1. I am currently covered by the above-mentioned insurance policy and will maintain coverage for the full
2020-2021 academic year.
2. I have compared this policy to the Student Blue Plan. (The Summary of Benefits can be viewed online at
www.bc.edu/medinsurance).
3. I acknowledge that my current policy provides reasonably comprehensive coverage of health services,
including primary care, emergency services, surgical services, hospitalization benefits, ambulatory patient
services, and mental health services, and that these services are reasonably accessible to me in the area
where I am attending school.
4. I acknowledge that my current policy provides coverage for lab work, diagnostic x-rays, physical therapy,
chiropractic care, and prescription coverage in the area where I attend school.
5. I certify that that I have determined that my plan, listed above, provides benefits that are at least
comparable to the Student Blue Plan.
6. I understand a health insurance plan that provides coverage through a closed network of providers, not
reasonably accessible to me in the area where I attend school, for all but emergency services does not
qualify for a waiver.
7. I understand the following MA Medicaid plans do not qualify as comparable coverage to waive BC’s Student
Health Insurance Plan: Children’s Medical Security Program, MassHealth Limited and Health Safety Net.
8. I understand that any out-of-state Medicaid programs do not qualify for a waiver.
9. I attest that no claims have been submitted for payment under the Student Blue Plan for the 2020-2021
policy year.
10. I further acknowledge that by submitting this signed waiver form that I/we assume full responsibility for
any medical expenses incurred until August 6, 2021 and that neither Boston College nor the Insurance
Company will be held responsible for any expenses I incur.
Attention: Students studying outside the United States:
I certify that the health insurance plan listed above provides reasonable and comprehensive coverage in the
location where I am studying. I further certify that if I visit the United States during the 2020-2021 academic year, I
will purchase a U.S.-based qualifying medical insurance plan (as described above) for the period of my stay in the
United States.
Attention: International students:
To ensure that international students are covered by a plan that provides coverage that meets or exceeds the
Student Health Insurance Plan, international students are not eligible to waive BC’s Student Health Insurance Plan
except in limited circumstances. The waiver form for international students can be downloaded at
www.bc.edu/medinsurance under the Forms tab.
I/we certify that the above information is true and accurate.
______________________________________________________________ ______________________
Student Signature Date
______________________________________________________________ ______________________
Parent or Guardian Signature (required if student is under 18) Date
