The Hawaii HC 5 form is an important document used by employees to notify their employers about their health care coverage status. This form is necessary for individuals who work for multiple employers, are claiming exemptions, or are making changes to their health care coverage. If you need to fill out this form, click the button below to get started.
The Hawaii HC-5 form plays a crucial role in ensuring that employees are aware of their health care coverage options and obligations under the Hawaii Prepaid Health Care Act. Designed for use by individuals who work for two or more employers, this form facilitates communication between employees and employers regarding health care responsibilities. It serves various purposes: notifying an employer of the employee's designation as either a principal or secondary employer, claiming an exemption from health care coverage, or waiving coverage due to alternative health insurance plans. Each section of the form requires specific information, such as the employer's name, address, and account number, as well as details about the employee’s health care status. Employees must retain a copy of the completed form for their records and provide it to their employer, who is responsible for maintaining the document for two years. The form also emphasizes the importance of timely updates, as it must be renewed annually by December 31. Understanding the nuances of this form is essential for both employees and employers to comply with state health care laws and ensure that health care needs are adequately addressed.
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.
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