Dartmouth College Health Service
5-7 Rope Ferry Road, HB 6143
Hanover, NH 03755
DSGHP Waiver Requirements
Plan Year: 2013 - 2014
Dartmouth College requires all students who are listed as active in the student information system (Banner), including students not taking classes or on a leave term, to have health insurance meeting specified standards of coverage. To insure this happens, all active Dartmouth students are automatically enrolled in the DSGHP each September 1st, and the related fee is billed to their student tuition account in August. To waive enrollment in the DSGHP students must submit a new, completed waiver petition each academic year by July 1 to avoid late fees.
2013 - 2014 DSGHP Waiver Conditions
All eight (8) conditions must be answered at the start of each academic year for DSGHP enrollment to be waived.
- My coverage is provided by a company licensed to do business in the United States and has a U.S. claims office and telephone number. (Foreign state government plans to NOT meet this requirement.)
- My plan provides coverage for inpatient and outpatient mental health care and chemical/substance abuse treatment and the benefits include at least twenty (20) outpatient mental health and/or biologically based illness visits in the Hanover, NH area. Additionally, I agree to fund additional outpatient mental health and/or biologically based illness visits, if they are required.
- The maximum benefit for my coverage is $500,000 or more per year.
- If my plan has in-network and/or out-of-network copayments, coinsurance and deductibles, I can afford to pay those costs.
- My plan includes medical and prescription coverage in the Hanover, NH area.
- Approved waivers will be valid for one (1) DSGHP plan year ending August 31, 2014. A new waiver petition will be required for the next plan year. Based on this, my plan will remain effective or be renewable for the DSGHP plan year beginning September 1, 2013 and ending August 31, 2014. If my coverage changes during this time I understand that I must apply for another waiver. I understand that failure to file a new waiver, if my plan changes, may result in automatic enrollment and an associated charge to my tuition account.
- I certify that all of the answers provided above are true and accurate. If upon audit my insurance coverage is found to not meet the above criteria, I understand that I will be enrolled in the DSGHP as an Unqualified Late Enrollee and the cost of the plan will be charged to my student account.
- I understand that in order for this waiver to be processed, I need to send a front and back copy of my medical and prescription insurance ID cards to the DSGHP office.
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