Student Health Insurance Program Waiver Form

WAIVING OUT OF THE CHSU STUDENT HEALTH INSURANCE PLAN

If you have active health insurance with benefits that meets all the criteria listed below, you may apply for a waiver of enrollment in the CHSU Student Health Insurance plan. You will need to have your current insurance ID card and information regarding your plan benefits to complete the process. You must submit a copy of your Health Insurance ID card's front and back with your request. Once you have submitted the required information, you will receive an email verifying if your waiver meets the CHSU waiver requirements. 

* CHSU bills a $50 admin fee to all CHSU students.  The admin fee will be reflected on your student account.

ACCEPTABLE WAIVERS 

The acceptable coverage to waive the CHSU Sponsored Student Health Insurance Plan must meet the following requirements:

  • A parent's employer group plan
  • A spouse's employer group plan
  • A Partner's Employer Group Plan
  • COBRA
  • Military/Veterans Benefits - Tricare
  • Medi-Cal - Student must live in California the entire academic year
  • Medicare
  • Individual health plans are acceptable by exception and will only be considered if it meets all the Individual Plan requirements listed below.

Individual plans must include the following:

  • Deductible MUST NOT be more than $2,500 individual, NO Exceptions.
  • Unlimited major medical coverage
  • Prescription coverage
  • Mental health coverage
  • Coverage for an annual exam
  • A provider network in the area of the CHSU campus (Clovis, CA) for primary care, specialty, hospital, surgery, diagnostic testing, maternity, and preventive services.

*Please Note- Short-term health insurance policies, traveler’s plans, or plans originating outside of the United States are NOT acceptable for waiving enrollment in the student health plan.

  • The waiver deadline for continuing students is June 30, 2022
  • The waiver deadline for incoming students is July 15, 2022

Waivers will not be accepted past the waiver deadline, NO EXCEPTIONS

PERIODIC WAIVER VERIFICATIONS

If your waiver is approved, it is still subject to periodic verification throughout the academic year to ensure the plan you submitted is still active and still meets the University’s health insurance coverage requirements. It is incumbent on the student to ensure their plan remains active and in compliance with CHSU's health insurance requirements throughout the current academic year, including summer and holidays.

If your plan is found to be inactive or out of compliance, CHSU reserves the right to enroll a student in the student health insurance plan from the start of the period of non-compliance (even if your termination date was in the past) through the end of the current academic year. If your plan is found out of compliance, you will receive an e-mail notification from HSAC, and you will have 14 calendar days to respond. If you have not responded within 14 calendar days, CHSU will proceed with enrollment in the student health insurance plan, assess your student account for the applicable premium charges, and notify your program of your non-compliance with CHSU’s health insurance requirements.

INVOLUNTARY LOSS OF COVERAGE/AGE-OUTS

If you originally waived out of the student health insurance plan but find that you need health insurance coverage later in the year due to an involuntary loss of coverage or if you have aged out of your parent's insurance plan, you can also enroll via the Health Sciences Assurance Consulting website. Students enrolling after the initial enrollment period due to an involuntary loss of coverage will be assessed a prorated portion of the insurance premium based on their enrollment dates. Students have 30 calendar days after an involuntary loss of coverage to enroll in the student health insurance plan or submit updated proof of coverage. Proof of coverage must show that the new coverage is in effect as of the termination date of previous coverage.  No gaps in coverage are permitted.

Once you have submitted the required information, you will receive an email verifying if your waiver meets the CHSU requirements. Please be aware that you will be automatically enrolled in the health insurance plan, and the health insurance charge will remain on your account if a waiver request is not completed and approved. CHSU will not accept waiver requests after the deadline.

If another health plan currently insures you, please take the time to compare your benefits and cost to the 2021/2022 CHSU student health insurance plan. The CHSU health plan offers very comprehensive benefits, and the cost for the group coverage may be lower than your current plan. Remember, you will need an involuntary loss of coverage to enroll in the student health plan after the annual open enrollment period has ended once you waive. If you will turn 26 during the academic year, it is a qualifying life event. Therefore you will be eligible to enroll in the CHSU student health insurance plan.

It is important to note that voluntary termination does not make you eligible for enrollment after the annual enrollment period has ended.

Students must maintain continuous enrollment in health insurance. If you are submitting new proof of coverage, it must begin within 24 hours of your previous coverage termination.  You are not eligible to waive if you have any coverage gap.

Insurance Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an insurance application is guilty of a crime and may be subject to fines and confinement in prison.

By submitting your waiver request, you acknowledge that you have read the Waiver Requirements and CHSU Insurance Policy and agree to abide by all terms of the Policy and understand HSAC will verify your coverage.

 

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

Students must submit a copy of the front and back of health insurance ID card.

Please enter your information. Fields with * are required

International Students or students who do not have a Social Security Number for the Social Security Field, please use 999999999

Please enter your medical insurance information. Fields with * are required

Students must submit a copy of the front and back of health insurance ID card.

Please enter your dental insurance information. Fields with * are required

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 document may be no larger than 5 Megabytes. If a document is larger than 5 Megabytes, please forward via email to chsu@hsac.com.

IMPORTANT - PLEASE READ THESE DIRECTIONS!!!***** Please attach copies of the front and back of your insurance ID card as it helps to expedite the verification process. ***** The additional documents must not be larger than 5 MB limit. If your submission will not go through and you receive the message that your files are too large, you will need to send them via email. Please submit your waiver without the attachments and forward the attachments via email to chsu@hsac.com

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
Date of Birth

Medical Insurance Information

Insurance Name
Group Number
Member/Subscriber Number
Insurance Plan Type
Provider Services Phone Number
Source of Coverage
Subscriber First Name
Subscriber Last Name
Subscriber Relation
Subscriber Date of Birth
Requested Termination Date

Documents

Document 1
Document 2

I hereby submit proof of personal health insurance and decline the sponsored Student Health Insurance Plan. I acknowledge that I am legally responsible for any and all medical expenses incurred by myself/dependant while enrolled.

Student Signature (or Parent's Signature if student is under Age 18)**

** 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.

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