Auburn University Mandatory Health Insurance Waiver Request Form Office of International Education 201 Hargis Hall, Auburn, Alabama, 36849 Fax 334-844-4983, email: insurance@auburn.edu Waiver request form for Non-Immigrant International Student and Scholar Health and Emergency Assistance Insurance Program completion and submission of this form does not guarantee a waiver from the Mandatory AU Requirement. All submissions received by the deadlines indicated below will be reviewed and you will be notified of the final decision. Instructions: Please fill in and sign pages 1 & 2. Then, submit this entire package (including pages 1 & 2) to your insurance company to be completed. Your insurance company must send this package back to the Office of International Education, Auburn University, prior to the deadline date and time. I hereby request that Auburn University waive the Mandatory Health and Emergency Assistance Insurance requirement based on the information provided on this form by my insurance company. Waiver Request is for Fall- Spring - Summer Semester -Year (i.e.: 2008 etc.) The Waiver Request must be submitted by the First day of class or the program in which you are participating. Complete this information box (Needed by your insurance company to complete the waiver form attached): Print or Type Clearly if we cannot read the information your request will not be considered ID Number (Student/Scholar BANNER ID #): Scholar/Student Name: Please identify how many dependents are on your visa status: Street address: Street address(continued): Spouse no - yes; Children: no - yes; how many children City: State: ZIP/Postal Code: Country: Phone #: FAX #: Email: Policy holder name on Insurance Policy: Number of dependents covered by this policy: Insurance Company Name : Policy # : Policy expiration date : U.S. Claims office name (Required) : Address (Required) : City/State (Required) : U.S. Claims Phone # (Required) : U.S. Claims FAX (Optional) : Page 1 of 5 Auburn University - Nonimmigrant Health Insurance Waiver Request Form version 04/1/2008
Statement on EQUAL TO OR GREATER THAN : AU automatically enrolls all international students, scholars and their dependents in a mandatory health and emergency assistance insurance program from the day they enter the US on their program until their departure. Waivers of this requirement must be presented prior to arrival or at the latest at the time the student or scholar reports in to begin their program. Waiver requests received following arrival and later than two weeks following reporting in will result in the automatic billing of the insurance premium. Should a waiver be granted during this period the student or scholar will be required to pay at a minimum one month health insurance premium. For waiver purposes the student or scholar must provide from their insurance company a completed waiver form that meets the EQUAL TO or GREATER THAN standard. Definitions: EQUAL TO: means that the proposed insurance provides at a minimum the same benefits as those provided under the AU policy. This means equal to ALL benefits listed on the waiver form and not just selected benefits. GREATER THAN: means that the proposed insurance provides for benefits that are greater in coverage than those provided under the AU plan. EQUAL TO OR GREATER THAN: means that the proposed insurance plan provides for some benefits that are EQUAL TO and others that are GREATER THAN. There are NO benefits on the proposed plan that are LESS than those provided by the AU plan. The entirety of the plan as outlined on the waiver form must be considered. If the proposed plan has specific benefits which are not equal to or greater than the AU benefits, the proposed plan is not equal to or greater than the AU policy regardless of whether the proposed policy has some benefits which are better than those offered by AU. Only those benefits outlined on the AU plan are considered, if the proposed plan has other benefits which are not included in the AU plan those benefits are not considered as part of the waiver review. For example the AU policy has special arrangements with the insurance vendor to remove any exclusions associated with self inflicted injury or alcohol abuse that are associated with the emergency assistance, medical evacuation and repatriation component of the insurance plan. Many insurance plans exclude coverage for emergency assistance and all other medical services under these conditions. AU has negotiated this support specifically for the Emergency Assistance component only. This is a key management and support element. If the proposed plan has exclusions for such support then the proposed insurance program is LESS THAN the AU program in its benefits plan. Additionally the AU plan includes a mental health component and significant benefits that are in compliance with suggested standards identified by the US Department of State regulations for health insurance. This Mandatory AU International Student and Scholar Health plan meets present day US and local health care standards as recommended by the AU International Advisory Council Insurance Committee and approved by the Auburn University Board of Trustees. Student/ Scholar Signature Required: I have read this Waiver Form and hereby authorize the above named insurance company to release the following information directly to Auburn University. By signing this document I understand the conditions and requirements of the waiver process. I further understand that forms received after the deadline and/or incomplete forms will result in a denial of the request. Student/Scholar Signature: Date: Print Student/ Scholar Name: Page 2 of 5 Auburn University - Nonimmigrant Health Insurance Waiver Request Form version 04/1/2008
Are the benefits of your policy Less than, Equal to or Greater Than the AU policy benefits listed below? Please Check the appropriate response for each item below: Not covered Less than Equal to Great than 1 Is the policy underwriter or insurance company licensed to do business in the state of Alabama. 2 Is the policy rated A by the AM Best Rating Company? 3 Is the participant provided with a permanent ID card for Major Medical policy? 4 Are claims paid within 13 to 20 working days of submission? If necessary, a request for additional information either from the student, scholar or medical provider must be sent by the contractor within 13-20 business days of receipt of the claim. Is this a condition of the plan? 5 Are ALL the services under this policy EXEMPT from the overall policy exclusion provisions related to self-inflicted injuries, suicide and the use of alcohol/intoxication? Emergency Medical Assistance Program (EMAP) 6 Does this policy have an Emergency Assistance Program Call Center?: includes access to a 24 hour/7 days a week worldwide emergency assistance service call center. Participants are provided with a listing of telephone numbers (toll free) by country. 7 Does this policy provide for unlimited Medical Evacuation per insured? Ground and Air Ambulance service and all coordination of transportation must be included. 8 Does this policy provide for unlimited Repatriation or Remains Coverage?: Includes the payment for preparation of mortal remains, cost involved with shipment and funeral directors expense, as well as coordination of transportation of the body to their place of residence in their home country. 9 Family Assistance Benefit: in the event that the insured participant or spouse requires hospitalization exceeding 7 days or in the event of the death of the participant, the company will provide economy, roundtrip airfare one designated family member (mother, father, brother, sister, spouse, son or daughter) or friend. All expenses must be approved by the contractor in advance. 10 Care for Minor Children arrange for the care of children left unattended as the result of a medical emergency and pay for any transportation costs involved in such arrangements. Major Medical Coverage 11 Is the Copay: $25 per outpatient physician s visit or less? 12 Is the Hospital Emergency Room Co-pay: $75 per visit or less? 13 Is the Deductible: $200 per coverage year or less? 14 Is the Maximum benefit amount $250,000 per accident or illness or greater? 15 Are usual, reasonable and customary (URC) charges paid at least at the 90 th percentile of the Medical Data Research Values and adjusted semi-annually? 16 Is 100% of coverage paid, after co-pay, if use an Approved Provider such as AU Medical Clinic operated by the East Alabama Medical Center Health Foundation? 17 Is the Major Medical Benefits: 80% for first $5,000; 100% from $5,001- $250,000 or greater for use of Non Approved Providers? 18 Is the Prescription benefit based on a $10 for Generic and $25 for Brand name Copay or less with no cap or limit? Inclusions: Drugs and medicines dispensed by a pharmacist on written prescription including birth control and emergency contraception? 19 Does coverage provide for Hospital room and board at the semi-private rate? 20 Is there URC coverage for hospital services and supplies (including but not limited to the cost of the operating room; laboratory tests; x-rays examinations; anesthesia; drugs excluding take home drugs or medications; therapeutic services; supplies; chemotherapy; radiation therapy; ER; intensive care; critical care; surgery; and other prescribed service)? (Please explanation of any limitations to coverage) 21 Is there URC coverage for physician, surgeon, anesthetist, radiologist, registered nurse or physiotherapist fees? (Please attach explanation of any limitations to coverage) 22 Is there coverage for Blood, plasma, oxygen, artificial limbs and eyes, casts, splints, trusses, braces, and crutches? (Please attach explanation of any limitations to coverage) Page 3 of 5 Auburn University - Nonimmigrant Health Insurance Waiver Request Form version 04/1/2008
Are the benefits of your policy Less than, Equal to or Greater Than the AU policy benefits listed below? Please Check the appropriate response for each item below: Not covered Less than Equal to Great than 23 Are expenses for outpatient surgery, services and expenses including emergency room, trauma center, physician office, outpatient surgery centers and ambulatory surgery centers covered in the same manner as inpatient? (Please attach explanation of any limitations to coverage) 24 Are expenses incurred for miscellaneous outpatient services including diagnostic x-ray services and laboratory procedures when prescribed by the attending physician and when followed by medical treatment covered in the same manner as inpatient? (Please attach explanation of any limitations to coverage) 25 Are Rental charges for wheelchair, hospital bed, or other special mechanical equipment to facilitate care or treatment covered? (Please attach explanation of any limitations to coverage) 26 Are the costs for ambulance services covered? (Please attach explanation of any limitations to coverage) 27 Are Home health care benefits covered as required by Alabama State Insurance Law? 28 Are Mammography benefits covered as required by Alabama State Insurance Law? 29 Is there outpatient treatment for alcohol or substance abuse for 30 visits per year and $100 max per day? 30 Is inpatient emotional or mental disorders coverage payable at 100%? and for up to 30 days per coverage year? 31 For maternity and newborn care, are hospital confinement, surgical benefits and care covered on a URC basis? Newborn infants must be enrolled in a dependent or other policy within 31 days of birth. a For dependent coverage: Is there WELL-CHILD care pediatric (preventative services including immunizations, developmental assessments and laboratory services appropriate for the age of the child) paid under physicians visits? (for dependent child policies/waivers only)? 32 Are there benefits for covered students and scholars for the diagnosis and treatment of intercollegiate/club sport injuries? 33 Is there dental treatment of accidental injury to sound, natural teeth, URC covered? 34 Is there a pre-existing conditions waiting period of 6 months or less following enrollment, for students, scholars and dependents in all classes? 35 Does this policy have Exclusions? Please list exclusions and policy limiting conditions below or attach a copy. YES NO NOTE: AU reserves the right to verify coverage at the beginning of each semester. All waivers will be reviewed in August of each year and will require new documentation/proof of coverage Page 4 of 5 Auburn University - Nonimmigrant Health Insurance Waiver Request Form version 04/1/2008
36 Please identify the EMERGENCY ASSISTANCE COMPANY (for items 6-10 above) and Contact Info Name of Emergency assistance company Address City State Phone # Fax # E-mail Web site 24/7 Emergency Assistance Phone Number 37 Please identify your US based Claims Office Contact Information Name of Claims Office if different from Policy Address City State Phone # Fax # E-mail Web site To be signed by Insurance Company Official and submitted directly to the Office of International Education: I hereby certify that the above named individual carries the identified insurance plan for the period indicated above and it is currently in effect. In our opinion (PLEASE CHECK ONE BOX): I am unable to complete this form as requested. NO our policy does NOT provide EQUAL TO OR GREATER THAN coverage as defined on page two YES our policy DOES provide coverage that is EQUAL TO, GREATER THAN, EQUAL TO OR GREATER THAN as defined on page two of this document. If this item is checked and there are inconsistencies in the attached pages please attach a written explanation otherwise the waiver will not be approved. I am aware that the above named individual is required to verify continuous coverage each semester s/he is enrolled at Auburn University. Remarks or comments: Company Name Telephone number Email address Signature PRINTED NAME Title Date This original signed document must be returned to the Office of International Education, Auburn University, 201 Hargis Hall, Auburn, Alabama, 36849-5159, Prior to the deadline Advance copies may be FAXED to: 334-844-4983, email insurance@auburn.edu Page 5 of 5 Auburn University - Nonimmigrant Health Insurance Waiver Request Form version 04/1/2008