Florida International University International Student Health Insurance Compliance Form Page 2
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1
2As per Florida Board of Governors, Section 7(d) 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.”
INSTRUCTIONS: Please check YES (meets or exceeds minimum requirements) or NO (does not meet) for each item listed.
Coverage Period: Policies must provide, at a minimum, continuous coverage for the entire period the
YES□ NO□
1.
insured is enrolled as an eligible student, including annual breaks during that period. Payment of benefits
must be renewable.
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
YES□ NO□
2.
charge per accident or illness, after deductible is met, for in-network, and 70% or more of usual,
customary, and reasonable charge for out-of-network providers per accident or illness.
Inpatient Mental Health Care: Must be paid at 80% in-network or 60% out-of-network of the usual and
YES□ NO□
3.
customary fees with a minimum 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
YES□ NO□
4.
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
YES□ NO□
5.
80% of usual and customary fees in-network or 60% out-of-network.
6.
YES□ NO□
Inpatient/Outpatient Prescription Medication: Must include coverage of $1,000 or more per policy year.
7.
YES□ NO□
Repatriation: $10,000 (coverage to return the student’s remains to his/her native country).
Medical Evacuation: $25,000 (to permit the patient to be transported to his/her home country and to be
YES□ NO□
8.
accompanied by a provider or escort, if directed by the physician in charge).
9.
YES□ NO□
No Exclusion for Pre-Existing Conditions.
Deductible: Maximum of $50 per occurrence if treatment or services are rendered at the Student Health
YES□ NO□
10.
Center; maximum of $100 per occurrence if treatment or services are rendered at an off-campus
ambulatory care or hospital emergency department facility.
11.
YES□ NO□
Minimum coverage: $200,000 for covered injuries/illnesses per policy year.
Insurance Carrier must, at a minimum, meet the rating requirements specified in Part 62.14(c)(1) of Title
12.
YES□ NO□
22 of the Code of Federal Regulations.
13.
YES□ NO□
Policy must not unreasonably exclude coverage for perils inherent to the student’s program of study.
14.
YES□ NO□
Claims must be paid in U.S. dollars payable on a U.S. financial institution.
15.
YES□ NO□
Policy provisions must be available from the insurer in English.
NOTE:
Medical Evacuation and Repatriation (#7 and #8) benefits are available if and only if all other criteria have
been approved.
COMMENTS:
Please indicate below any comments about the policy coverage and any of the above items:
TO THE INSURANCE COMPANY REPRESENTATIVE: I have verified the information on this form and completed each item
above. I certify that the following coverage indicated is now in force. If the above noted policy is terminated, I will notify
Florida International University, Student Health Services, immediately.
Name:___________________________________________
Title:______________________________________
Signature:_________________________________________
Date: _____________________________________
Telephone:________________________________________
Fax: ______________________________________
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