Outline
The Hawaii HC-5 form plays a crucial role in ensuring that employees understand their rights and responsibilities regarding health care coverage under the state’s Prepaid Health Care Act. Designed for individuals who work for multiple employers or are seeking to change their health care status, this form allows employees to notify their principal and secondary employers about their health coverage needs. Whether you are claiming an exemption, terminating an existing waiver, or simply designating which employer will provide your health care, the HC-5 form serves as an essential tool in managing your health care options. It's important to note that this form should only be used under specific circumstances, such as when you work for two or more employers for at least 20 hours a week. By completing this form, you can clarify your health care coverage status, ensuring that your employers are aware of their obligations. Furthermore, it provides a structured way to communicate any changes in your coverage needs, allowing you to navigate the complexities of health care with confidence.
Sample - Hawaii Hc 5 Form
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
FORM
Use this form if the employee works at least 20 hours per week and:
•Works for 2 or more employers** or • Claims an exemption or waiver from health care coverage or
• Terminates an exemption or |
• Changes principal and/or secondary employer designation** |
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THIS SECTION IS FOR THE EMPLOYER TO COMPLETE. |
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Employer name |
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DOL account number |
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Address |
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Phone no. |
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See employee’s selection below and take appropriate action. Give a copy of this completed form to the employee. Keep this completed, signed form on file for 2 years. The employee’s selection below is applicable only within calendar year 2023. If the employee will be renewing the selection after 2023, have the employee complete the form for the appropriate year.
FOR THE EMPLOYEE TO COMPLETE:
Do not use this form if: • You work for only 1 employer and that employer provides you with health care coverage or
•You work less than 20 hours per week for your employer
In accordance with the provisions of the Hawaii Prepaid Health Care Act (Chapter 393, Hawaii Revised Statutes), this is to notify my employer that: (Check appropriate box.)
1. Of the two or more concurrent employers that I work for (at least 20 hours a week), you have been selected as the principal** employer and are required to provide me health care coverage (Section
**The principal employer is the employer who pays the employee the most wages. However, if the employee works for 1 employer at least 35 hours per week and that employer does not pay the employee the most wages, the employee chooses the principal employer.
2. Of the two or more concurrent employers that I work for (at least 20 hours a week), you have been selected as the secondary** employer and are therefore relieved of the responsibility to provide me health care coverage until you are otherwise notified (Section
3. I am exempt from health care coverage because I am: (Check appropriate box.) (Sections
a. covered by a Federally established health insurance or prepaid health care plan, such as Medicare, Medicaid or medical care benefits provided for military dependents and military retirees and their dependents.
b. covered as a dependent (e.g. spouse, child, etc.) under a qualified health care plan.
c. a recipient of public assistance or covered by a
d. a follower of a religious group who depends upon prayer or other spiritual means for healing.
4. I waive coverage from my employer’s health care plan because I have obtained the plan named _____________
_____________________ from the health care plan contractor named _________________________________.
I understand this waiver is binding for the 2023 calendar year. I submitted a copy of my plan to my employer to forward to the Department of Labor and Industrial Relations with this form. (Section
5. The coverage exemption/waiver previously indicated in items 2, 3 or 4 is no longer applicable; you are therefore required to provide me health care coverage (Section
Requested effective date of coverage: ____________________.
Print employee name |
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Employee signature |
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Address |
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Phone no. |
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Date |
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Keep a copy of your completed, signed form for yourself. RETURN COMPLETED FORM TO EMPLOYER. |
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Call (808)
Auxiliary aids and services are available upon request. Please call (808)
Important Notice about Language Assistance: This document contains important information. If you need language assistance at no cost to you, please contact us by phone or in person immediately.
It is the policy of the Department of Labor and Industrial Relations that no person shall, on the basis of race, color, sex, marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/court record, sexual orientation, and National Guard participation, be subjected to discrimination, excluded from participation in, or denied the benefits of the Department’s services, programs, activities, or employment.
Form Information
| Fact Name | Fact Description |
|---|---|
| Form Purpose | This form notifies employers of an employee's health care coverage status and any changes in employer designation. |
| Applicable Law | The form is governed by the Hawaii Prepaid Health Care Act, specifically under Chapter 393 of the Hawaii Revised Statutes. |
| When to Use | Employees should use this form if they work for multiple employers, are claiming an exemption, or are changing their employer designation. |
| Employer Responsibilities | Employers must provide health care coverage as indicated in the form and retain a copy for two years. |
| Exemption Criteria | Exemptions can apply if the employee is covered by a federal health plan, a dependent under a qualified plan, or follows a religious group for healing. |
| Submission Guidelines | The form should not be submitted to the State Department of Labor unless requested. It must be renewed annually by December 31. |
Detailed Guide for Filling Out Hawaii Hc 5
Completing the Hawaii HC-5 form is a straightforward process. This form is essential for notifying your employer about your health care coverage status. After filling it out, you will need to keep a copy for your records and submit the completed form to your employer.
- Obtain the Hawaii HC-5 form from the Department of Labor and Industrial Relations or your employer.
- Fill in the employer's name and address in the designated fields.
- Enter the DOL account number provided by your employer.
- Provide the employer's telephone number.
- Check the appropriate box that applies to your situation regarding health care coverage:
- If you have two or more employers, indicate if one is your principal employer or secondary employer.
- If you are exempt from health care coverage, check the relevant box and provide necessary details.
- If you are waiving coverage, specify the name of the plan and the health care plan contractor.
- If a previously indicated exemption or waiver is no longer applicable, check the appropriate box.
- Write the requested effective date of coverage.
- Print your name in the designated area.
- Sign the form to certify the information provided is accurate.
- Include your address and phone number.
- Record the date of completion.
Once completed, ensure you keep a copy for your records. Submit the form to your employer, who will retain it for their records. Remember that this form must be renewed every December 31.
Obtain Answers on Hawaii Hc 5
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What is the Hawaii HC-5 form?
The Hawaii HC-5 form is a notification document that employees use to inform their employers about their health care coverage status under the Hawaii Prepaid Health Care Act. It is specifically designed for employees who work for two or more employers, are claiming an exemption or waiver from health care coverage, or are changing their employer designation.
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Who should use the HC-5 form?
This form is intended for employees who:
- Work for two or more employers and each employer pays them at least 20 hours a week.
- Are claiming an exemption or waiver from health care coverage.
- Are terminating their exemption from health care coverage.
- Are changing their principal or secondary employer designation.
However, if an employee works for only one employer that provides health care coverage or works less than 20 hours per week, they should not use this form.
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What information do I need to complete the HC-5 form?
To fill out the HC-5 form, you will need the following information:
- Your name and address.
- Your employer's name and address.
- Your employer's Department of Labor account number.
- Your telephone number.
- Details about your health care coverage status, including any exemptions or waivers you are claiming.
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What should I do after completing the HC-5 form?
After you have completed and signed the HC-5 form, keep a copy for your records. You should then provide the completed form to your employer. It is essential that your employer receives this notification to ensure compliance with health care coverage requirements.
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How long should my employer keep the HC-5 form?
Your employer is required to keep the completed and signed HC-5 form for a minimum of two years. This retention is important for record-keeping and compliance purposes.
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Where can I get assistance if I have questions about the HC-5 form?
If you have any questions regarding the HC-5 form, you can call the Department of Labor and Industrial Relations at (808) 586-9188. They can provide guidance and clarify any concerns you may have about the form or the health care coverage requirements.
Common mistakes
Filling out the Hawaii HC-5 form can be straightforward, but many people make common mistakes that can lead to complications. One major error is not keeping a copy of the completed form. It's essential to have a record for your own reference, especially if any questions arise later.
Another frequent mistake is failing to provide accurate employer information. Make sure to double-check the employer's name, address, and DOL account number. Incorrect details can delay the processing of your health care coverage.
Many individuals also overlook the importance of selecting the correct box on the form. Whether you are identifying your principal or secondary employer, or claiming an exemption, it is crucial to check the right option. Misunderstanding your employment situation can lead to incorrect health care coverage assignments.
People often forget to sign and date the form. A signature is necessary to validate your submission. Without it, the form may be considered incomplete, causing further delays in your coverage.
Another common issue is not understanding the requirements for exemptions. For example, if you claim an exemption based on coverage from another plan, ensure that you provide the name of that plan and its contractor. Failing to do so can result in the denial of your exemption.
Some individuals mistakenly believe they can use this form even if they work for only one employer that provides health care coverage. This form is only for those with multiple employers or specific exemption needs. Using it incorrectly can lead to unnecessary confusion.
Additionally, people sometimes ignore the requirement to inform their employer if their exemption or waiver status changes. If you no longer meet the criteria for exemption, you must notify your employer promptly. Not doing so can result in a lapse in coverage.
Finally, many forget about the renewal requirement. The form must be renewed every December 31. If you don’t submit a new form, your coverage might be affected, leading to gaps in health care benefits.
Documents used along the form
The Hawaii HC-5 form serves as an important notification tool for employees regarding their health care coverage responsibilities under the Hawaii Prepaid Health Care Act. Several other forms and documents are commonly utilized in conjunction with the HC-5 to ensure compliance and clarity regarding health care coverage and employment status. Below is a list of these forms, each described briefly to provide a better understanding of their purpose.
- Hawaii HC-1 Form: This form is used by employers to report employee health care coverage information to the State Department of Labor. It helps ensure that employees receive the necessary health care benefits as required by law.
- Hawaii HC-3 Form: This document is utilized by employees to apply for an exemption from the health care coverage requirements. It outlines the specific conditions under which an employee may be exempt from mandatory coverage.
- Hawaii HC-4 Form: Employers use this form to notify the Department of Labor about any changes in health care coverage for employees. This ensures that the state has updated information regarding employee benefits.
- Employee Health Coverage Waiver Form: This form allows employees to formally decline health care coverage offered by their employer. It typically requires the employee to provide details about their alternative health care plan.
- Health Care Coverage Verification Form: This document is often required by employers to verify that employees have adequate health care coverage. It helps ensure compliance with state regulations.
- Notice of Employee Rights: Employers must provide this notice to employees, informing them of their rights regarding health care coverage under the Hawaii Prepaid Health Care Act.
- Dependent Health Coverage Form: This form is used by employees to enroll dependents in their health care plan. It collects necessary information about the dependents to ensure they receive coverage.
- Health Care Coverage Termination Form: This document is submitted by employees to formally notify their employer of the termination of health care coverage. It is essential for updating employer records.
Understanding these associated forms can facilitate a smoother process for both employees and employers in navigating health care coverage requirements in Hawaii. Proper completion and submission of these documents help maintain compliance with state regulations and protect the rights of employees regarding their health care benefits.
Similar forms
The Hawaii HC 5 form serves specific purposes related to employee health care coverage under the Hawaii Prepaid Health Care Act. Here are eight documents that are similar to the HC 5 form, along with their key similarities:
- Form HC-1: This form is also used for notifying employers about health care coverage but focuses on initial enrollment rather than changes in status.
- Form HC-3: Similar to the HC 5, this document is for employees who wish to terminate their health care coverage, providing a formal notice to their employer.
- Form HC-4: This form serves to request a change in health care plan, allowing employees to switch their coverage while informing their employer.
- Form HC-6: This document is utilized for employees who need to appeal a denial of health care coverage, paralleling the HC 5 in its notification purpose.
- Form HC-7: Similar in function, this form is for employees who wish to reinstate their health care coverage after a waiver, emphasizing the ongoing nature of health care obligations.
- Form HC-8: This form is for reporting changes in employment status that may affect health care coverage, aligning with the HC 5's focus on employment-related notifications.
- Form HC-9: This document is used for documenting health care coverage eligibility, similar to the HC 5 in its aim to clarify an employee's status.
- Form HC-10: This form notifies employers about changes in dependents covered under an employee's health plan, sharing the HC 5's goal of keeping employers informed.
Dos and Don'ts
When filling out the Hawaii HC-5 form, it’s crucial to follow specific guidelines to ensure your submission is accurate and effective. Here’s a list of important do’s and don’ts to keep in mind:
- Do keep a copy of your completed and signed form for your records.
- Do provide the completed form to your employer promptly.
- Do check the appropriate boxes that apply to your situation carefully.
- Do ensure that your employer’s name and address are filled out correctly.
- Do write clearly and legibly to avoid any confusion.
- Don't use this form if you only work for one employer who provides health care coverage.
- Don't forget to renew the form every December 31, as it must be updated annually.
By adhering to these guidelines, you can help ensure that your health care coverage needs are met without unnecessary complications. Take action now to avoid any delays in your coverage!
Misconceptions
The Hawaii HC 5 form is an important document for employees working in multiple jobs or those seeking health care coverage exemptions. However, there are several misconceptions surrounding this form that can lead to confusion. Below is a list of common misconceptions along with explanations to clarify each point.
- Misconception 1: The HC 5 form is only for employees with multiple employers.
- Misconception 2: Employees do not need to keep a copy of the completed form.
- Misconception 3: The form must be submitted to the State Department of Labor.
- Misconception 4: All employees must fill out the HC 5 form every year.
- Misconception 5: The HC 5 form guarantees health care coverage.
- Misconception 6: Employees can choose any employer as their principal employer.
- Misconception 7: Waiving health care coverage means an employee cannot receive any health care benefits.
- Misconception 8: The HC 5 form is only relevant for full-time employees.
- Misconception 9: The HC 5 form is not important for employees receiving public assistance.
This form is also applicable for individuals who are seeking an exemption or waiver from health care coverage, regardless of how many employers they have.
It is essential for employees to retain a copy of the completed and signed HC 5 form for their records. This can help in future discussions with employers regarding health care coverage.
Employees should not submit this form to the State Department of Labor unless specifically requested. Instead, it should be given to the employer and kept for personal records.
The form needs to be renewed every December 31, but not all employees will need to fill it out each year. It depends on changes in employment status or health care coverage.
While the form notifies employers of an employee's health care needs, it does not guarantee coverage. Employers must comply based on the information provided in the form.
Employees must designate the employer who pays the most wages as their principal employer, unless they work at least 35 hours a week for another employer who does not pay the most wages.
Employees who waive coverage through the HC 5 form can still receive health care benefits from other plans that meet the requirements of the Prepaid Health Care Act.
This form is relevant for employees who work at least 20 hours per week, regardless of whether they are full-time or part-time across multiple jobs.
Employees receiving public assistance may still need to complete the HC 5 form if they are working and wish to notify their employers about their health care coverage status.
Key takeaways
Filling out the Hawaii HC-5 form is an important step for employees who need to communicate their health care coverage status to their employers. Here are some key takeaways to keep in mind:
- Keep a Copy: Always retain a completed and signed copy of the HC-5 form for your records.
- Multiple Employers: Use this form if you work for two or more employers and need to designate a principal employer for health care coverage.
- Health Care Exemptions: You can claim an exemption from health care coverage under specific circumstances, such as being covered by Medicare or Medicaid.
- Waiver of Coverage: If you have alternative health care coverage that meets the requirements of the Prepaid Health Care Act, you may waive your employer’s health care plan.
- Notification of Changes: If your coverage status changes, such as terminating an exemption or changing your principal employer, use this form to notify your employer.
- Employer Responsibilities: Employers must provide coverage as required and keep the completed form for two years.
By following these guidelines, you can ensure that your health care coverage is properly managed and that your rights are upheld.