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HealthInsuranceInstructionsandForm-Fillable Health Insurance Instructions and Form - Revised

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The University of Hawaii (UH) requires all international students on F-1 student visas to have health
insurance. Students may purchase the University of Hawaii student health insurance plan or purchase
an insurance plan from a US-based company or from a health insurance company in your home
country. The health insurance plan must meet all of the following requirements:
1. You are required to have health insurance for each semester that you are enrolled in classes.
Your plan must cover you for the entire period of enrollment. If you will be attending UH Hilo for more than
one year, you may purchase health insurance for one year at a time.
2. Comprehensive medical coverage = at least $100,000 US per accident/illness.
Your plan must provide medical benefits (doctor visits, hospital, surgery, laboratory tests, x-rays, etc.) of at
least $100,000 US for each accident or illness.
3. In-patient/out-patient medical (including mental health) coverage at no less than 75% of the
usual/customary charge.
Your plan must pay at least 75% of covered medical expenses (including mental health coverage) for both
in-patient (stay at an in-patient facility/hospital) and out-patient (doctor’s office, out-patient department of a
hospital or ambulatory surgery center) services.
4. Repatriation coverage = at least $25,000 US.
If you should die in the U.S., your plan must provide at least $7,500 US to send your body/remains back to
your home country.
5. Medical evacuation coverage to your home country = at least $10,000 US.
If your doctor recommends that you return to your home country for treatment and/or recovery due to a
serious illness or injury, your plan must provide up to $10,000 US for you to return home.
6. No more than $500 US deductible per accident or illness.
Your plan deductible cannot exceed $500 US for each accident or illness. Most insurance plans require
you to pay for part of your health expenses (this is called the “deductible”) before they will start to pay for
any covered services. Some plans also have deductibles per year instead of per accident or illness. As
long as your plan does not exceed the $500 US deductible (per accident/illness or per year), then this
requirement will be fulfilled.
7. May require a waiting period for pre-existing conditions that is reasonable under current industry
standards (typically no longer than 6 months).
Your plan may require a waiting period to cover pre-existing conditions, but the waiting period should be
reasonable under current industry standards (typically no longer than 6 months). A waiting period means
that your plan will not cover any pre-existing condition for a certain amount of time.
INSTRUCTIONS
1. Fill out Section A and B of the form.
2. If you are purchasing the University of Hawaii student health insurance plan
(http://www.hmsa.com/portal/?gid=student), you do not need to fill out Section C.
3. Your insurance company must complete all parts of Section C and sign and date the form.
IMPORTANT: Your insurance company must initial each of the minimum coverage requirements.
4. This form AND a copy of your health insurance plan may be emailed, mailed or personally delivered to
the University of Hawaii at Hilo International Student Services Office:
International Student Services
University of Hawaii at Hilo
200 W. Kawili Street
Hilo, Hawaii 96720
USA
Email: mellon@hawaii.edu
University of Hawaii at Hilo
Health Insurance Form
for F-1 International Students
UNIVERSITY OF HAWAII AT HILO
F-1 STUDENT HEALTH INSURANCE FORM
SECTION A
_______________________________________ _______________________________
Name of all F-2 Dependents covered under this plan (leave blank if none): _________________________________
I acknowledge that University of Hawaii (UH) policy requires international students to have health insurance for every term I
am enrolled at the University. If I choose a health insurance plan other than the University student health insurance plan, I
agree to obtain the insurance company’s certification that the plan meets the University’s minimum requirements.
________________________________________________ _____________________________
SECTION B (Check one)
☐ I will purchase the University of Hawaii student health insurance plan. If you will purchase the University of
Hawaii student health insurance plan, attach a copy of your receipt with this form.
☐ I will purchase a different health insurance plan.
SECTION C
This section below must be completed by the health insurance company if you will NOT be purchasing
the University of Hawaii student health insurance plan.
Name(s) of insured individual(s):
_________________________________________ ___________________________________
Health Insurance Company: ____________________________________________________________
Policy Number/Plan Type: ____________________________
Coverage Period: From: __________________ (mm/dd/yyyy) to _________________ (mm/dd/yyyy)
While enrolled at the University of Hawaii at Hilo, international students are required to have health insurance that
meets ALL of the following minimum coverage requirements (all amounts are in USD). Vision and dental coverage is
not required. Health insurance company: Initial each line below to verify all coverage requirements.
____ Comprehensive medical coverage = at least $100,000 US per accident/illness
____ In-patient/Out-patient medical (including mental health) coverage at no less than 75% usual/
customary charge
____ Repatriation coverage = at least $25,000 US
____ Medical evacuation coverage to home country = at least $10,000 US
____ No more than $500 US deductible per accident or illness
____ May require a waiting period for pre-existing conditions that is reasonable under correct industry standards
(typically no longer than 6 months)
I certify that the minimum coverage requirements stated above are provided by this policy/plan. I am qualified to
make this determination as an authorized agent/employee of the above insurance provider.
_________________________________ __________________________________________________
_________________________________ __________________________________ ______________
Signature Title Date
Last Name, First Name
UH Student ID #
Student Signature
Date
Student’s name (please print)
Print Name
Contact Information (email and/or phone number)
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Completed 2 March 2020

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