new hire enrollment presentation - hawaii employer-union ......presentation hawaii employer-union...
TRANSCRIPT
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New Hire Enrollment Presentation
Hawaii Employer-Union Health Benefits Trust Fund
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Who We Are Premiums and ContributionHealth Plan Options Health Plan Selection Making ChangesEnrollment Form
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Options Health Plan Selection Making Changes Enrollment Form
Health Plan Selection Who We Are Knowing what to consider when The EUTF, our agency and our mission
selecting a health plan
Health Plan Options Enrollment Form Details on available health plan options Completing and submitting forms for for employees and eligible dependents health plan enrollment
Premiums and Contributions Making Changes Health plan premium information and Qualifying Events and form employer/employee contributions submission when making changes
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Who We Are
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Who We Are
State of Hawaii Employer-Union Health Benefits Trust Fund
Premiums and Contribution Health Plan Options Health Plan Selection Making Changes Enrollment Form Who We Are
Our Mission Who We Are The EUTF is a State agency administratively attached to the department of Budget and Finance. The EUTF was established on July 1, 2003 and provides medical, prescription drug, dental, vision, and life insurance benefits to nearly two hundred thousand eligible State and county employees, retirees and their dependents.
We care for the health and well being of our beneficiaries by striving to provide quality health benefit plans that are affordable, reliable, and meet their changing needs. We provide informed service that is excellent, courteous and compassionate.
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Health Plan Options
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EUTF Reference Guide for Your
Health Benefits
For Active Employees Plan Year July 1, 2020 - June 30, 2021
What's inside? Wellness Programs and Money Saving Tips
Health plan information
Prem ium and employer con tr ibution amounts
Hawaii Employer-Union Health Benefits Trust Fund (EUTF)
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Health Plan Options
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Selection Making Changes Enrollment Form Health Plan Options
Health Plan Options
Medical • Hawaii Medical Service Association (HMSA) • Kaiser Permanente
Prescription Drug • CVS Caremark - For HMSA Subscribers • Kaiser Prescription Drug
Chiropractic Coverage • American Specialty Health Group (ASH Group)
- For HMSA & Kaiser Subscribers
Supplemental Plan • Hawaii-Mainland Administrators (HMA)
Dental & Vision • Hawaii Dental Service • Vision Service Plan
Life Insurance • Securian
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Health Plan Options
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Selection Making Changes Enrollment Form Health Plan Options
Medical Plan Options
Preferred Provider Organization (PPO) • Freedom of choice • Offers in and out of network benefits • Out-of-pocket cost based on coinsurance
Health Maintenance Organization (HMO) • Select a PCP who will coordinate care • Out-of-network services require a referral • Out-of-pocket cost based on copayments
EUTF PPO Medical Plan Options 90/10 Plan – HMSA Medical with ASH Group Chiropractic coverage and CVS Caremark Prescription Drug
80/20 Plan – HMSA Medical with ASH Group Chiropractic coverage and CVS Caremark Prescription Drug
75/25 Plan – HMSA Medical with ASH Group Chiropractic coverage and CVS Caremark Prescription Drug
EUTF HMO Medical Plan Options HMSA HMO with ASH Group Chiropractic coverage and CVS Caremark Prescription Drug
Kaiser Comprehensive Medical and Prescription Drug coverage with ASH Group Chiropractic coverage
Kaiser Standard Medical and Prescription Drug coverage with ASH Group Chiropractic coverage
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Health Plan Options
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Selection Making Changes Enrollment Form Health Plan Options
Other Plans A supplemental medical and prescription drug plan under HMA is offered to employees who have non-EUTF medical and prescription drug coverage. In order to be enrolled in the HMA supplemental plan, your primary insurance cannot be Medicare.
Dental and vision benefits are available for the
Supplemental Medical Plan HMA
Dental Plan HDS Dental
employee, employee’s spouse or partner and eligible dependents.
Life insurance is 100% employer paid and is available for the employee only.
Vision Plan VSP Vision
Life Insurance Securian
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»;:-
-..-..~ ... __ ~. , , . • , "' ... ... .. .. •• .. .. •• - ALL .. PLo, ,.. ""c .. , co.,,.,.., Op ..... .,, ~ ....,,,.~"4.V ... Ua1,,ic c...,,"4R~R C 00
---_ ---"'._ ..._..,. ~ su •8 ..,.:,, ~. Ls s,,."' Op,.,...,,.., Har,. "••,. .,.,,.,_o"ees """o o,..,_., o -.-o - ""• "'""o ON o,. APr.,,. , ..... ., ..... ,.. , .•• ,,
~ ~ ~ ,.,GU, b/ ~~ID,k
,.n,~Al~C8/ ~~01',4
llllor,th1y EIJ1p1oy••
Contr1bu110,, l\,font11/y
En-,Ployer
Percent Contribution f:~
lo er ~ P.o,.j ~,M MGYJico/ w 4zs;, CVs Con.»,al",t;-,,c ..,,.,,,/..,--.,,~,o
"roi., $311114
s :IQ,- oa 4{1 6%
$/()9 !I{;
S/37 9n $967 54 s,o,,. ✓,/
$;> ,,, [>4 S.?6(J !lo 4Ej 7% .Sb1a 9{j So.t,; Oo -.19 ,OoQ $1 ~, 92
St 914 44
$533 80 $:J07 Ou ~0°o
ss21 eo
$.333 :?2
$Q!3ij 44 $7,11 96 S'7a%
.$1 265 16
$1'108
S14;, tu fi90 sa 7%
$11113~
.S17905
$3[,fi IO / 06
684%
~49 2,2
s22,. 19
$442.~ I 96
67 1% $1 090 Oti
$387 14 6 90
~2% $ 1 :389 28
$95
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Premiums
EFFECTI\IE JULY 1, 2020
HAWAII EMPLOYER.UNION HEAL TH BENEFITS TRUST l'UND ACTIIIE EMPI._OYEES
BU DD, 01, 0.2, D3, 04, 06, 07, oa, OS, 10, 11 , 12, 13, 14
BU' o 00, 01 , 0:2, 05, 04 , 06,, 07, 08, 09, 10, 11 , 12, 13, 14: ALL EMPLOYERS
BU Os, FOR HAWAII PUBLIC CHARTER SCHOOLS, STATE O,F HAWAII HST A 1/EBA EMPLOYEES WHO 0 .PTED TO TRANSFER TO EUTF PLAHS OR BU OS EMPLOYEE.$ HIRED ON OR AFTER JANUARY 1, 2D11
Semi -Monthly Monthly Monthly Type Df Employee- Em,ployee Em,pl oyer Percent
Benefit Plan Enrollment Contribution Contributior C
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Health Plan Selection
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Employer-Union Health Benefits Trust Fund
State of Hawaii
Who We Are Health Plan Options Health Plan Selection Making Changes Enrollment Premiums and Contribution
Things to Consider
The monthly amount paid for your health insurance shared between the employer and employee. PREMIUMS
Deductibles do not apply to all plans or all services. They cannot be paid in advance and are renewed annually. Deductibles must be paid each calendar year on a claim-by-claim basis before benefits subject DEDUCTIBLE to the deductible become available.
Calendar Year - January 1st to December 31st Includes medical and prescription drug benefits. Plan Year – July 1st to June 30th Includes dental and vision benefits.
CALENDAR YEAR PLAN YEAR
In-network - Physicians, hospitals, pharmacies, and other providers contracted with your health insurance. Out-of-network - Providers are not contracted with your health insurance carrier.
IN-NETWORK OUT-OF-NETWORK
Your out-of-pocket cost for covered services. COPAYYMENT • Copayment is based on a fixed dollar amount COINSURANCE • Coinsurance is based on a percentage.
MAXIMUM The maximum amount in coinsurance and copayments you will pay for covered medical and prescription drug cost within a calendar year. OUT-OF-POCKET
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Health Plan Selection
Employer-Union Health Benefits Trust Fund
State of Hawaii
Who We Are Health Plan Options EnrollmentHealth Plan SelectionPremiums and Contribution Making Changes
Maximum Out-of-Pocket (MOOP) • Financial protection • All covered coinsurance, copayments and deductibles apply towards MOOP • Insurance company keeps track of out-of-pocket • When MOOP is reached – 100% coverage • Resets every calendar year
EUTF 90/10 PPO Plan HMSA
$2,000/$4,000 (medical) $4,350/$8,700
(CVS prescription drug)
EUTF HMO HMSA
$1,500/$3,000 (medical) $4,350/$8,700
(CVS prescription drug)
EUTF 80/20 PPO Plan HMSA
$2,500/$5,000 (medical) $4,350/$8,700
(CVS prescription drug)
EUTF HMO Comprehensive Kaiser
$2,000/$6,000 (medical and prescription drug)
EUTF 75/25 PPO Plan HMSA
$5,000/$10,000 (medical) $2,900/$5,800
(CVS prescription drug)
EUTF HMO Standard Kaiser
$2,500/$7,500 (medical and prescription drug)
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Rick is considering enrolling in either the 90/10, 80/20 or 75/25 Self-only plan
(Low dollar example) HMSA PPO Plan Comparison for Self-only
Annual Employee Premium Contribution*
Rick anticipates 4 doctor visits during the calendar year. His doctors charge $100 per
visit before insurance pays. Total $400
Calendar Year Plan Deductible
Calendar Year Maximum Out-Of-Pocket (MOOP)
HMSA 80/20 HMSA 90/10 HMSA 75/25
$4,634 $2,971
Coinsurance 10% $40
Coinsurance 20% $80
$767
Coinsurance 25% $100
$0$0 $300
$0 $0$4,634 $2,971 $0$767
$300
Coinsurance less than
$2,000 MOOP
Coinsurance less than
$2,500 MOOP
Coinsurance less than
$5,000 MOOP
$3,051 $867Total Estimated Annual Cost: $4,674
The HMSA 75/25 PPO Plan for Self-only offers Rick the most savings in this scenario
*Annual employee premium contribution amounts are estimates. Please note that amounts vary each plan year.
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Rick is considering enrolling in either the 90/10, 80/20 or 75/25 Self-only plan
(High dollar example) HMSA PPO Plan Comparison for Self-only
Annual Employee Premium Contribution*
Rick anticipates $19,100 in covered in-network medical expenses (with $300
subject to the 75/25 deductible) from January 2020 - April 2020
Calendar Year Plan Deductible
Calendar Year Maximum Out-Of-Pocket (MOOP)
HMSA 80/20 HMSA 90/10 HMSA 75/25
$ 4,634 $ 2,971
Coinsurance 10% $1,910
$ 767
Coinsurance 20% $2,500
Coinsurance 25% $4,700
Coinsurance 20%$3,820
$0 $0$ 4,634 $ 2,971
Coinsurance 25%
$6,791
$18,800X 25%$4,700
$0$ 767Total Estimated Annual Cost:
Coinsurance exceeds
$2,500 MOOP
Coinsurance + deductible reaches
$5,000 MOOP
$6,544 $5,471
$0$0 $300
Coinsurance less than
$2,000 MOOP
$5,767
The HMSA 80/20 PPO Plan for Self-only offers Rick the most savings in this scenario
*Annual employee premium contribution amounts are estimates. Please note that amounts vary each plan year.
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Coinsurance 15%500
Malia is considering enrolling in the Kaiser Comprehensive or Standard plan
Kaiser HMO Plans Comprehensive Plan Standard Plan Annual Employee Premium Contribution* $3,225 $810
Malia will undergo surgery and was told the cost before insurance could be $50,000 at an in-network Kaiser facility this year.
No Charge Coinsurance 15% $7,$2,500
Calendar Year Maximum Out-Of-Pocket (MOOP)
$2,000 Not met
$2,500 Met
Total Estimated Annual Cost: $3,225 $3,310
Total estimated annual savings under the Kaiser Comprehensive plan: $85
*Annual employee premium contribution amounts are estimates. Please note that amounts vary each plan year.
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Enrollment
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Enrollment Form
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Options Health Plan Selection Making Changes Enrollment Form
DUAL ENROLLMENT
Dual Enrollment is not allowed
• No person may be enrolled in any EUTF benefit plan as both a retiree/active employee and dependent, nor may children be enrolled on more than one retiree/active employee plan (dual enrollment). In addition, if you and your spouse/partner are both retirees/active employees, the employer’s contribution cannot exceed a family plan contribution in accordance with Chapter 87A-33-36, Hawaii Revised Statutes.
• Children cannot be enrolled by more than one employee or retiree-beneficiary.
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Enrollment Form
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Options Health Plan Selection Making Changes Enrollment Form
DEPENDENT ELIGIBILITY
• Legal spouse or partner (domestic or civil union)
• Children by birth, marriage, adoption or placement for adoption
o Children are covered until age 26 for medical and prescription drug plans
o For dental and vision coverage, children are covered until age 19, or until age 24 if unmarried and a full-time student
o Coverage can be continued for an unmarried child, regardless of age, who is incapable of self-support due to mental/physical incapacity that existed prior the child reaching age 19
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Health Plan Selection Making Changes Enrollment Form
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1-1 Emi:,lay,,
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Employee Data
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oyer-U · ion Hea11ih Berneffi "f rust Fund
EUTF ACTIVE EMPL10 .YEE EC-1 HEAL 1H BENEFITS ENROLUMENT FORM
Ca
Emallrnem: TyP,e fYcbu n:11:1st cheGk m1e ibm;:J:
EMPLOYEE DA TA ~ e5Ch ~ ioo,cr.igii,y; p
N:ew H-re a
Qual'ifying Evem: a
:i-..hmiL ·•• fmm ta U'r 11 =::.....,n:i acicc.
O p.en Enro.llmem: a
I N:ew H-rie Of" Qualifying !Event Date: ______ Qualifying Event De.scripti'Olil: _________ _ Social Secu -, No.
Employee Data Enrollment Type
Select the event for which you are submitting the enrollment form. Mark the New Hire box if you’re newly hired, Qualifying Event box if you are making changes outside of the Open Enrollment period, or the Open Enrollment box during the annual or limited open enrollment period. If submitting the enrollment form for a qualifying event, give a brief description of the event and input the date the qualifying event occurred.
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Hawaii Employer-Union Health Benefits Trust IFu11d
.ACTIVE EMPLO'YE.E EC-1 HEALTH BENEFITS E.NROLLIMEINT FOIRM
Ai l Bar ainun Units Exce t BU12
Submit 1hiEi rm ID your personnel] offi'ce.
DOE ,employees submit to.: IDOE-!EBUI
POBox'.2360 Honolulu 1,111, 96804
Cl~ar Fonn
New Hire Event 1Qpen Enrol lrnent
New Hi're or 1Qualilfyirmg Event. Dat •= Qualiifying Event. De.sctiption:
EMPLOYEE DATA
Full tNam ... Soci Socuriity No. iY EUlF ID No .. : ------------------------1. ... ast M '. 1.
Resid'gnoe Ma.ling Actd'Jess:
----------------- -----------------
Marital Status: S ng e Married
Z{p Code
Domes-lie Pa11ner
M dr, es s:
Gender.
IMarriag;e Dale: ______ _
lt-lome Cell Pho:n.@': Pho:n.@•: ---------- ----------Spouse/Partner Name: SSN:
State Zip Code
Birthdate: -------Male Female
Email: ----------------11:rrthdate:
Enrollment Procedures
x 01 - 01 - 2020
Kealoha John K 555-55-5555
555 Kealoha Street
Honolulu HI 96800
06 19 1960 x x 02 14 1980
(808) 555-5555 (808) 123-4567 [email protected]
Jane Kealoha 555-12-3456 2/01/1965
mailto:[email protected]
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Coverage and Start date
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COVERAG!E START DATE Do iR!!li mp dilr.s: seGtioo. Read! ;me ""EC-1· ,Enrd meat FOiml lr:rsi!n.rcHom;"' :anu ca pJete ·tifir.s: secmoo b.ei"are rn0Yciff9 oo. · :arin::ir;ie, •ti'oo Optian 1 :J O:Jve~ st:irts · · "b ,staJili 1"' day . -Hhe pay periiool • -the effe...iive date af caver~e
~- ( ooop_ Cptian #2 CJ Cm.re~ amd p co. ·rs pay pe g event date. ( " or ttie ·1 .:. e mDliT ~ Optian #3 :J . d l!lf co. of the !x!DJnd P2T m'i'ini:a eve date. ( · o · ttie noon-th)
Option 1:Date of Hire or event date*
Option 2:First day of the first pay period following the event (1st or the 16th of the month)
Option 3:First day of the second pay period following the event (1st or the 16th of the month)
*If no selection is made option 1 will be used
Option 1: Date of Hire or event date*
Option 2: First day of the first pay period following the event (1st or the 16th of the month)
Option 3: First day of the second pay period following the event (1st or the 16th of the month)
*If no selection is made option 1 will be used
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Option 1* • Coverage begins on the date
of hire or event date.
• Contribution start date will bethe first day of the pay period inwhich the event occurs.
*If no selection is made option 1 will be used
1 2 3 4 5 6
7 8 g 10 11 12, 13
16 17 18 191 20
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1 2 3, 4
5 6 7 8 9 10 11
12 13 14 15 16 17 18
19 20 21 22 23 2.4 25
26 27 28 29 30 3,1
Contribution Start Date
Pay Period
Hire date
April
May Start Date Coverage
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1 2 3 4 5 6
7 8 g 10 11 12, 13
14 15 16 17 18 19 20
22 23 24 25 2.6 27
30
1 2 3 4
5 6 7 8 9 10 11
12 13 14 15 16 17 18
19 20 21 22 23 2.4 25
26 27 28 29 30 3,1
Pay Period
April
May
Option 2 • Coverage and contributions beginon the first day of the first payperiod following the event.
Hire date
CoverageStart Date
Contribution Start Date
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1 2 3 4 5 6
7 8 g 10 11 12, 13
14 15 16 17 18 19 20
21 22 23 24 25 2.6 27
28 30
2 3, 4
9 10 11
12 13 16 17 18
19 20 21 22 23 24 25
26 27 28 29 30 31 Pay Period
May
April
Option 3 • Coverage and contributions begin on the first day of the second pay period following the event.
Hire date
CoverageStart Date
Contribution Start Date
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Enrollment Form
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Options Health Plan Selection Making Changes Enrollment Form
Pay Lag
If you are a newly hired employee or enrolling in benefits for the first time, your pay period deduction amounts may be doubled for at least one (1) to two (2) pay periods to accommodate for processing time and the payroll lag.
If applicable, you will receive a separate notice, EUTF Health Insurance Premium Deduction Notice, to inform you of the additional premiums to be collected and the pay periods that will be adjusted.
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Plan selection
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PLAIN SELECTION EFFECTIVE 7/1/20 THROUGH 6/30/21
Medical, Chlro and Prescription Dru (select one) HMSA PPO 90110 Medical, Ch iro and CVS Prescription Drug 0 Cancel/Waive □ Self □ Two-Party □ Family Monlhly Emplo ee Rremium $386.18 $-93-7.74 $1,196.14 HMSA PPO 80/20 Medical, Ch iro and CVS Prescription Drug 0 Cancel/Waive □ Self □ Two-Party □ Family Monlhly Employee Rremium $247.58 $600.94 $766.44 HMSA PPO 7512.5 Medical, Ch iro and CVS Prescription Drug 0 Cancel/Waive □ Self □ Two-Party □ Family Monlhly Emplo ee Rremium $63.92 $155.22 197.88 HMSA HMO Medical, •Chiro and CVS Prescription Drug D Cancel/Waive □ Self □ Two-Party □ Family Monlhly Employee Rremium $501.60 $1,218.24 $1,553.98 Kaiser HMO Comprehensive Medical, Chiro and Prescri ption Drug 0 Cancel/Waive DI Self □ Two-Party Family Monlhly Employee Rremium $268.74 $653.08 $834.26 Kaiser HMO Standard Medical , Chiro and Prescription Drug □ Cancel/Waive □ Self □ Two-Party □ Family Monlhly Employee Rremium $67..46 $163.90 20!l10 HMA S upplementa.l Med ical and Prascription Drug □ Cancel/Waive □ Self □ Two-Party □ Family (Must have roverage under a non-EJTF health plan to be efigibla for Supplemental) $14.16 $30.00 $33.00
Dental (se lect one) Hawaii Dental Service Cancel/Waive □ Self □ Two-Party □ Family Monlhly Employee Rremium $14.48 $28.94 $47.62
Vision select one Vision Service Plan 0 Cancel/Waive □ Self □ Two-Party □ Family Monlhly Employee Rremium $2.46 $4.56 $5.98
Life select one Securi.an
Enrollment Form
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Options Health Plan Selection Making Changes Enrollment Form
X
X
X
X
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Check the box of each plan you wish to enroll in. You may enroll in only one medical/prescription drug plan.
A spouse/partner and/or dependent child may enroll in the same plans as the employee, but may not enroll in health plans on their own.
Life insurance is 100% employer-paid and is available for the employee only.
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Dependent Information
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Employee's Name:: ---------------st .11 e .and GD . ty Coom.l!nriions: No• p&S0/1' ma,, be ewolied i .any EUIF benefit pJar1 as bcdi .a retiree/a;c/i1,1:e · royee and depe.rrden . or may children be err rolled 0111 more than cne, wireelactive. ,. yee plan (dual enroJin:rem') . . i a.ddilron, ff you and . our- spo .se,pariner- a.r:e bo.f!:J ,;e '~e&-".acttve employees he emplo:yer's cmifrib~tioo cannot exceed a fam, y pfan1 cmimbuticm in aorxwdam::e L\gt/J• Chapter 87 A-33-3.6' Hawa ii Re ,'v:ied Statutes. Both· retiree&°a.c.tive• empk!yees BITI? able to select EUTF Seff-.only p-lan . but ,not Self-only e. d 2-P1:1rty- plans or Seff-.only arid Fan uy piar1s.
DEPENDEN'l INFORMA IION Comple depe ent i ormamon and ind· ·ate plarn ·selectiorn i adding/re · ing depe n.ts.
Coo:nm ~Adm ele1e Last Niim e, Firs ·. id • e lni iaE Girlfl date SSNI R~ship Ge .eri ,,., ' tca.\ x Derrtal Vision
□ □ □ □ □ □
□ □ □ □ □ □
□ □ □ □ □ □
□ □ □ □ □ □
□ □ □ □ □ □
If dep de ts are age ·1 Q to 23 .and cov d iu der y r · entsE and/l[l rr \!isicn [P~ - ', p1ease ::: 1 iti oertific9f ion from the schooE rieg~strnr ori n silionel clearinghouse i · · they arie a I ime sfudent De(,· "lee eligibi ity in atio 1is availab •OOI" e at eutf.h
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Enrollment Form
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Options Health Plan Selection Making Changes Enrollment Form
Proof Documents
Enrollment Type Required Proof Documents SELF PLANS No proof documents required
ADDING A SPOUSE/PARTNER Marriage certificate Domestic partnership documents with verification documents*
(available at eutf.hawaii.gov)
ADDING A DEPENDENT CHILD Birth Certificate* Guardianship Decree (if legal guardian) Adoption Decree (if child is placed for adoption or adopted)
(Social Security numbers required for all newly added dependents)*
DEPENDENT CHILDREN AGE 19 – 23 WHO ARE FULL-TIME STUDENTS AND ENROLLING IN DENTAL & VISION PLANS
Student Certification Letter (A letter from school’s registrar or verification certificate from the National Clearinghouse. Transcripts are not accepted)
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Other Insurance Information
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Employee·s Name
:
State and County C
ootribution.s:- No per.
-;on may be enrol
kd in any EUfF be
nefit plan as both
a retiree/active, em
pJoJ
children be enmJ1ed
cm more than one
~ 'ir.,,e/ar;.five em()l
ovee pl aft {dual en
dment}. /.n addific
m. if vou and~ .:sp
ow;e,i
em~es. the em
s,loyer's oontmufio
n cannot ex~ a
falf'i~ rHan oontJi
bution in accordaw;;
e v.ittl Chapter 87 A
.J3-36
DEPENDENT INFO
RMATION
Complete depende
,nt (including spou
se and children) i
nfo,mation and ind
ica:e p\an selectio
n if add'ing/rl
Continue Add Delete
Last Nan-le. First,
Mdile Initial
Birth date SSN
Rela1i~ Ger
□ □
□ □
□ □
□ □
□ □
If depende-nts are a
ge 19 to 23and cov
ered under yam den
tal and/orvis.Dn ptm
s. ple-ase slt!mit c
ertification
clearinghouse Ddi
caring they a.re a ,.
..m,e student. De-ta
iled eligibiity in"orm
ation is a._.ailable o
OTHER INSURAN
CE INFORMATION
tf you 0< any of you
r depelldenls .are
c:ov~d under an
other noo-EUTF Il
e.a/th plan(.s)
Type of Plan: {e..g .
m e
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Employee Signature
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OTHER !INSURANCE INFORMATION
If yoo or any of your dependents are co11:ered under anotfler oor,-EUTF health plan(s) provide data below.
Type of Plan: (eg. Medi.call, Denta'l}i Name of Plan: ,(eg. HMSA, Q1111est), S1111bsoriber's Name(s:):
EMPLOYEE S~GNATU RE I am elig ible for the coverage requested and declare thatu1e i 111dilliduals listed on lhis emu lment form are· a!so eligible. I 1.mdersland ~hat the benefit elections made on lllis appl icalio:n are· in etted. as long as I corilinue to meet E:UTPs eligibility requirements, or unlil I es1eot to dha111ge ~hem subjecl. to Ille· provisions of EUTF's pla111 rules .. I understand lflat if I waive coverage for myself m my de·pe1111dents that ltthey cannot em o'.11 for benefits iin EUTF"s Plari unless eligible at Ihle next Ope111 Einrdl me111t 1Pe1fod m earlier, if llle:re is a mid--year Special Enrollment event s,uct, as loss of other coverage, marriage, b iirlh or adoption. I ha.ve read Ihle· be111elit materials, understand Ille limitatio·ns and qualificalions of U1e IEUTF benefrls pmgram and ag ree fo abide by the te:rms a·nd ocmditions of Ille beriefit 1pla.ns elected. I allJllioriz_e my employer or finance officer to make fhe pre£tax or after•lax deductions, adjustmenl:s or ca111cel afilons from my salary, wages, or ,olfl.er compensation fm the monthly employee oonlribution iri accordance willl ~pplica'bl'e laws, ru l'es and requlations.
A pe;rsori 1A111.o krio ·ng1y malres a fa'lse stalemenl. iri conneciiori wJlfl an applicatiori for ariy beneli ma,y be subject to 1imprison:merit arid firies. Addili:o:nally, mowingly ma'ki ng a false sta1eme:nt may subject a peT:sori to lerminalion of e:nrol merit, denial offu . re erimllment, m oiVlil damages. I agree to immediately notify fhe Fund in M i irig ,of any changes ~hat would result iri the loss or change of es1ig'ibility ot my ,or any of my dependent- lberiefloiary's benefits. I understand lllat Ille F11md reserves !he right to lerminale lberielils .and to see:k recovery ,of any ,overpayment of benefits resulting from my fail'ure to 1Provide wri en mo.tire wjlfliri forty five (45) days of the eve111t lllat caused the chang,e m ineligibility. EUTF 1retains lhe· righl to terminate coverage i 111 Ille event of non-paymtmt, if pa,ymen is applicable. This fmm sup ersedes all fom1s and submissioris previously made for EUTF coverage. I hereb-y declare !hat the above slaterne111ts are !rue to~ best of my knowledge and belief, and I understand that II am subject to penallies for ipe~my.
Employee Signature Date John Kealoha 07/01/2020
Employees must submit the enrollment form and required proof documents to departmental human resource or personnel office within 45 days, except birth which was 180 days. All documents must be received in order to process members enrollment.
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HAWAII EMPLOYER-UNION HEAL TH BENEFITS TRUST FUND
Due, XX XX, )()00(
SAMH ALOHA l!Br 9999999 ll3. WW.O STREET 11O:-:OL\.1.\i, Ill 96$0)
~...,-1),p,,r.ma
-
Making Changes
48
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Employer-Union Health Benefits Trust Fund
State of Hawaii
Who We Are Health Plan Options Premiums and Contribution Health Plan Selection Making Changes Enrollment
Common Qualifying Life Events
• Marriage • Divorce • Death • Loss of Coverage • Acquisition of Coverage • Adding or Removing Dependents
• Birth • Adoption or placement for adoption • Legal guardianship, foster child* • Newly eligible/ineligible student
*Legal guardianship and foster children are covered until the age of majority, 18.
49
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Employer-Union Health Benefits Trust Fund
State of Hawaii
Who We Are Health Plan Options Premiums and Contribution Health Plan Selection Making Changes Enrollment
Making Changes to Your Enrollment
Complete EC-1 Enrollment form
• Forms are available online at eutf.hawaii.gov
Submit EC-1 form within 45 days of Qualifying Life Event
• Birth - 180 days
Submit Proof Documents within 45 days
• All required proof documents must be submitted in order to process enrollment change requests
• Contact EUTF if proof documents will take longer than 45 days
50
https://eutf.hawaii.gov
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Employer-Union Health Benefits Trust Fund
State of Hawaii
Who We Are Health Plan Options Premiums and Contribution Health Plan Selection Making Changes Enrollment
Open Enrollment
Changes that can be made during Open Enrollment:
• Add, remove, or change plans
• Add or remove dependents
New coverage and rates are effective July 1
Plan year is from July 1 to June 30
51
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:
- ,Em~-.....,n Hoaltl
I UTF ACTIV PLOYE C-1 HEAL TH B N iflTS ENROlLMENIT FORM
~-,,.· - a.!1• Chlilil.-V l-1
-Hirw or 0llillt,1n,g l!van1DMa. ______ a.,Mrylllp_.,.,..,
~JI ...... I oil
SARAH ALOHA 123.WW.OsruEi HO. 'OL\.'L ', HJ S
HAWAII EMPLOYER,U 10 HEALTH BENEFIT TRU FUND
Due: xx xx, xxxx
This Confinnation Notice details the enrollment changes that were made lo yo, carefully review its contents to make sure it does not contain any en-ors . You~ opportwuty to correct en-ors that you made in sel,,ctin; your cover~• (e .; . pl dependents) on your enrollment fonn by notifyin; EUTFwithin 15 ca.l,,nd.a.r da this notice . Any ._pproved changes will be made retroactively to the effective d .., noted below. You will be responsibl,, for any a.dditiona.1 preminns .
PJ,,a.se submit your corrections in writin; by compl,,tin; the .. t ta.ched Correctiv. Fonn. Keep._ copy of the Corrective Action Request Fonn for your records . Inot heu from you in writin;within 15 ca.l,,nd.a.r days from the date of this notic will remain in effect .., indicated. Any a.dditiona.1 changes lo your plans will not next Open Enrollment period, unless you experience ._ mid-yeu qua.l.ifyin; even changes under the EUTF Administrative Rllles .
52
Who We Are Premiums and ContributionHealth Plan Options Health Plan Selection Making ChangesEnrollment Form
State of Hawaii Employer-Union Health Benefits Trust Fund
Who We Are Premiums and Contribution Health Plan Options Health Plan Selection Making Changes Enrollment Form
New Hire Recap
EC-1 Enrollment Form
• Complete all sections of the EC-1
• Attach any proof documents
• Submit forms within 45 days of your hire date to:
• Human Resource Officer • Personnel Office
• Review your Confirmation Notice carefully
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Mahalo
53
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