The Hawaii HC-5 form serves as a notification for employees to inform their employers about their health care coverage status under the Hawaii Prepaid Health Care Act. This form is essential for individuals who work for multiple employers, are seeking exemptions from health care coverage, or need to update their employer designations. To ensure compliance and proper coverage, it is important to fill out this form accurately.
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The Hawaii HC 5 form serves as an essential tool for employees navigating their health care coverage responsibilities under the Hawaii Prepaid Health Care Act. This form is particularly important for individuals who work for multiple employers, claim exemptions, or need to change their health care coverage status. Employees must complete the HC 5 form if they work for two or more employers and have been designated a principal or secondary employer, or if they are terminating an exemption from health care coverage. Additionally, those who have obtained alternative health care plans or who fall under specific exemption categories must also use this form. It is crucial for employees to retain a copy for their records and provide the completed form to their employer. Employers, in turn, are required to keep this documentation for two years and must comply with the coverage requirements indicated by the employee. Understanding the HC 5 form is vital for ensuring compliance with state health care laws and securing the appropriate health benefits for employees and their families.
HC-5 (Rev.09/22)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
FORM HC-5 EMPLOYEE NOTIFICATION TO EMPLOYER FOR CALENDAR YEAR 2023
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**
THIS SECTION IS FOR THE EMPLOYER TO COMPLETE.
Employer name
DOL account number
Address
Phone no.
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 393-6).
**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 393-16).
3. I am exempt from health care coverage because I am: (Check appropriate box.) (Sections 393-17 and 393-22)
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 State-legislated health care plan governing medical assistance (e.g. MedQuest).
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 393-21).
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 393-18).
Requested effective date of coverage: ____________________.
Print employee name
Employee signature
Date
Keep a copy of your completed, signed form for yourself. RETURN COMPLETED FORM TO EMPLOYER.
Call (808) 586-9188 with any questions about this form.
Auxiliary aids and services are available upon request. Please call (808) 586-9188; a request for reasonable accommodation(s) should be made no later than ten working days prior to the needed accommodation (s).
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.
Filling out the Hawaii HC-5 form is an important step for employees who need to notify their employer about their health care coverage status. This form requires specific information and must be completed accurately to ensure compliance with the Hawaii Prepaid Health Care Act.
After completing the form, your employer will review it and take the necessary actions based on your selections. It's essential to keep a copy for your records and ensure that your employer retains the original for their files.
The Hawaii HC-5 form is a notification form that employees use to inform their employers about their health care coverage status. It is specifically designed for employees who work for two or more employers or those who are seeking an exemption from health care coverage under the Hawaii Prepaid Health Care Act.
This form should be used by employees who meet any of the following criteria:
Do not use this form if:
The principal employer is the one who pays you the most wages among your multiple employers. If you work at least 35 hours a week for one employer but that employer does not pay the most wages, you can choose which employer to designate as your principal employer.
Once you have completed and signed the HC-5 form, keep a copy for your records. Then, provide the signed form to your employer. They are required to keep it for two years.
The form allows you to communicate your health care coverage status to your employer. Depending on your selections, your principal employer may be required to provide you with health care coverage, or you may be exempt from coverage under specific circumstances.
If your employment status changes, such as if you start or stop working for an employer, you may need to fill out a new HC-5 form. This ensures that your health care coverage status is accurately reflected and that your employer is aware of any changes.
The HC-5 form must be renewed every December 31. If you need to make changes or updates to your health care coverage, be sure to submit the updated form by this deadline.
If you have questions about the HC-5 form, you can call the Department of Labor and Industrial Relations at (808) 586-9188. They can provide guidance and answer any questions you may have about filling out the form or your health care coverage options.
Neglecting to Keep a Copy: Many individuals forget to keep a copy of their completed form for their records. This can lead to confusion or disputes later on, especially if there are discrepancies about what was submitted.
Incorrect Employer Designation: Failing to accurately identify the principal and secondary employers can create issues. The principal employer is the one who pays the most wages. If this is not clearly marked, it can lead to complications in coverage.
Missing Required Signatures: Some people overlook the necessity of signing the form. Without a signature, the form may be considered incomplete, which could delay health care coverage.
Not Checking the Right Boxes: It’s crucial to check the appropriate boxes that apply to your situation. Misunderstanding or overlooking this step can result in incorrect coverage designations.
Providing Incomplete Information: Failing to fill in all required fields, such as the employer's address or DOL account number, can lead to processing delays. Ensure all information is complete and accurate.
Ignoring Submission Guidelines: Some individuals mistakenly submit the form to the State Department of Labor & Industrial Relations. Remember, this form should only be given to your employer and not submitted to the state unless requested.
The Hawaii HC-5 form is essential for employees navigating health care coverage requirements in the state. Several other documents often accompany this form to ensure compliance with the Hawaii Prepaid Health Care Act and to clarify the health care coverage status of employees. Below is a list of related forms and documents that may be necessary.
These documents work together to ensure that both employers and employees understand their rights and obligations regarding health care coverage in Hawaii. It is important to keep these forms updated and properly filed to avoid any compliance issues.
The Hawaii HC-5 form shares similarities with the IRS Form W-4, which is used by employees to indicate their tax withholding preferences. Both forms require employees to provide personal information and make selections that affect their employer's responsibilities. The W-4 allows employees to claim allowances and exemptions, while the HC-5 enables employees to notify their employers about health care coverage selections and exemptions. Both forms serve as essential communication tools between employees and employers, ensuring compliance with respective regulations.
Another document comparable to the Hawaii HC-5 form is the Employee Eligibility Verification Form (I-9). The I-9 form is utilized to verify an employee's identity and eligibility to work in the United States. While the HC-5 focuses on health care coverage, both forms require employees to disclose personal information and provide documentation to support their claims. The I-9 must be completed by employees upon hire, similar to how the HC-5 must be submitted when health care coverage needs to be established or modified.
The Health Insurance Marketplace Application is also similar to the Hawaii HC-5 form in that it allows individuals to apply for health coverage and report their eligibility for various health care programs. Both documents require personal information and details about existing coverage or exemptions. While the HC-5 pertains specifically to employer-sponsored health care in Hawaii, the Marketplace Application addresses broader health insurance options available to individuals and families across the United States.
The COBRA Election Notice serves a similar purpose in informing employees about their health care options after employment ends. Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), employees can continue their health coverage for a limited time after leaving a job. Like the HC-5, the COBRA notice requires employees to make selections regarding their health care coverage. Both documents are crucial for ensuring that employees are aware of their rights and responsibilities regarding health care coverage.
The California Employee Health Benefits Notification is another comparable document. This form notifies employees about their health benefits options and requirements in California. Similar to the HC-5, it outlines the responsibilities of both the employee and employer regarding health care coverage. Both documents aim to ensure that employees are informed about their health care choices and the implications of their selections.
Lastly, the New York State Health Care Coverage Notification is similar to the HC-5 form. This document informs employees about their health care coverage options and requirements under New York law. Both forms require employees to provide information about their health care status and make decisions that affect their coverage. They serve as essential tools for communication between employees and employers, ensuring compliance with state health care regulations.
Filling out the Hawaii HC-5 form correctly is crucial for ensuring your health care coverage is properly managed. Here are some important do's and don'ts to keep in mind:
Understanding the Hawaii HC-5 form is crucial for employees and employers alike. However, several misconceptions can lead to confusion. Here’s a breakdown of nine common misunderstandings:
Clearing up these misconceptions can help ensure that both employees and employers navigate health care responsibilities effectively. Always stay informed and proactive about your health care coverage.
Here are some key takeaways regarding the Hawaii HC-5 form:
If you have any questions, contact the appropriate department for assistance. They are available to help ensure you understand your rights and responsibilities regarding health care coverage.