Waiver Terms of Agreement

Student Health Insurance 2017 - 2018 Plan Year

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, 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 meets the University's requirements and 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 8/14/2018.

Students who submit a waiver during the applicable Open Enrollment Period will have the entire student rate refunded on their Student Account, which includes up to a $60 administrative fee, upon approval of the waiver.  Fall waivers also apply to any 2016-2017 Early Summer Arrival Premier Plan charge and related terms of coverage for incoming students.  Prorated refunds are not granted.
 

Fall 2017-2018 Plan Year:

Term of Coverage: 8/15/2017 - 8/14/2018
Applicable Open Enrollment Period: Late June - September 15, 2017

  • $2,680 per student
  • $5,361 per student and spouse or student and one child
  • $8,042 per student and two or more children
  • $8,042 per student, spouse, and one child
  • $10,723 per student, spouse, and two or more children

Spring 2017-2018 Plan Year:

Term of Coverage: 1/1/2018 - 8/14/2018
Applicable Open Enrollment Period: second week in December 2017 - January 31, 2018

  • $1,680 per student
  • $3,361 per student and spouse or student and one child
  • $5,042 per student and two or more children
  • $5,042 per student, spouse, and one child
  • $6,723 per student, spouse, and two or more children
Late Enrollments

After Open Enrollment, only eligible students who then enter the University, who then become involuntarily ineligible by their employer group plan, or terminate their group coverage at the end of their employer plan year during their Open Enrollent Period are permitted to purchase the Premier Plan. Students and their eligible dependents that have become involuntarily ineligible by their group employer plan due to age or job status or end of plan year termination may enroll in the Premier Plan within 31 days of having been notified of their ineligibility.   In addition, students who wish to enroll eligible dependents after the applicable Open Enrollment Period must do so within 31 calendar days of acquiring a new dependent through a qualifying event.  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 Student Health Insurance approval and Applicable Student Code of Conduct Provisions)

I have health insurance from another source that has an unlimited benefit maximum. 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 waiver 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 or if applicable, the date required as an incoming Early Summer Arrival student. 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 2017-2018 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 Waiver Terms and Agreement for the 2017-2018 Premier Plan and is applicable to any 2016-2017 Early Summer Arrival coverage for which I have been mandated and charged. I attest that the information provided to waive the Premier Plan is correct and understand it is subject to Student Health Insurance approval and applicable Student Code of Conduct Provisions.