Student Health Insurance Program Waiver Form - 2019-2020

Waiver Process For the 2018-2019 Academic Year - Currently Open

Waiver Process for the 2019-2020 Academic Year  - Only open to Continuing students and Incoming PA students

Waivers will be accepted on the following dates for the 2019-2020 Policy Year

  • Continuing Students from April 15 - June 15, 2019
  • Incoming PA Students from April 15 - May 15, 2019
  • Incoming 2019 - 2020 Students from June 1 - July 17, 2019 - Are not eligible to submit your waiver until after June 1, 2019

Maintaining health insurance coverage is mandatory for all full-time DMU students and all students MUST be covered by a domestic health insurance plan. All students are required to enroll in the DMU - Sponsored Student Health Insurance Plan unless an acceptable Waiver is provided in a timely manner. The acceptable coverage to waive the DMU - Sponsored Student Health Insurance Plan must have comprehensive coverage throughout the United States.  Your plan must have a provider network for primary care, specialty, hospital and diagnostics care in Iowa or in states where students are designated for rotations.  HMO plans only qualify for the state in which you are residing, in Iowa you must have an Iowa HMO.

  • Parent's Employer Group plan
  • Spouse's Employer Group plan
  • Partner's Employer Group Plan
  • COBRA
  • Military/Veterans Benefits - Tricare
  • Iowa Medicaid - Student must be a permanent resident in Iowa for the entire academic year and all rotations must be in Iowa for the entire academic year
  • Other State Medicaid - Student must be a permanent resident of the state providing Medicaid and all rotations must be in the same state for the entire academic year
  • Medicare

Individual health plans are acceptable by exception and will only be considered with a minimum of the following benefits:

  • Maximum Out of Pocket Expense of no more than $6,600
  • Deductible Maximum of $1,500 per Individual
  • Unlimited Lifetime Benefits
  • Unlimited Office Visits
  • Wellness Benefit
  • Comprehensive Prescription Plan (cannot be restricted to generic only)
  • Inpatient and outpatient Mental Health Benefits
  • If you have active domestic health insurance with benefits which meet the criteria above you may apply for waiver of enrollment in the DMU student health plan. You will need to have your current insurance ID card and information regarding your plan benefits to complete the process. Once you have submitted the required information you will receive an email verifying if your waiver meets the DMU requirements.

Full-Time Students on Out-of-State Clinical Rotations/Experiences

In addition to the requirements above, students attending clinical rotations/experiences outside of Iowa are required to have comprehensive health insurance coverage as stipulated by DMU's rotation site affiliation agreements. Students completing any out-of-state clinical rotations/experiences during an academic year are not eligible to waive with any state Medicaid coverage, including Iowa Medicaid,as it does not provide comprehensive coverage when you are rotating out of state. Your insurance coverage must also have national in-network provider coverage, which includes the states in which you may rotate. If you will be completing all clinical rotations/experiences in state, you may waive with Medicaid coverage from the State of Iowa. Students requesting to waive with Medicaid coverage must attach a copy of their rotation schedule for the entire academic year to their waiver submission by the required waiver deadline.  If you are unable to provide a full academic year schedule you will not be eligible to waive with Medicaid coverage.  No mid-year  changes are allowed.

 

Please be aware that waivers will not be accepted after the posted deadline and any student who has not submitted a waiver request by the waiver deadline will be enrolled in and charged for the DMU student health plan.

 

By submitting your waiver request you are acknowledging that you have read the Waiver Requirements and agree to abide by the DMU Insurance Policy.

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

You must submit a copy of your Health Insurance ID card with your waiver submission.

Please enter your information. Fields with * are required

Your Student ID is also required. This is the 7 digit number that begins with 0. Continuing students can find this in the My Profile section of My Pulse. Incoming students can find this within your DMU username.

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

You must submit a copy of your Health Insurance ID card with your waiver submission.

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 dmu@hsac.com.

***** 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 "Woops something broke" the documents you submitted are too large. Please submit your waiver without the attachments and forward the attachments via email to dmu@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
Insurance Address
Insurance Address 2
Insurance City
Insurance State
Insurance Zip
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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