This is the second in a series of occasional articles on NCAA insurance issues.

Recently implemented NCAA legislation requires member schools to certify that student-athletes are insured against athletics injuries, but it's up to those schools to decide whether to fully pay the cost of that insurance themselves -- or share the burden with or even place it squarely on the shoulders of student-athletes and their families.

Some institutions cover the cost themselves, but others -- believing insurance premiums are too high for tight budgets that also must support broad opportunities for athletics participation, quality coaching and expenses of competition -- have made the tough decision to require that student-athletes obtain their own coverage before setting foot on a field or court.

Most member schools, representing all three divisions, probably are somewhere in between -- they may provide at least secondary coverage to back up insurance purchased by student-athletes and their families, and bigger programs also may pay for costs that aren't covered by that insurance, including deductibles and co-pays.

"It's not unusual for a school to provide secondary coverage, using student-athletes' primary insurance as much as they can," said Jerry Weber, head athletic trainer at the University of Nebraska, Lincoln, who believes his own institution's approach is typical of most Division I schools.

"When I came here, we had a $2,500-deductible policy for every student-athlete, and that became unbearable. We just couldn't do that," he said, explaining why the school switched to a secondary policy with a $10,000 deductible to cover athletics injuries.

"Parents sign off on -- and have an understanding -- that we're going to send bills to their insurance company, or expect them to file a claim with their insurance company. Then we'll pay their deductible, co-pay, anything their insurance doesn't pay."

However, as escalating insurance costs in recent years have prompted institutions like Nebraska to adjust policies, it has led others to stop purchasing coverage and require student-athletes to pay their own way.

"If you want to maintain participation opportunities, with the same number of sports and the same coaching, the same quality of travel or uniforms or whatever -- and you know your funding is going to be reduced -- something has to give," said James Watson, director of athletics at Division II member West Liberty State College, which requires student-athletes to provide their own insurance for athletically related injuries before they are permitted to compete.

He says it's analogous to high-school "pay-to-play" policies, where schools that are strapped by decreasing community funding ask families to take on the cost of participating in sports.

"I've used the analogy that it's one thing to own a car, but you've also got to buy insurance for it. If I want to drive my car, nobody's going to want to buy insurance for me."

It's not an easy choice to make, especially for schools like Watson's that previously have provided coverage.

"As costs began to escalate, I began to look for cost savings," Watson said. "We put in some deductibles, and ultimately made a decision to go the route that costs us zero dollars -- and that may cost us some players."

Competitive pressures

Ultimately, expense may trump the fear of losing recruits at some schools, but competitive pressures clearly push many others to maintain high levels of coverage, even as costs mount.

"Coaches for years have told us it's recruiting suicide not to tell athletes they're 100 percent, 24/7, 12-months-a-year covered," said Kim Harmon, University of Washington team physician and a member of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports.

Washington covers athletics injuries or medical conditions that directly affect participation in athletics during a season, but even that significant commitment can leave student-athletes uncovered for much of the year.

"People are expecting colleges and universities to take total, complete care of them, and oftentimes they are recruited to an institution that way," Harmon said. "But the sad fact is, most institutions can't afford to do that."

Weber said student-athletes and their families often don't realize that fact -- and coaches battling competitive pressures don't always make it clear to prospective student-athletes.

"Coaches have gone out on the recruiting trail, especially from schools that had a lot of resources, and they'd tell parents, don't worry, anything that happens, we'll take care of it," Weber said. "Well, unfortunately, they forgot to specify, that's anything that happens on the field or in the weight room. You'd have parents say, 'Oh, that's great,' and drop the $125-a-month policy they had on him or her."

Communicating options

The new NCAA certification requirement's primary purpose is to ensure that student-athletes are insured for athletics injury up to the $75,000 deductible of the Association's Catastrophic Injury Insurance Program. However, institutions also are being urged to use certification as an opportunity to make sure student-athletes understand what is covered by schools, and what is not.

"We send written information to students that clearly outlines (coverage)," Harmon said. "We try to educate coaches about what they can say and what they can't say when they're recruiting. And, when students come in for orientation, we discuss options."

In cases where student-athletes are not covered by parents' insurance, they may be encouraged to purchase a student insurance policy. Such policies typically do not cover athletics injuries, Harmon noted, but they help cover situations unrelated to athletics.

At schools where student-athletes must insure themselves against athletics injuries, it is important to be certain that a policy does the job -- which may mean student insurance isn't enough.

Fortunately, at West Liberty State, most student-athletes arrive on campus with sufficient coverage.

"We've had minimal problems," Watson said. "We've been doing this for about three years, (and) in a student-athlete population of 350, we only had about 10 kids who weren't covered. We steered them to a local broker who handles a variety of policies, and those kids bought policies to be insured."

But West Liberty State isn't necessarily typical in that regard. Schools likely vary widely in percentages of student-athletes who arrive on campus without insurance coverage, and even those who are covered may be served through arrangements such as health maintenance organizations (HMOs).

"I know the HMO is an issue," Watson said. "If you're a kid from California here in West Virginia, you may be flying home at Christmas to have a knee done, rather than having it done next Monday."

Choosing what to cover

In Division I, another recent legislative change grants institutions leeway to cover just about any medical situation that may arise for a student-athlete -- regardless of whether it directly impacts athletics participation. But that doesn't mean a school can afford to exercise that option.

"If a kid ends up with cancer, and they were depending on the athletics department to take care of them, well, we'd do what we can," Harmon said. "It used to be we couldn't because of NCAA rules, but those have changed and we can. But that could pretty much shoot the entire athletics budget."

The NCAA Risk Management Task Force that Weber served on intended to give Division I institutions the ability to pay costs stemming from injuries or illnesses that prevented student-athletes from competing.

"The original language that came out of our committee sought permissive legislation that would allow Division I schools to pay for something," he said. "Let's say, a starting left tackle goes down with appendicitis in the middle of the season, and he doesn't have insurance, and you need to get him back on the team. In order to ask them to pay the physical price to get back, you'd like to pay their expenses to bring them back during the season."

However, the Division I Board of Directors broadened the reach of the legislation, and while that action supports student-athlete well-being, it also puts most institutions in the position of making hard decisions about what they can afford to provide.

Many opt to self-insure against expenses arising from student-athlete coverage, but Harmon sees some difficulty in that approach.

"When institutions act as secondary insurers, there's a danger that athletics administrations are making medical decisions, and that's a conflict of interest," she said. "When the rubber hits the road, it comes down to what you can afford to do."

There are other options for institutions to explore.

"Some institutions have talked about using the (Division I) Special Assistance Fund to purchase student insurance for athletes who don't have it -- particularly those who are Pell Grant-eligible," Harmon said. The fund, which is administered through Division I conference offices, can be used to pay for premiums for optional medical coverage, among other uses.

"I think that's a reasonable model, though you still have the problem that, at most places, (student insurance) doesn't cover athletics injury," Harmon said. "So, that leaves the athletics departments out in the cold a little bit, but it's better than nothing."

Harmon expects that as medical costs continue to rise for athletics departments -- currently at a rate between 15 to 20 percent per year -- NCAA institutions will continue to seek better solutions for providing coverage.

"I think this is going to continue to boil until there is some kind of national response," she said.

Seeking solutions

One possible national response is governmental action, including pursuing solutions such as universal health care or a national insurance plan, but Harmon is skeptical about achieving any consensus on that approach anytime soon.

"A lot of those choices probably are politically inexpedient," she said. "It's hard to think of a government solution that's going to be palatable, because you're talking about allocation of limited resources, and nobody wants to talk about that, and nobody's going to get elected that way."

So, what remains?

"I'm hopeful that organizations like the NCAA can use their collective bargaining power to set up secondary insurance opportunities for institutions, or even better yet, set up a secondary insurance policy that student-athletes can purchase that includes athletics injuries," Harmon said.

Weber, who said the task force spent time discussing that "umbrella" approach, and Watson each see merit in an NCAA-sponsored initiative.

"A lot of us have to go out and independently negotiate and buy secondary insurance," Weber said. "What if we all got together, by division or the entire NCAA, and negotiated a mandatory policy under which a company would agree to cover every college athlete at that level? Hopefully, you'd have a lower premium because of the buying power of the group."

"I think the Association at least has to look at having someone underwrite something that all member schools could buy into," Watson said. "Volume is what reduces the cost, and is the only thing that reduces the cost."

Acknowledging widespread membership interest, the NCAA national office staff is exploring the possibility of sponsoring group access to coverage.

Juanita Sheely, NCAA travel and insurance manager, said that possibility was considered during the Risk Management Task Force's deliberations, but no action was taken because there was no consensus at the time on whether institutions wanted or needed such a program. Schools typically still were able to obtain coverage affordably.

"We've kept an eye on things and just this past fall started discussions again on the possibility," said Sheely, who anticipates asking presidents on the NCAA Executive Committee, Division I Board of Directors and Divisions II and III Presidents Councils to consider whether they are interested in negotiating a plan.

Whatever approach turns out to be achievable, it's clear that athletics programs already are experiencing significant frustration -- and often are making hard decisions -- when it comes to choosing whether to provide insurance coverage for student-athletes.

"People say, what's the matter, don't you want to treat your student-athletes as well as other student-athletes are treated?" Watson said. "Well, sure we do. But something has to give. Getting out of the insurance business is, I feel, the prudent way to go. It's a formula for bankruptcy."

"People are very frustrated and concerned," Harmon said. "Everybody wants to do right by their student-athletes, but people are being priced out of the market. It's becoming more and more difficult, just because it's too expensive."