UMASS-BOSTON
STUDENT HEALTH INSURANCE PLAN

Annual 2024-2025 POLICY PERIOD
DEPENDENT(S) COVERAGE ENROLLMENT FORM

Dependent coverage, if elected, begins and ends with the student’s coverage and must be purchased at the same time the student enrolls in the plan.

Coverage may be purchased for your eligible dependents after the initial enrollment period only if one of the following qualifying events has occurred during the Policy Year: 1) birth of a child; 2) adoption of a child; 3) marriage; 4) spouse’s/child’s loss of other creditable coverage; or 5) spouse’s/child’s entry into the United States. You must make the request by submitting a “Qualifying Event Enrollment Form” to University Health Plans, with supporting documentation showing that the qualifying event occurred within the last 60 days.

The deadline to complete the Dependent Enrollment Form is October 1, 2024.

Students who are currently enrolled in the University of Massachusetts – Boston Student Health Insurance Plan for the current policy year and did not submit a dependent enrollment form by the Fall deadline, cannot submit a dependent enrollment later in the same academic year unless the dependent has experienced a qualifying event (i.e., loss of other coverage, marriage, birth, entry into the United States).

TO CONTINUE THE DEPENDENT ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Student Health Plan

Qualifying Event Enrollment Form

Benefit Information

Blue Cross Blue Shield Info

Prescription Info

Optional Plans

Additional Information

Qualifying Event Enrollment Form

Students who waived the Student Health Insurance Plan (SHIP) and recently lost their other coverage or moved to the US should contact the University of Massachusetts - Boston Bursar's Office at bursar@umb.edu or 617-287-5350 to request a qualifying event enrollment. The deadline to complete the enrollment form is 60 days from the qualifying life event.

Students will be asked to provide supporting documentation and the prorated premium will be added to the tuition statement. The first day of coverage in the SHIP will be the first day without coverage under the prior plan or entry into the US.

Contact Information

For waiver, enrollment, eligibility, general benefit questions or plan issues
contact University Health Plans at 833-251-1126.

For specific benefit or claims questions
contact Blue Cross Blue Shield of Massachusetts at 888-753-6615.

University Health Plans Broker License # 000123936000
William E. Devine Broker License # 34773