Health Insurance Form For F-1 International Students - University Of Hawaii At Hilo
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2University of Hawaii at Hilo
Health Insurance Form
for F-1 International Students
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
( ), 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
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