverage if they have alternate coverage through their parents, their spouse, a job, etc. A request for a waiver must be returned by a certain date with the required proof of coverage or the student is automatically enrolled in the school-sponsored plan. A loose waiver system only requires students to attest that they have alternate coverage by signing a form or checking a box. A hard waiver system requires students to submit specific proof of coverage, often a copy of an insurance card, with their waiver application. Finally, a few colleges mandate coverage in the school-sponsored plan for some or all students. Under this system, students are automatically enrolled in the student health insurance plan and cannot be granted waivers if they have alternate coverage.[29]

States and College Systems with Coverage Requirements

Currently three states - Massachusetts, New Jersey, and Idaho - require college students to have insurance coverage. Kentucky had a coverage mandate, but it was overturned by a county circuit court in 1992, less than a year after it went into effect.[30] In addition, the governing boards of large university systems have instituted coverage requirements in Montana, California, Illinois, and Minnesota. Finally, many individual schools have chosen to require insurance for students. Nationally, about 90 percent of private colleges and 25 percent of public universities mandate health insurance coverage for students.[31] With the exception of colleges in California, public universities with voluntary student health insurance plans are primarily located in the south and southwest states, which tend to have high uninsured rates.[32]

Massachusetts

The statute requiring college students to carry health insurance in Massachusetts has been in place since 1989. It requires all students attending college three-fourths of full-time or more to have coverage in a qualifying student health insurance program (QSHIP) offered through their college or an alternate plan with comparable coverage. Students with alternate coverage must waive QSHIP participation annually. Minimum standards for QSHIPs are defined in statute. They include a maximum benefit of at least $25,000, 60 days inpatient mental health coverage, 24 visits annually for outpatient mental health, and hospital expenses must be paid at 80 percent of reasonable and customary charges. Maximum co-pays are set at $100 for emergency room visits with no admission and $50 if admitted, $50 for outpatient hospital services, and $25 for physician visits. Pre-existing conditions must be covered no later than six months after enrollment and alternate coverage must have accessible services in the area of the college. The law also sets up an annual reporting requirement from colleges to the Massachusetts Division of Health Care Finance and Policy.[33] In 2002, about 70 percent of college students, or 289,000 people, in Massachusetts were required to carry insurance under this statute. Of these students, about 30 percent enrolled in school-sponsored QSHIPs and 70 percent received a waiver for alternate coverage.[34]

New Jersey

In 1991, the New Jersey Legislature passed legislation requiring all full-time students in public and private institutions of higher education to have health insurance coverage. In addition, it required all institutions of higher education to make student health insurance plans available to their students. The law also requires colleges to take the costs of health insurance into account when determining eligibility for financial aid. If students have alternate health insurance coverage, they must present proof of it to their school annually to receive a waiver from the school-sponsored coverage.[35]

Idaho

In 2002, the Idaho Board of Education implemented regulations requiring public, four-year universities to offer student health insurance and all full-time students at such institutions to maintain health insurance coverage. Colleges may allow students to waive the school-sponsored plan if they provide proof of equivalent alternate coverage. Additionally, colleges must monitor and enforce this requirement.[36]

Requirements in Large University Systems

In several states that do not have state laws requiring student health insurance coverage, the governing boards of public university systems have adopted such requirements. In 2000, the University of California System and the Montana University System passed student health insurance requirements. The University of Minnesota-Twin Cities has required health insurance since the 1970s. Beginning in the 2005-2006 academic year, this requirement will be extended to the other three campuses in the university’s system. All public universities in Illinois require students to have health insurance coverage, but not as a result of a state law. Rather, each university’s governing board individually adopted student health insurance mandates. Many date back to the 1970s.[37]

International Students

Certain international students are required by federal law to have health insurance coverage in effect while they are studying at colleges in the United States. Students that come through formal exchange programs with J-1 visas and their dependents are required to have health insurance that meets minimum standards set by the U.S. State Department.[38] Though not required to by law, many international students with other types of visas, including those with F-1 visas, are required to have health insurance by their college. In many cases, international students are singled out for coverage requirements because they may be less familiar with the private health care system in the United States. Both international students and their colleges could face financial risks if uninsured, visiting students or their dependents incurred significant medical costs.[39]

Medical Students

In Texas, governing boards of health-related institutions can require students to have insurance according to Senate Bill 505, passed in 2001. The law instructs schools’ governing boards to determine the minimum standards for coverage required of students. In health-related institutions that require coverage, students may be provisionally enrolled for one semester without coverage so they have adequate time to obtain coverage. The law also requires schools to incorporate an estimate of the cost of insurance coverage into the cost of education for the purpose of determining financial aid.[40]

Texas’ law applies to the nine health-related institutions in the state.[41] One of the primary purposes for the law was to protect students at health-related institutions and the institutions themselves from the increased risks associated with direct patient contact. [42] There was no opposition to the law when it was up for debate, but legislators were concerned about the affordability of coverage.[43]

Reasons for Insurance Coverage Mandates

There are multiple reasons why states and colleges have adopted student health insurance coverage requirements. One primary reason is to address high uninsured rates and related problems on college campuses. The University of Ohio adopted an insurance requirement in part due to the difficulties faced by college health practitioners attempting to refer uninsured students off-campus for specialized medical care. They were concerned that uninsured students would not be able to access needed care other than what was available on campus or through an emergency room.[44] The University of California System adopted a measure requiring all undergraduates to have insurance in part because of increasing withdrawals due to health-related issues. Some students facing mounting medical bills were forced to drop out and others in HMOs had to move back home to get required, non-emergency health care.[45]

Another primary reason that colleges have chosen to require health insurance coverage is to increase the viability of their insurance plan. If all students are required to have coverage, adverse selection will be avoided and risks will be spread over a bigger pool of students.[46] These factors should improve the experience of the plan and allow for lower premiums and/or expanded coverage. Voluntary plans tend to have more exclusions and lower benefit levels.[47] In many cases, voluntary student health insurance plans remain viable because international students, who are required to carry insurance, indirectly subsidize coverage for domestic students that opt in.[48] Additionally, if a student is subject to an insurance requirement, the cost of a student health insurance plan can be included in calculations to determine financial aid, making coverage more affordable for students.[49]

Conclusion

Despite the fact that the college population is relatively young and healthy on average, health insurance coverage offers important protections to this population. Unfortunately, many college students lack health insurance. High uninsured rates among college students present many challenges both for uninsured students and the larger college community. Some colleges and states are attempting to address these problems by requiring coverage for students. While such requirements are not the only option available to colleges and states attempting to combat high uninsured rates on campuses, they are becoming more common.

Notes

Chapter 2. Overview of Student Health Insurance Plans

Colleges often offer school-sponsored health insurance to students for the same reasons many offer health care on campus – they have an interest in maintaining the health of their student body so students can achieve their educational objectives.[50] College students, like other young adults, can easily fall through the cracks when it comes to accessing coverage. This is especially true if a student’s parents do not have employer-sponsored health insurance coverage. To mitigate some of the difficulties students face in accessing coverage, many colleges and universities offer student health insurance plans. This chapter defines student health insurance plans, describes components of plans sold in Texas, and discusses the relevant legal framework that separates them from other health insurance products.

What Is Student Health Insurance?

Student health insurance plans are insurance products offered by commercial carriers that have contracted with colleges, which in turn make coverage available to some or all of their students.[51] The plans, which are different from accident-only policies, are offered by most colleges in addition to any medical services that may be provided at a reduced cost through a health center on campus.[52] Individual colleges or college systems select an insurance carrier with which to contract, generally as part of a bid process. The college often plays a role in determining plan components; therefore, the level of coverage and cost of these plans varies greatly across colleges. Some colleges offer comprehensive plans that compare favorably to employer-sponsored insurance in terms of benefits; however, others offer coverage inadequate even to meet the needs of the traditionally healthy college population.[53] In Texas, student health insurance is regulated as blanket accident and health insurance under the Texas Insurance Code, Chapter 125. It is considered a group insurance product, but it is not necessarily subject to the same provisions as employer-sponsored coverage.

In 2000, the American College Health Association (ACHA) released an updated version of Standards for Student Health Insurance/Benefit Programs, which is meant to guide institutions of higher education in the development of quality student health insurance plans. One of the ten standards instructs colleges to design a plan with the knowledge “that students rely upon its student health insurance/benefit program for their primary source of health insurance protection,” and thus, provide “an appropriate scope of coverage.”[54] To provide such coverage, the guidelines recommend a plan have a minimum level of benefits that cover preventative health care, mental health care, and catastrophic illness and injuries.[55]

Stephen L. Beckley, a health care benefits consultant who specializes in higher education and one of the four members of the ACHA committee that drafted Standards for Student Health Insurance/Benefit Programs, has defined appropriate coverage in student health insurance plans in more specific terms. He asserts that components of a student health insurance plan, including covered benefits, definitions, limitations and exclusions, should be consistent with those generally found in large, employer-sponsored health insurance coverage.[56] Mr. Beckley estimates that more than 85 percent of the student health insurance plans found at colleges nationwide fail to comply with the ACHA guidelines.[57]

Components of Student Health Insurance Plans

The following section presents many of the components of student health insurance plans in general as well as the range of options and coverage found in plans offered by institutions of higher education in Texas.[58] All references in this chapter to student health insurance plans found at Texas colleges and universities[59] come from an analysis of the majority of plans currently offered through colleges in the state. Between July 2004 and February 2005, TDI reviewed plan details from marketing materials and summaries of benefits from 37 different student health insurance plans that were made available to students at 65 colleges and universities in Texas during the 2004-2005 academic year.[60] A few colleges with school-sponsored coverage did not provide the requested materials, but most student health insurance plans sold in Texas have been taken into account.

Medical Underwriting

Unlike in the individual health insurance market, medical underwriting is not used in student health insurance plans. Colleges and universities that receive any federal funding are prohibited by Section 504 of the Rehabilitation Act of 1973 from discriminating against any student based on a handicap. As it relates to student health insurance, this law prohibits denying coverage based on a health condition or basing premiums on health status.[61] This is an advantage for students with chronic conditions who may be uninsurable in the individual market. No student health insurance plan offered through a college in Texas asked any questions related to health on the application and no plan charged different premiums based on health status. However, once insured, all covered people are subject to any pre-existing condition provisions that limit coverage for existing medical conditions for a specific period of time, depending on the terms of the policy.

Eligibility

Eligibility requirements for student health insurance vary by school. Some plans extend eligibility to any student who is registered and attending classes, but more limited eligibility structures are common. One of the most common restrictions limits enrollment to students that are registered for a minimum number of hours. Another common restriction excludes students that are only registered in online or correspondence classes. Many plans allow covered students to enroll their dependents as well. Though the ACHA guidelines do not specifically address student eligibility, they state that covered students should be allowed to enroll their spouse or domestic partner and children.[62]

In Texas, about one-half of plans extend eligibility to any registered student, and the other half limit eligibility to students who are taking a minimum number of hours. Number of hours required for eligibility in a fall or spring semester range from three hours to 12 hours, but six credit hours is the most common standard. To maintain eligibility, most plans require students to actively attend classes for the first 31 days of the enrollment period. Any student that withdraws before that point will lose coverage and be eligible for a refund. Students that withdraw, graduate, etc. after 31 days cannot cancel their coverage and receive a refund unless they enter the military.

With few exceptions, plans in Texas do not allow students to maintain insurance eligibility if they take a semester off. Nor do they allow students who are not taking classes over the summer to purchase coverage for the summer semester(s) unless coverage was purchased previously as a spring/summer package. Approximately one-third of Texas plans allow students to extend their coverage temporarily following graduation. Continuation periods available to graduates range from three to 18 months, but the most common length is 6 months.

All but a few Texas plans allow covered students to also purchase coverage for their spouse and dependent children. The age at which dependent children lose eligibility in these plans ranges from 19 to 25. Although it was relatively rare, a few plans specifically extend eligibility to a covered students’ domestic partner.

Enrollment Periods

Student health insurance plans generally provide several options regarding the length of time for which coverage can be purchased. Almost every plan offers enrollment periods that correspond generally with the fall, spring, and summer semesters. Nearly 60 percent of plans offer students the option to purchase spring and summer coverage together in January, and about one-third of plans lack a spring-only option so that students must buy spring and summer coverage together. Students must meet the eligibility criteria each time they enroll, so the ability to buy spring and summer coverage together allows students who are not taking summer classes to remain insured.

About three-fourths of plans also offer students the option to purchase coverage for the entire academic year (September through August) in the fall. An annual enrollment option provides the benefit of continuous coverage for twelve months, but the entire year must be paid for up front. In addition to semester enrollment periods, a number of plans offer students the option to purchase coverage quarterly and a few allow students to buy coverage on a monthly basis. A student that purchases coverage for shorter periods of time may be more at risk of intermittent coverage if he or she takes a semester off or simply forgets to renew coverage.

Integration with Campus Health Services

One of the benefits of student health insurance plans is that they often integrate with and fully cover services delivered at the health center on campus. For example, mental health benefits can supplement services provided at student counseling centers. Plans can also cover charges for fee-for-service treatment at the student health clinic.[63] Many plans waive deductibles and co-payments for services obtained at the student health center. In addition, such services are often covered 100 percent, while coinsurance would apply to medical services obtained off-campus.[64] ACHA guidelines recommend a plan design that “encourages utilization of campus health and counseling services, where doing so provides cost effective and high quality care for students.”[65]

Approximately one-third of student health insurance plans in Texas coordinate in some way with student health centers. This feature was common in the plans offered by public universities,[66] most of which have student health centers, but it was not common in the plans of junior colleges,[67] many of which lack health care facilities on campus. Of plans that integrate with student health centers, most waive the deductible for services received on campus and cover such services at 100 percent.

Catastrophic Coverage and Maximum Benefits

Unlike employer-sponsored health insurance plans, the maximum benefit in student health insurance is generally applied per injury or illness as opposed to a lifetime maximum. Many school-sponsored plans offer a basic benefit with a relatively low per injury/illness maximum, and in addition, offer enrollees the option of purchasing additional catastrophic coverage. This optional coverage may increase the basic maximum benefit three or four times. Beckley believes that to be adequate as the sole source of health insurance coverage for students, the lifetime maximum benefit should be at least $500,000 and that catastrophic coverage should be included in the basic plan.[68]

All plans in Texas include a maximum benefit level, but the terms of the maximum vary by policy. More than 70 percent of plans include a maximum benefit per injury or illness. A few plans have either a lifetime maximum or an annual maximum, or a combination of the two. Benefit maximums vary from $2,000 per injury/illness up to a $1,000,000 lifetime limit. The average maximum benefit is $105,200; however, that figure is skewed by the few plans with significant maximum benefits. The median and mode maximum benefit in Texas plans is $50,000.

Approximately one-third of plans in Texas offer students the option to purchase additional catastrophic coverage. The total maximum benefits of plans including the optional catastrophic coverage ranged from $25,000 to $1,000,000, and this limit was most often structured per injury or illness. The average maximum benefit with additional overage is $203,200 and the median is $110,000. Plans offered by public universities most often contained this additional coverage option.

Fewer than 20 percent of plans in Texas have an out-of-pocket maximum. These provisions limit an enrollee’s liability by paying 100 percent of covered charges from the out-of-pocket limit up to the maximum benefit. In Texas plans that include a maximum out-of-pocket limit, these provisions generally take effect after the policyholder has incurred $1,000 to $3,000 in covered health care costs or after the insurer has paid $10,000 to $12,000 in covered health care costs.

Cost Sharing

Cost sharing is common in the student health insurance plans found in Texas. About two-thirds of plans require coinsurance and deductibles. Under the most common coinsurance structure, 80 percent is covered in-network and 60 percent is covered out-of-network. Most plans require an annual deductible that ranges from $50 to $750, but a few plans require a deductible per accident or illness that ranges from $10 to $150. The average in-network, annual deductible is $213, and the median is $150. The average out-of-network, annual deductible is $245, and the median is $225.

Prescription Coverage

Outpatient prescription drug coverage varies considerably among student health insurance plans. It is impossible to determine what level of coverage is adequate in a plan without first considering whether a college has a pharmacy in its student health clinic and to what degree prescription drugs are discounted through the pharmacy.[69] Approximately three-fourths of plans in Texas provide some prescription drug coverage, but most cap annual coverage at a particular dollar amount. Limits to coverage range from $50 to $6,000. Most limits apply per year, but a few are per illness or injury. Of plans that cap annual coverage of prescriptions, the average annual limit is $496 per year, and the median and mode limit is $300 per year. Only three plans in the state do not cap prescription coverage. These plans, each of which is offered by a private university, cover 80 percent to 100 percent (minus a co-pay) of prescription charges at in-network pharmacies and 60 percent to 80 percent of charges out-of-network. Plans offered through private colleges are more likely than public colleges to include prescription coverage, and plans offered through four-year universities are more likely than two-year colleges to provide prescription benefits. The most generous prescription limits as well as the most restrictive limits are found in plans offered by private colleges.[70]

Maternity Coverage

Title IX of the Education Amendments of 1972, which prohibits gender discrimination at colleges that receive federal funds, requires student health insurance plans to cover pregnancy as any other temporary illness or disability. Plans must include this coverage not only for students, but also for a student’s enrolled spouse.[71] Maternity coverage is treated very differently in the student health insurance market than the individual market, where such coverage is generally sold as a rider, and is expensive due to adverse selection.[72] Materials from two-thirds of student plans offered in Texas explicitly state in the schedule of covered benefits that pregnancy is covered on the same terms as any other temporary illness or disability. Summaries of benefits from the remaining one-third of plans, which are more likely to be sold through private colleges, either do not mention maternity coverage or do not indicate that it is either covered or excluded as a temporary disability.[73]

Medical Evacuation and Repatriation

Most plans in Texas include specific benefits for medical evacuation and repatriation of remains. These benefits may be useful to international students and domestic students that are studying abroad or traveling during vacations. Generally, most plans include a benefit for medical evacuation up to $10,000 and repatriation up to $7,500. These are the benefit amounts prescribed by federal law for all students entering the United States with J-1 visas.[74]

Other Covered Expenses

ACHA guidelines recommend that student health insurance plans have coverage sufficient to be the sole source of health insurance for students. Specifically, ACHA recommends that plans, at a minimum, have sufficient coverage for preventative health care, mental health care, and catastrophic illness and injuries.[75] All student health insurance plans offered in Texas have some form of coverage for hospitalization, inpatient and outpatient surgery, physicians’ visits, and outpatient expenses for laboratory work, tests, and/or X-rays. For the most part, however, these benefits and other benefits have limitations applied to them in addition to cost-sharing and plan maximum benefits. About one-half of plans sold in Texas place limits on hospital expenses. Some plans limit coverage of hospital room and board expenses at $100 per day up to $400 per day. Other plans limit coverage of all expenses related to hospitalization per day, per confinement, or per year at $600 to $5,000.

A few plans offer no coverage for emergency treatment, and only one-third of plans offer emergency treatment without limitations other than cost-sharing and plan maximum benefits. Two-thirds of plans offer some coverage for inpatient and outpatient mental health treatment, but more than four out of five limit the benefits. Common limitations to inpatient mental health coverage include $3,000 per year and 30 days per year. Outpatient mental health care coverage is commonly limited to $50 per visit up to a maximum of $500. Only one-quarter of plans include specific language about coverage for drug and alcohol abuse treatment.

Exclusions and Limitations

ACHA guidelines state that student health insurance plans should minimize pre-existing condition exclusions and waiting periods. The regulation of student health insurance plans in Texas allows the pre-existing conditions of previously uninsured students to be excluded for no longer than 12 months if a student does not receive medical advice or treatment for their condition during that year. If a student receives advice or treatment for their pre-existing condition after their policy takes effect, that pre-existing condition can be excluded until 12 consecutive months have passed where they receive no advice or treatment for their condition, up to a maximum of 24 months.[76] With one exception, all plans offered in Texas exclude pre-existing conditions unless continuously insured, generally for the first 12 months of coverage.

Student health insurance plans tend to have multiple exclusions, many of which are for medical services that may be useful to the college population. Most plans reviewed exclude routine exams and preventative care; however, some plans make an exception for annual well-woman care. More than three-fourths exclude elective abortions and self-inflicted injuries, including attempted suicide. More than one-half contain exclusions for organ transplants, injuries obtained while under the influence of alcohol or drugs, injuries resulting from “high risk” activities such as skydiving or bungee jumping, and injuries from fighting except when in self-defense. Almost one-quarter of plans exclude inpatient mental health care and one-third exclude outpatient mental health care. More than one in six plans excludes outpatient prescriptions and three plans specifically exclude contraceptives. Ten percent of Texas plans contain a specific exclusion for expenses relating to accidents while riding motorcycles, three-wheelers, and all-terrain vehicles. Many of these exclusions are not traditionally found in employer-sponsored health insurance plans.

Costs of Coverage

Premiums for Student Health Insurance Plans in Texas

Premiums for student health insurance vary dramatically by plan and college, reflecting to some degree the level of coverage provided. The most expensive plans tend to be those with the most generous benefit structures, while the least-expensive plans do not provide major medical coverage . Nationally, student health insurance plans that comply with ACHA’s standards have average student premiums of $1,200 to $1,500 for 12 months of coverage.[77] More than 80 percent of the plans available in Texas cost less than $1,200 annually.[78] In the 36 Texas plans for which premium information was obtained, the average annual student-only premium for the 2004-2005 academic year (September through August) is $775 and the median is $680. Annual premiums for student coverage range from $79 to $2,052. Figure 2.1 shows the distribution of annual student premiums in Texas plans.

Dependent coverage is considerably more expensive than student coverage. Annual premiums for student and spouse coverage range from $558 to $8,246. The average annual premium for student and spouse coverage is $3,169. The median premium is $2,660, which is nearly four times the student-only median annual premium. Annual premiums for student and child coverage range from $138 to $4,104. The average student and child premium is $1,806 per year and the median is $1,690 per year.[79]

Annual premiums for student, spouse, and child coverage range from $536 to $9,985; the average is $4,177. The median annual premium is $4,095, which is five times the student-only median annual premium. More than one-half of the student health insurance plans sold in Texas charge an additional premium per child to cover an enrolled student’s additional children. This pricing structure differentiates student health insurance from most group health insurance plans, where a set child premium is generally charged regardless of how many children the enrollee has. Annual premiums for additional child coverage range from $59 to $1,780; the average is $945 per year and the median is $939 per year.

Figure 2.1
Distribution of Annual Student Premiums in Texas
Student Health Insurance Plans - Student-only Coverage

Source: Analysis of plan materials for 37 school-sponsored student health insurance plans made available for the 2004-2005 academic year through 65 colleges and universities in the state of Texas, July 2004-February 2005.

Almost one-third of plans in Texas offer students the option to purchase additional catastrophic coverage. The annual premiums for this coverage range from $109 to $435. The average annual cost of this additional benefit is $189 and the median cost is $181.[80]

Two plans sold in Texas charge higher premiums for older students. One plan divides students into three age categories for pricing purposes: under 35, 36 to 45, and 46 to 50. The other plan charges premiums that are 50 percent higher for students and spouses that are older than 35 years.

Cost Comparison to Other Health Insurance Products

Ideally, school-sponsored health insurance plans will provide affordable coverage to students that is a good value relative to coverage students may get in the group and individual health insurance market. In 2004, the average annual premium for an individual in an employer-sponsored group health insurance plan was $3,695,[81] compared to an average of $775 for annual, student-only coverage in a Texas student health insurance plan. On average, 84 percent of a single employee’s health insurance premium was paid for by his or her employer in 2004, making the average employee contribution $558 in 2004.[82] Thus, the average annual amount contributed by a single enrollee in an employer-sponsored plan in 2004 was about $200 less per year than what Texas college students or their parents paid for coverage in the average student health insurance plan.

The comparison to family coverage in group health insurance is similar. The average annual premium for family coverage in an employer-sponsored, group health insurance plan was $9,950,[83] compared to $4,177 for student, spouse, and child coverage in Texas student health insurance plans. Employers covered 72 percent of the costs of family coverage in employer-sponsored plans in 2004, leaving enrollees to pay $2,661 on average for coverage.[84] On average, Texas students who enroll their spouse and child in school-sponsored coverage will pay $1,500 more annually.

Average annual premiums for individual health insurance are not as easy to estimate as employer-sponsored coverage. In most cases, premiums vary by an enrollee’s age, gender, and location and are dependent on which benefits the enrollee chooses to include and exclude. A study by the Kaiser Family Foundation and eHealthInsurance found that individual policies sold through eHealthInsurance in the first half of 2003 to 18 to 24 year olds in the south-central region of the United States had average annual premiums of $1,045 for single coverage and $1,590 for family coverage.[85] Based on these estimates, average annual coverage for students is less expensive through school-sponsored plans in Texas than it is in the private, individual market, but student, spouse, and child coverage is more expensive than family coverage in the individual market.

Conclusion

Though they have much in common with other forms of health insurance, student health insurance plans are unique products designed to integrate with college resources and reflect the needs of college students. Few of the student health insurance plans offered in Texas would meet the standards recommended by the American College Health Association. These plans may not meet the needs of students that have chronic conditions or take prescriptions daily, and they may not provide financial security for students who experience a serious accident or illness. For the average college student, however, who is relatively young and healthy, these plans may be more than adequate to meet their needs. It is difficult to generalize about the adequacy of student health insurance plans offered in Texas because some services that are not covered in a plan may be readily available through the student health center and pharmacy. It is the combination of health care services available on campus funded by a health center fee and benefits in a student health insurance plan that ideally would be adequate to meet a student’s health care needs and protect them financially in case of a medical emergency.

Notes

Chapter 3. Texas College Students Access to and
Attitudes about Health Insurance

In general, national surveys that collect data on the uninsured are ill-equipped to capture some data that is specifically relevant to the college population. For example, the Current Population Survey administered by the U.S. Census Bureau does not differentiate student health insurance plans offered through colleges from private, individual plans purchased directly from agents or companies.[lxxxvi] To craft policies that will reduce uninsured rates on college campuses, policymakers and college administrators will need to understand who uninsured students are and their barriers to accessing coverage in general and school-sponsored, student health insurance plans in particular. To meet this need for information, the Texas Department of Insurance (TDI) collaborated with campus officials across the state and gathered college-specific data as part of its first-ever survey of Texas college students.

Methodology of Student Survey

TDI worked with nine colleges and universities in Texas to survey current college students about health insurance. In December 2004 and January 2005, letters were sent from TDI to administrators at 16 Texas colleges inviting them to participate in the survey. Institutions recruited for this survey were chosen in order to assemble a diverse group in terms of size, type, and location. The nine colleges that ultimately participated in the survey were Baylor University, El Paso Community College, Midwestern State University, Southern Methodist University, St. Mary’s University, Texas State University, Texas Tech University, University of Texas-Austin, and University of Texas-Pan American. Each participating college, with the exception of El Paso Community College, offers a student health insurance plan.

The Texas Department of Insurance developed a web-based survey, the 2005 Survey of College Students' Health Insurance Coverage, which contained 22 questions about insurance coverage, attitudes about health insurance, and various demographic factors. The surveys were posted on TDI’s website, but they were not accessible without the specific link. Colleges were asked to send an email with the survey link and a request to take the survey to a randomly selected sample of at least 2,000 student email addresses, but the decisions on how to distribute the survey were left to individual colleges.

All colleges except the University of Texas-Austin (UT) sent the survey recruitment email to students from a college staff person. UT instead provided TDI with a list of 4,028 randomly selected student email addresses, and the survey recruitment email was sent from TDI. Four colleges opted to send the survey link to their entire student body. Exceptions included UT, Texas State, Texas Tech, El Paso Community College, and Baylor. Texas State and Texas Tech each emailed the survey link to approximately 2,000 randomly selected student email addresses. El Paso Community College emailed the survey link to the 1,346 students enrolled in their online learning program. Baylor was especially interested in gathering data on their graduate student population and chose to send the survey link to 2,000 undergrads in addition to all 2,015 graduate, seminary, and law students. A few colleges sent a follow-up email in addition to the original request to remind students about the survey.

All survey recruitment emails with the link to the survey were sent between February 1, 2005, and March 2, 2005. Surveying was completed at all colleges by March 17, 2005. The web-based surveys were available to students for at least two weeks following the day the students received the survey link. Response rates in general were predictably low, as the survey was completely voluntary and students were not offered anything in return for participating in the survey. Table 3.1 shows the approximate number of students to whom the survey request was sent and the number of survey respondents by college.

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[1] For more information on all research and analysis activities undertaken as part of the original and supplemental State Planning Grants, go to www.tdi.state.tx.us/company/spg.html.

[2] Sara R. Collins, Cathy Schoen, Katie Tenney, Michelle M. Doty, and Alice Ho, Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help (New York: The Commonwealth Fund, May 2004), p. 3. Online. Available: http://www.cmwf.org/usr_doc/collins_ritepassage.pdf. Accessed: March 7, 2005; and S. Todd Callahan and William O. Cooper, “Gender and Uninsurance among Young Adults in the United States,” Pediatrics, vol. 113, no. 2 (February 2004), pp. 291-297.

[3] Texas Department of Insurance, Working Together for a Healthy Texas: Interim Report of the Texas State Planning Grant (Austin, Tex., September 30, 2004), pp. 11-12. Online. Available: http://www.tdi.state.tx.us/general/pdf/spgint04.pdf. Accessed: March 7, 2005. Data from the March 2003 Current Population Survey.

[4] Ibid., p. 13. Analysis by Texas Health and Human Services Commission.

[5] Collins et al., Rite of Passage?, p. 2.

[6] Center for Public Policy Priorities, Who Gets Health Care from Medicaid and CHIP in Texas? (February 2003), pp. 2, 4. Online. Available: http://www.cppp.org/products/alertsflyers/healthflyers/whogetsMC.pdf. Accessed: March 18, 2005.

[7] Sara R. Collins, Cathy Schoen, Michelle M. Doty and Alyssa L. Holmgren, Job-Based Health Insurance in the Balance: Employer Views of Coverage in the Workplace (New York: The Commonwealth Fund, March 2004), p. 6. Online. Available: http://www.cmwf.org/publications/publications_show.htm?doc_id=221573. Accessed: March 7, 2005.

[8] Texas Insurance Code, Article 3.51-6, Section 1(b).

[9] House Bill 1440, 77th Texas Legislature, regular session (2001).

[10] Office of House Bill Analysis, H.B. 1440 77(R) Bill Analysis. Online. Available: http://www.capitol.state.tx.us/cgi-bin/tlo/textframe.cmd?LEG=77&SESS=R&CHAMBER=H&BILLTYPE=B&BILLSUFFIX=01440&VERSION=5&TYPE=A. Accessed: April 12, 2005.

[11] Collins et al., Rite of Passage?, pp. 3-4.

[12] Ibid., p. 3, Chart 5. Data from the 2001 Medical Expenditure Panel Survey. Analysis by Sherry Glied and Douglas Gould for the Commonwealth Fund.

[13] Texas Department of Insurance, Working Together for a Healthy Texas, p. 12 (online). Data from the March 2003 Current Population Survey.

[14] Kevin Quinn, Cathy Schoen and Louisa Buatti, On Their Own: Young Adults Living Without Health Insurance (New York: The Commonwealth Fund, May 2000), p. 19. Online. Available: http://www.abtassociates.com/reports/ES-youngad.pdf. Accessed: March 8, 2005. Data from the March 1999 Current Population Survey.

[15] Collins et al, Rite of Passage?, p. 4. Data from the 1996 Panel of the Survey of Income and Program Participation. Analysis by Pamela Farley Short and Deborah Graefe for the Commonwealth Fund.

[16] Sana Siwolop, “In Loco Parentis Doesn’t Necessarily Pay the Doctor,” New York Times, Late Edition (August 10, 2003), sec. 3, p. 8; and Dr. Lawrence Neinstein, “The Healthy Student: A Parent’s Guide to Preparing Teens for the College Years” (Blue Springs, Mo: Society for Adolescent Medicine, August 2003), p. 7 (booklet).

[17] Collins et al, Rite of Passage?, p. 3, Chart 5. Data from the 2001 Medical Expenditure Panel Survey. Analysis by Sherry Glied and Douglas Gould for the Commonwealth Fund.

[18] John M. Dorman, “Sexually Transmitted Diseases among College Students,” in Principles and Practices of Student Health, ed. Helen M. Wallace, Kevin Patrick, Guy S. Parcel, and Judith B. Igoe (Oakland: Third Party Publishing Company, 1992), p. 688.

[19] Ted W. Grace and Kevin Patrick, “Common Infection Illnesses among College Students,” in Principles and Practices of Student Health, ed. Helen M. Wallace, Kevin Patrick, Guy S. Parcel, and Judith B. Igoe (Oakland: Third Party Publishing Company, 1992), p. 631.

[20] U.S. Department of Health and Human Services, Office on Women’s Health, Pap Test, July 2002. Online. Available: http://www.4woman.gov/faq/pap.htm. Accessed: April 19, 2005.

[21] Mary Duenwald, “The Dorms May Be Great, but How’s the Counseling?”, New York Times (October 26, 2004), Section F, p. 1.

[22] U.S. Centers for Disease Control, National Center for Health Statistics, Health United States 2004 (Hyattsville, Md.: NCHS, 2004), Table 32. Online. Available: http://www.cdc.gov/nchs/data/hus/hus04.pdf. Accessed: March 8, 2005.

[23] Ibid. Table 84.

[24] Quinn et al., p. 6.

[25] Collins et al., Rite of Passage, p. 5. Authors’ analysis Commonwealth Fund Biennial Health Insurance Survey (2003) data.

[26] Associated Press, “More Colleges Making Health Insurance Mandatory,” Toledo, Ohio, February 15, 2005.

[27] American College Health Association, Standards for Student Health Insurance/Benefit Programs, July 2000, p. 1. Online. Available: http://www.acha.org/info_resources/SPHPHE_statement.pdf. Accessed: February 26, 2005.

[28] Stephen L. Beckley and Associates, Inc., Student Health Insurance/Benefit Program Enrollment System Definitions, revised May 1, 2004. Online. Available: www.slba.com/enrollment.html. Accessed: June 10, 2004.

[29] Ibid.

[30] Kentucky Revised Statutes, Secs. 304.18-115; and Pincombe v. Commonwealth of Kentucky, Department of Insurance, Franklin Circuit Court No. 91-CI-1097, 1992.

[31] Siwolop, “In Loco Parentis,” sec. 3, p. 8.

[32] Stephen L. Beckley, Review of the American College Health Association's Standards for Student Health Insurance/Benefits Programs (SHIBPs), revised July 13, 2003. Online. Available: http://www.slba.com/review.html. Accessed: March 7, 2005.

[33] 114.6 Code of Massachusetts Regulations, Secs. 3.01-3.13.

[34] Massachusetts Division of Health Care Finance and Policy, “Qualifying Student Health Insurance Program Report, Fall 2002” (Excel spreadsheet).

[35] New Jersey Administrative Code, Secs. 8:57-7.1 to 7.5.

[36] Idaho State Board of Education, Policies and Procedures, Section III.P.16. Online. Available: http://www.idahoboardofed.org/policies/iii/p.asp. Accessed: March 7, 2005.

[37] Ed Ehlinger, Sue Jackson, and Gary Christenson, “Institutional Requirement for Health Insurance for Students in Post-Secondary Education,” March 1, 2005, slide 22. PowerPoint presentation to the Minnesota House of Representatives Health Care Cost Containment Subcommittee.

[38] Code of Federal Regulation, Title 22, Section 514.14.

[39] American College Health Association and the Association of International Educators, Health Insurance for International Students and Scholars and Their Dependents. Online. Available: http://www.acha.org/info_resources/insur_intl_student.pdf. Accessed: March 6, 2005.

[40] Texas Education Code, Sec. 51.961.

[41] The nine health-related institutions in Texas include: Baylor College of Medicine, Texas Tech University Health Sciences Center, The Texas A&M University System Health Science Center, The University of Texas Health Science Center at Houston, The University of Texas Health Science Center at San Antonio, The University of Texas M.D. Anderson Cancer Center, The University of Texas Medical Branch at Galveston, The University of Texas Southwestern Medical Center at Dallas, and University of North Texas Health Science Center at Fort Worth.

[42] Telephone interview with Stacey Silverman, Program Director, Texas Higher Education Coordinating Board, July 7, 2004.

[43] Texas House of Representatives, Higher Education Committee, Testimony on Senate Bill 505, 77th Texas Legislature, regular session (April 10, 2001), 0:01:20-0:36:09. Audio archive online. Available: http://www.house.state.tx.us/committees/audio77/290.htm. Accessed: April 19, 2005.

[44] The Ohio State University, Health Insurance Requirements for Students. Online. Available: http://shi.osu.edu/articles.asp?ID=138. Accessed: March 7, 2005.

[45] Claire Vannette, “UC Students Charged for Mandatory Insurance,” The Guardian via U-Wire, University of California–San Diego, September 18, 2001.

[46] Ehlinger et al., “Institutional Requirement for Health Insurance,” slide 12 (PowerPoint presentation).

[47] Ibid., slide 13.

[48] Ibid., slides 14-15.

[49] Telephone interview with Stephen L. Beckley, Higher Education Healthcare Management and Benefit Consultant, Stephen L. Beckley and Associates, Inc., March 3, 2005.

[50] American College Health Association, Standards of Practice for Health Promotion in Higher Education, Second Edition, revised January 2005, p. 1. Online. Available: http://www.acha.org/info_resources/SPHPHE_statement.pdf. Accessed: February 26, 2005.

[51] There are some individual health insurance products that are sold to college students directly by agents or insurance companies but are not endorsed or sponsored by a particular college or university. For the purposes of this report, such plans are not considered student health insurance.

[52] Lynn Rosellini, “Health Care Headaches,” U.S. News & World Report, vol. 132, no. 12 (April 15, 2002), p. 52.

[53] Sana Siwolop, “In Loco Parentis Doesn’t Necessarily Pay the Doctor,” New York Times, Late Edition (August 10, 2003), sec. 3, p. 8.

[54] American College Health Association, Standards for Student Health Insurance/Benefit Programs, July 2000, p. 1. Online. Available: http://www.acha.org/info_resources/SPHPHE_statement.pdf. Accessed: February 26, 2005.

[55] Ibid.

[56] Stephen L. Beckley, Review of the American College Health Association's Standards for Student Health Insurance/Benefits Programs (SHIBPs), revised July 13, 2003. Online. Available: http://www.slba.com/review.html. Accessed: February 27, 2005.

[57] Stephen D. Blom and Stephen L. Beckley, “6 Major Challenges Facing Student Health Programs,” The Chronicle of Higher Education, vol. 21, issue 21 (January 28, 2005), p. B25.

[58] Institutions of higher education in Texas as listed in Texas Higher Education Coordinating Board, Texas Higher Education Facts – 2004, Austin, Texas, 2004. Online. Available: http://www.thecb.state.tx.us/reports/pdf/0445.pdf. Accessed: February 18, 2005; and Texas Higher Education Coordinating Board, “Certified 2003 Enrollment and Preliminary Fall 2004 Enrollment in Texas Institutions of Higher Education” (Excel spreadsheet). The institutions of higher education in Texas include: 35 public universities, including 31 public, four-year universities and four public, two-year, upper-division universities; 57 public, two-year colleges, including 50 public, community college districts, four campuses of the Texas State Technical College System, and three two-year, Lamar state colleges; 39 independent, four-year colleges and universities; two independent, two-year junior colleges; eight public, health-related institutions and medical schools; and one independent medical school.

[59] The use of the word colleges or the phrase colleges and universities throughout this paper refer in general to all institutions of higher education.

[60] Plan materials were collected from college and plan websites, and additional plan materials were collected from colleges as part of TDI’s 2004 College and University Student Health Insurance Survey. Plans analyzed include those offered through: Alamo Community College District, Angelo State University, Baylor College of Medicine, Baylor University, Dallas Baptist University, East Texas Baptist University, Huston-Tillotson College, Lamar Institute of Technology, Lamar State College - Orange, Lamar State College - Port Arthur, Lamar University, LeToureau University, Midwestern State University, Odessa College, Our Lady of the Lake University, Prairie View A&M University, South Texas Community College, Southern Methodist University, Southwestern Adventist University, St. Edward's University, St. Mary's University, Stephen F. Austin State University, Tarleton State University, Texas A&M International University, Texas A&M University, Texas A&M University at Galveston, Texas A&M University System Health Science Center, Texas A&M University-Commerce, Texas A&M University-Corpus Christi, Texas A&M University-Kingsville, Texas A&M University-Texarkana, Texas Christian University, Texas Southern University, Texas State Technical College - Harlingen, Texas State Technical College - Marshall, Texas State Technical College - Sweetwater, Texas State Technical College - Waco, Texas State University, Texas Tech University Health Science Center, Texas Tech University, Texas Wesleyan University, Texas Woman's University, Trinity University, University of Dallas, University of Houston, University of Houston Clear Lake Campus, University of Houston Downtown Campus, University of Houston Victoria Campus, University of North Texas, University of North Texas Health Science Center, University of Texas - Pan American, University of Texas at Arlington, University of Texas at Austin, University of Texas at Brownsville, University of Texas at Dallas, University of Texas at El Paso, University of Texas at San Antonio, University of Texas at Tyler, University of Texas Medical Branch at Galveston, University of Texas of the Permian Basin, University of Texas Health Science Center-Houston, University of Texas Health Science Center-San Antonio, University of Texas M.D. Anderson Cancer Center, University of Texas Southwestern Medical Center Dallas, and West Texas A&M University.

[61] American College Health Association, Update: Implications of the Civil Rights Restoration Act of 1987 upon Student Health Insurance Plans, March 1989, pp. 7-10. Online. Available: http://www.slba.com/crra.pdf. Accessed: March 2, 2005.

[62] Beckley, Review of the American College Health Association's Standards (online).

[63] Beckley, Review of the American College Health Association's Standards (online).

[64] Stephen L. Beckley, Health Insurance Choice for College Students, updated October 10, 2003. Online. Available: http://www.slba.com/choicearticle.html. Accessed: February 27, 2005.

[65] American College Health Association, Standards for Student Health Insurance (online).

[66] The use of the phrase public university specifically refers to public, four-year universities or two-year, degree granting, senior colleges.

[67] The use of the phrase junior college throughout this report incorporates all forms of two-year colleges including state colleges, community colleges, and state technical colleges.

[68] Beckley, Review of the American College Health Association's Standards (online).

[69] Beckley, Health Insurance Choice for College Students (online).

[70] Author’s analysis of plan materials for 37 school-sponsored, student health insurance plans in Texas.

[71] American College Health Association, Update: Implications of the Civil Rights Restoration Act of 1987 (online).

[72] Beckley, Health Insurance Choice for College Students (online).

[73] Author’s analysis of plan materials for 37 school-sponsored, student health insurance plans in Texas.

[74] Code of Federal Regulation, Title 22, Section 514.14.

[75] American College Health Association, Standards of Practice for Health Promotion in Higher Education, Second Edition, revised January 2005, pg. 1. Online. Available: http://www.acha.org/info_resources/SPHPHE_statement.pdf. Accessed: February 26, 2005.

[76] Texas Insurance Code, Title 8, section 1251.108.

[77] Blom and Beckley, “6 Major Challenges Facing Student Health Programs.”

[78] All premium amounts in this report are given for 12 months of coverage offered according to an academic calendar year (September through August).

[79] Ibid.

[80] Ibid.

[81] Kaiser Family Foundation and the Health Research and Educational Trust, Employer Health Benefits 2004 Annual Survey (September 9, 2004), pp. 2-3. Online. Available: http://www.kff.org/insurance/7148/index.cfm. Accessed: February 26, 2005.

[82] Kaiser Family Foundation and the Health Research and Educational Trust, Employer Health Benefits 2004 Annual Survey, pp. 2-3 (online).

[83] Ibid.

[84] Kaiser Family Foundation and the Health Research and Educational Trust, Employer Health Benefits 2004 Annual Survey, pp. 2-3 (online).

[85] Kaiser Family Foundation and eHealthInsurance, Update on Individual Health Insurance, revised August 2004, pp. 4-5. Online. Available: http://www.kff.org/insurance/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=44678. Accessed: February 26, 2005. The south-central region in the study includes the states of Alabama, Arkansas, Kentucky, Louisiana, Missouri, Tennessee, and Texas.

[lxxxvi] U.S. Bureau of the Census and U.S. Bureau of Labor Statistics, Current Population Survey March Supplement, Codebook, Person Variables. Online. Available: http://www.bls.census.gov/cps/ads/sddperv.htm. Accessed: April 23, 2005.