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UCLA
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UC-Sponsored Student Health Insurance Plan (SHIP)
2017-18 Plan Year Waiver Criteria
I.
All plans must provide unrestricted access to an in-network primary care provider, in-network hospitalandfull,
non-emergency medical and behavioral health care within 150 miles of campus or the student¡¯s place of
residence while attending school.
NOTE: This criterion applies toallplan types without exception, including Medi-Cal or Medicaid, Medicare,
TRICARE/military, HMOs (including Kaiser, WHA, and others), Covered California or other U.S. federal or state exchange
plans, all employee-sponsored and individual plans.
II.
Coverage is currently active and the student agrees to maintain health coverage throughout the entire academic
year. If your current insurance coverage is terminated, contact the Student Insurance Office as quickly as possible
to discuss your health insurance options.
III.To satisfy UC¡¯s health insurance requirement for enrolled students, the plan held by the student must provide the
following (this applies to all students regardless of gender):
1)Be a Medi-Cal/Medicaid, Medicare, TRICARE/Military, Covered California or other U.S. federal or state
exchange plan, or a UC Employee Health Plan,OR
2)Be an employer-sponsored group health plan or individual plan that covers the following benefits:
a) Has an annual out-of-pocket maximum of $7,150 orlessfor an individual or $14,300 orless
for a family. Deductibles, copayments, and coinsurance paid by the member accrue toward
meeting the out-of-pocket maximum. A higher out-of-pocket maximum is allowed if the
subscriber has a Health Savings Account (HSA) or a Health Reimbursement Account (HRA)
b) Inpatient and outpatient hospital stays for medical and surgical care
c) Covers inpatient (hospital) and outpatient care for mental health and substance abuse
disorder conditions the same as any other medical condition.
d) Doctor office visits for medical, including mental health, and alcohol/drug abuse conditions
e) Emergency room and ambulance services
f) Medications prescribed by a doctor
IV.
For international students, the followingadditionalcriteria apply. The plan must:
1)Havenoper-medical or per-mental health/substance use disorder condition maximum benefit limits
2)Cover services related to suicidal conditions, including attempted suicide or suicidal thoughts
3)Cover medical services for injury from participation in all types of recreational activities or amateur sports
4)Not be a health care reimbursement plan with the student¡¯s home country or another party
5)Not be a pharmacy reimbursement plan with the student¡¯s home country or another party
6)Havenopre-existing condition exclusion or limitation; if the plan has a pre-existing condition waiting
period, that period has expired
7)Have no lifetime maximums on benefits
8)Have a complete master policy written in standard English with benefits expressed in U.S. dollars
9)Have a claims payment office with an address and phone number in the United States
10)Pay at least $50,000 annually for medical evacuation
11)Pay at least $25,000 for repatriation of remains
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http://www.studenthealth.ucla.edu
https://shb.ais.ucla.edu/shibboleth-idp/profile/SAML2/Redirect/SSO?execution=e1s2
UC SHIP Waiver
Application (Please
note that 3rd party login id are
currently not able to do SHIP transactions. The student themself must do the
SHIP transaction.
http://www.studenthealth.ucla.edu/FormsDocuments/2015-16%20UC%20SHIP%20Cal.050615.pdf
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Annual
09/25/17 – 09/23/18
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´ÙÀ½±Û | syracuse university | ||
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ÀÌÀü±Û | New York University |