Student Health Insurance Enrollment Form

ENROLLING IN THE CHSU STUDENT HEALTH INSURANCE PLAN

If you wish to enroll in the student health insurance plan for the 2022/2023 academic year, you must submit your enrollment request. Students enrolling after the plan begins will have their coverage backdated to the plan's start unless they have experienced an involuntary loss of coverage.

CHSU STUDENT HEALTH INSURANCE PLAN INFORMATION 2022/2023**

The Effective Date of the CHSU Student Health Insurance Plan Policy for 2022/2023 has changed to 07/01/2022-6/30/2023.  For students currently enrolled on the CHSU student plan for 2021/2022, your insurance coverage will continue on the 2021/2022 policy year until 07/31/2022.  Your coverage on the 2022/2023 policy year will be effective 08/01/2022 and your premium will be pro-rated.

**All insurance coverage is subject to applicable state form and rate filing approval and, once approved, to the terms of the Master Policy. We have not yet received approval from the state insurance department for the 2022/2023 benefits, features and rates described in this document. As part of the approval process, the State may require us to make changes to the benefits, features and/or rates. We will notify you if that happens.  

The student health insurance plan allows students to waive or enroll each semester.  Premium payment will be assessed to your CHSU student account in two payments. The first payment will be assessed for the fall 2022 semester, and the second payment will be assessed for the spring 2023 semester. 

STUDENT HEALTH INSURANCE PLAN PREMIUMS 2022/2023 - EFFECTIVE 07/01/2022 - 06/30/2023

Plan Rates Plan Dates Premium* Fall Semester Spring Semester
Continuing Students - newly enrolled for 2022-2023 07/01/2022 - 06/30/2023 $2,896.00 $1,448.00 $1,448.00
Continuing Students - currently enrolled for 2021-2022 08/01/2022 - 06/30/2023 $2,655.00 $1,328.00 $1,327.00
Incoming Medical Students 07/19/2022 - 06/30/2023

$2,754.00
 

$1,377.00 $1,377.00

* CHSU bills a $50 admin fee to all CHSU students.  The admin fee is not included in the premium listed above but will be reflected on your student account.

Students who are receiving financial aid may be eligible for a budget increase to cover the student health insurance plan premiums' costs. For more information on eligibility and the process for increasing your budget, please contact the Office of Financial Aid.

CHSU STUDENT HEALTH INSURANCE PLAN INFORMATION 2022/2023

The student health insurance plan for the 2022/2023 academic year is offered through Aetna Student Health and administered by Health Sciences Assurance Consulting (HSAC). Plan details include:

 Deductible

 $250

 Co-Insurance

 80% – Preferred Provider Organization (PPO), 60% – Non-PPO

 Out of Pocket Maximum (Individual)

 $6,850

 Office Visit

 $25 Copayment, 100% coinsurance

 Emergency Room Visit

 $150 Copayment (Waived if Admitted), subject to the deductible

 Prescription Drugs

 $25/$45/$60

 

 

 

 

 

 

 

 

 

To view the full 2022/2023 Summary of Benefits, please click here

STUDENT HEALTH INSURANCE PLAN PREMIUMS 2021/2022 - EFFECTIVE 08/01/2021 - 07/31/2022

The student health insurance plan allows students to waive or enroll each semester. For the 2021/2022 Policy year, the student plan will be effective from 08/01/2021 to 07/31/2022.  Premium payment will be assessed to your CHSU student account in two payments. The first payment will be assessed for the fall 2021 semester, and the second payment will be assessed for the spring 2022 semester. 

Plan Rates Plan Dates Premium*
Continuing Students 08/01/2021 - 07/31/2022 $2,896.00
Incoming Medical Students 07/19/2021 - 07/31/2022 $3,009.23

* CHSU bills a $50 admin fee that is not included in the premium listed above, and is billed to all CHSU students

ENROLLING YOUR DEPENDENTS

You will provide your dependent's information during the Enrollment Process.  HSAC will contact you with an invoice and instructions for paying your dependent's premium.

To continue the Enrollment Process, please click the Student Verification button.

 

To begin the enrollment process please enter your demographic information below and click the "next" button at the bottom to continue.

Please enter your information. Fields with * are required

Please add any dependents (Spouse, Domestic Partner, Child):

Please include your Dependents information here. Your premium as a student will be billed to your student account, you will be contacted by HSAC for separate payment for your dependents premium.

  • Dependent 1

  • Dependent 2

  • Dependent 3

  • Dependent 4

  • Dependent 5

Add Dependent

Please choose your insurance coverage:

  • Dependents Also?

If you have any extra documents you would like us to have, please upload them here. Only .doc, .docx and .pdf files are accepted. Up to two documents may be uploaded. Each file may be no larger than 10 Megabytes.

Please Confirm the information you entered, then click submit.

Student Information

Last Name
Middle Initial
1
First Name
Gender
Social Security Number
Student ID
Home Address
Home Address 2
Home City
Home State
Home Country
Home Zip
Phone Number
Personal Email
University Email
Program
Date of Birth

Dependent 1

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Dependent 2

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Dependent 3

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Dependent 4

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Dependent 5

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Insurance Information

Medical
Medical For Dependents
Requested Enrollment Date

Documents

Document 1
Document 2

Digital Signature

** By typing your name in the Signature field, you hereby certify that the information entered into this form is true and correct to the best of your knowledge.

  • Comments

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