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Terms and Conditions For Waiving the 2012-2013 Premier Plan

Notification of Terms and Conditions to Students Eligible to Waive the 2012-2013 Premier Plan During Their Applicable Open Enrollment Period

University Mandate

Georgetown University (GU) requires most students who are charged GU tuition and registered in Resident Thesis Research or registered for nine or more credit hours in a GU degree program (eight or more credit hours if a Law or Graduate student) to have the Premier Plan, Policy #2012-32-01, underwritten by United HealthCare Insurance Company and designed specifically for GU students unless they decline the coverage during their applicable Open Enrollment Period and show that they have coverage under another policy that remains in effect throughout the academic year.

Eligible students are mandated coverage only once per academic year, at the beginning of the first academic term in which they are first eligible. Eligible students receive a charge on their Student Account for their applicable Term of Coverage and corresponding Premium Rate. Once an eligible student is enrolled, the coverage remains in effect for the remainder of the Plan Year, through 8/14/2013.

Students who submit an approved waiver during the applicable Open Enrollment Period will have the entire student rate refunded on their Student Account. Prorated refunds are not granted.

Fall 2012-2013 Plan Year:

Term of Coverage: 8/15/2012 - 8/14/2013
Open Enrollment: 2nd week in July - September 15, 2012

• $2,075 per student
• $6,063 per student and spouse
• $6,063 per student and child(ren)
• $9,547 per student and family

Spring 2012-2013 Term

Term of Coverage: 1/1/2013 - 8/14/2013
Open Enrollment: 2nd week in December 2012 – January 31, 2013

• $1,317 per student
• $3,787 per student and spouse
• $3,787 per student and child(ren)
• $5,945 per student and family

Late Enrollments

After Open Enrollment, only eligible students who then enter the University or who then involuntarily become ineligible by their private insurance carrier are permitted to purchase the Premier Plan. Students and eligible dependents that have become involuntarily ineligible by their private insurance carrier (due to age or job status) may enroll in the Premier Plan within 31 days of having been notified of their ineligibility. Contact the GU Student Health Insurance Office to obtain the proper forms and instructions for such mid-year enrollments. Part-time students who are enrolled for less than 9 credit hours are not eligible to purchase the Premier Plan except Law and Graduate students who are enrolled for at least 8 credit hours and resident thesis research students.

Student Agreement When Waiving the Premier Plan Coverage (Subject to Applicable Student Code of Conduct Provisions)

I have health insurance from another source that covers at least $100,000 per illness and $100,000 per injury. I understand that I MUST have health insurance throughout my academic year. I attest that my health insurance (even if an HMO) will cover most inpatient and outpatient services rendered in the Washington, D.C. metropolitan area. To the extent that my health insurance does not provide coverage for health care expenses I incur, I understand that I am obligated to pay for those services. I understand that the other insurance company’s information indicated in this survey may be given to health care providers upon their request to bill for health care services I obtain, and that Georgetown University Hospital may bill my insurance company for medical services rendered to me.

I understand that the effective date of my other insurance coverage must be on or before the last day of my Open Enrollment Period. I understand that if I do not submit the waiver survey with the requested responses by the last day of my Open Enrollment Period, I will remain enrolled and will be responsible for the Premium charged to my student account for the Premier Plan. If I authorized any providers to send claims to the 2012-2013 Premier Plan for payment prior to the submission of this form, I understand this waiver will be rescinded and I will be responsible to pay the Premium. I also understand if I waive after my Open Enrollment Period, a $100 late waiver fee will be applied to my student account and that all waivers are subject to approval by Georgetown University Student Health Insurance.

I understand that the submission of a waiver to Student Health Insurance indicates agreement to the Terms and Conditions for Waiving the 2012-2013 Premier Plan and I attest that the information provided to waive the Premier Plan is correct and is subject to applicable Student Code of Conduct Provisions.

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