The Hawaii HC-5 form is an essential document used by employees to notify their employers about health care coverage status under the Hawaii Prepaid Health Care Act. This form is particularly relevant for individuals working for multiple employers, claiming exemptions, or changing their health care coverage designations. Understanding its requirements and proper usage is crucial for both employees and employers to ensure compliance with state health care regulations.
The Hawaii HC-5 form is an essential document for employees navigating their health care coverage responsibilities under the Hawaii Prepaid Health Care Act. This form serves multiple purposes, primarily allowing employees to notify their employers about their health care coverage status when they work for two or more employers. It is particularly important for those claiming exemptions or waivers from health care coverage, changing their employer designations, or terminating existing exemptions. Employees must be aware that this form is not necessary if they work for only one employer who provides health care coverage or if their hours are below the required threshold. The HC-5 form requires employees to specify their principal employer, who is responsible for providing health care coverage, as well as any secondary employers who may be relieved of this duty. Additionally, the form includes options for employees to declare their exemption status based on various qualifying conditions, such as being covered by government health plans or having alternative health care arrangements. Proper completion and submission of the HC-5 form are crucial for ensuring compliance with state regulations and securing necessary health care benefits.
Filling out the Hawaii HC-5 form can be straightforward, but many individuals make mistakes that can lead to delays or complications. One common error is failing to provide accurate employer information. Ensure that the employer's name, address, and DOL account number are correctly filled out. Inaccurate details can cause confusion and may result in the form being rejected.
Another frequent mistake is neglecting to check the appropriate boxes on the form. The HC-5 requires you to indicate your status clearly, whether you are designating a principal employer or claiming an exemption. Omitting this crucial step can lead to misunderstandings regarding your health care coverage responsibilities.
Many people also overlook the importance of signing and dating the form. A signature signifies your agreement with the information provided, while the date indicates when the notification was made. Without these, the form may not be considered valid, and your employer may not process it correctly.
Some individuals forget to keep a copy of the completed form for their records. Retaining a copy is essential for your personal documentation and can serve as proof if any disputes arise later. Always make sure to have a signed version for your own files.
Another mistake involves not understanding the implications of waiving health care coverage. If you choose to waive coverage, you must provide the name of the plan and the contractor. Failing to include this information can render your waiver ineffective, leaving you without necessary health care coverage.
Lastly, people often misinterpret the requirements for working hours. The HC-5 form specifies that you must work at least 20 hours per week for two or more employers to use it. If you work fewer hours or only for one employer, this form is not applicable. Misunderstanding this can lead to unnecessary complications in your health care coverage process.
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.
The Hawaii HC-5 form is an important document for employees who need to notify their employers regarding health care coverage. Several other forms serve similar purposes in various contexts. Below is a list of nine documents that share similarities with the Hawaii HC-5 form, highlighting their respective functions.
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