P
lease take a moment to read the information below to determine which option would
best meet your needs
Your insurance must be in effect as of the first day of each semester, and throughout your continuous enrollment
at FGCU.
OPTION 1: United Health Care Insurance Plan (Provider Name: Gallagher-Koster)
Information on this plan can be found at this link:
https://www.gallagherstudent.com/students/student-home.php?idField=1184
As a service to our students, the applicable insurance premium costs will be posted on your FGCU student
account EACH semester.
The insurance premiums (costs) are determined annually by the insurance provider. For the 2019-2020
academic year, premium rates are: $1,031 for the fall 2019 semester, $1,627 for spring2020/summer
The FGCU rate is what your student account will be charged if you do not provide proof of an alternative
insurance by the first day of classes.
The insurance premiums must be paid in full coinciding with FGCU tuition and fee payment deadlines via
yo
ur GULFLINE account or in person at the cashier’s office.
This plan is fully compliant with Federal Healthcare Reform Regulations which includes:
Please see the link above for more information on the plan details and coverage
More information for Parents can be found on this link:
https://www.gallagherstudent.com/school-
parents/index.php?idField=1184&KosterWebSID=3vmsd29er1a29ogfff8ta07pn3
OPTION 2: Alternative Medical Insurance Coverage:
IF you purchase one of the plans listed below, you only need to send your Insurance ID card and documentation
of the policy termination date. The compliance form is not needed if you use one of the insurances listed below
because they meet all the Florida BOG requirements.
(ISP)-International Student Protection: www.intlstudentprotection.com
Plans showing Florida Trail Blazer Basic or Florida Trail Blazer Elite,
Insurance for Students: www.insuranceforstudents.com
ISO Insurance: https://www.isoa.org/
International Student
Health Insurance
International students must comply with the Florida Board of Governors rule requiring all international students to
have medical insurance in order to register or enroll in classes. Rule 6.009(2) provides that, “no international student
in F or J non-immigrant status shall be permitted to register, or to continue enrollment, at a university without
demonstrating that the student has adequate medical insurance coverage for illness or accidental injury and which
includes the following minimum requirements” which are discussed in detail on page 3 of this document.
Specifically, this rule requires that insurance policies must provide, at a minimum, continuous coverage for the entire
period that the insured is enrolled as an eligible student, including breaks between or during terms (for students
enrolled in more than one term/semester, this means a full year).
* Rates for 2020-2021 will be posted when they become available
Each student must choose their own insurance; we cannot choose it for you. The companies that we list
are only examples of companies that other students have used. Please do NOT send any insurance
plans for our office to review.
If you choose another insurance company other than the ones listed above:
Students must submit the Health Insurance Compliance Form if they plan to use an alternate insurance
provider that meets the State requirements. This form should be completed by your insurance provider
and sent directly to our office.
This form may be submitted as early as you wish. The best way to avoid the FGCU insurance fee from
being assessed to your account is to submit these forms before tuition fees are assessed to your
account. (Approximately 3 weeks before the first day of each semester)
Although you may have some form of medical insurance, the University can only accept your insurance if
it meets our requirements. (Please read the instructions on the FGCU International Student Medical
Insurance Compliance Form (page 3) which also outlines the minimum requirements established by the
State of Florida.)
Alternate insurance waiver forms must be received by the last day of add/drop EACH semester AND meet
ALL the minimum requirements.
International Services will not accept alternate insurance waiver forms after the ADD/DROP cutoff date.
IF YOUR FGCU STUDENT ACCOUNT IS CHARGED THE INSURANCE FEE
The only way for the fee to be removed (BEFORE ADD/DROPP) is to provide proof of alternate
insurance that meets the minimum State requirements. (see page 3)
AFTER THE ADD/DROP date the insurance fee will remain on the student’s
account and late fees may be applied.
PLEASE NOTE: PAYMENT ARRANGEMENTS, ISSUES WITH WIRE TRANSFERS, SCHOLARSHIPS,
ETC. SHOULD ALL BE HANDLED WITH THE CASHIER’S OFFICE PRIOR TO THE LAST DAY OF
ADD/DROP TO ENSURE THAT YOU ARE NOT DROPPED FROM CLASSES FOR FAILURE TO PAY
THEIR INSURANCE FEES.
The insurance carrier needs to check and sign the form and return to our office via fax or email
(cfells@fgcu.edu
or Fax: 239-590-7977)
International Student Health Insurance Compliance Form (page 1 of 2)
The Insurance Policy must include the following mandated benefits:
Coverage Period: Policies must provide continuous coverage for the entire period the insured is enrolled as an
eligible student, including annual breaks during that period. Payment of benefits must be renewable.
* COVERAGE PERIODS/DATES DIFFER FROM THE ACADEMIC CALENDAR DATES. This ensures that there is no
lapse in coverage
Basic benefits: room, board, hospital services, physician fees, surgeon fees, ambulance, outpatient services
and outpatient customary fees must be paid at 80% or more of usual, customary, reasonable charge per
accident/illness, after deductible is met for in-network, and 70% or more of usual, customary, or reasonable
charge for out-of-network providers per accident/illness.
Minimum coverage: $200,000 for covered injuries/illnesses per policy year.
Inpatient mental health care must be paid at 80% in-network or 60% out-of-network of the usual and
customary fees within a minimum of 30-day cap per benefit period.
Outpatient mental health care must be paid at 80% in-network or 60% out-of-network of the usual and
customary fees for a minimum of 30 (preferably 40) sessions per year.
Maternity benefits must be treated as any other temporary medical condition and paid at no less than 80% in-
network or 60% out-of-network of the usual and customary fees.
Inpatient/Outpatient prescription medication offers coverage of $1,000 or more per policy year.
Exclusion of pre-existing conditions: First six months of policy period, at most.
Deductible: maximum of $50 per occurrence if treatment or services are rendered at the Student Health
Center, maximum of $100 per occurrence if treatment or service is rendered at an off -campus ambulatory
care or hospital emergency department facility. Policy must not unreasonably exclude coverage for perils
inherent to the student’s program of study.
Repatriation: $25,000 (coverage to return the student’s remains to his/her native country)
Medical evacuation: $50,000 (to permit the patient to be transported to his/her home country and to be
accompanied by a provider or escort, if directed by the physician in charge).
Policy provisions must be available from the insurer in English.
Claims must be paid in U.S. dollars payable on a U.S. financial institution.
Insurance Carrier must, at a minimum, meet the rating requirements specified in Part 62.14(c)(1) of the Title
22 of the Code of Federal Regulations, regulating U.S. Department of State Exchange Visitor Program (EVP).
INSURANCE COMPANY REPRESENTATIVE: By signature, I attest this policy covers the above basic benefits. I
certify that the coverage is now in force and if the policy is terminated, I will notify FGCU ISO immediately. I
understand that FGCU is relying on this information to permit the student to register or continue enrollment.
Print Name: Position:
Signature: Date:
STAMP (Required)
TO BE COMPLETED BY INSURANCE COMPANY REPRESENTATIVE
click to sign
signature
click to edit
International Student Health Insurance Compliance Form (page 2 of 2)
To comply with Florida State Board of Governors Regulation BOG 6.09, International Students must have health
insurance. Students in F and J status must maintain health insurance coverage from the first day of class until the
last day before the next semester, thus insuring that there is no lapse in coverage.
Insured’s Name
Coverage Start Date Coverage End Date
(mm/dd/yy) (mm/dd/yy)
Insurance Company Policy #
Agent name:
Agent email Address Agent Phone Number
U.S Claims Company Address: (If Available)
U.S Claims Company Phone: (If Available)
I authorize my insurance company to release the information on this form to Florida Gulf Coast University.
By signing below, I agree to the following requirements established by FGCU and I agree to abide by them.
1. Alternate insurance policies are approved for limited periods not exceeding one academic year and the
requirements for alternate policy coverage are subject to change.
2. I must have my policy information re-certified EACH semester.
3. Failure to have continuous coverage which meets the minimum requirements outlined on the attached
checklist will result in a hold being placed on registration and I will be dropped from enrollment at FGCU.
4. If the alternate insurance coverage is not approved, this does not mean FGCU or any of its employees
recommend that I cancel any existing, pending, or proposed insurance coverage.
5. The policy presented must meet the minimum requirements established by FGCU and the State of Florida
with respect to specific medical insurance coverage criteria
6. I understand that the insurance I have chosen may not be comparable to the plan provided through
FGCU/ Gallagher-Koster. I also understand that by using an alternate plan, there is a potential for higher
deductibles, co-pays and out of pocket expenses
Student Name (Please Print):
Student FGCU ID# (UIN)
Signature of Student: Date:
Florida Gulf Coast University
International Services Office
10501 FGCU Blvd. South
Fort Myers FL 33965-6565 USA
Office Contact: Carey Fells
Phone: (239) 590-7925
Fax: (239) 590-7977
Email: cfells@fgcu.edu
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome