New Hire Enrollment Presentation - Hawaii Employer-Union ......Presentation Hawaii Employer-Union...

46
New Hire Enrollment Presentation Hawaii Employer-Union Health Benefits Trust Fund 1

Transcript of New Hire Enrollment Presentation - Hawaii Employer-Union ......Presentation Hawaii Employer-Union...

  • New Hire Enrollment Presentation

    Hawaii Employer-Union Health Benefits Trust Fund

    1

  • 81 e1

    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

    3

  • 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

    7

  • 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)

    R

  • 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

  • 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

  • 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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  • 28

    Health Plan Selection Making Changes Enrollment Form

    .....

    -

    1-1 Emi:,lay,,

  • Employee Data

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  • 30

    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.

    XX X

  • 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]

  • 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

  • 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

    23 24 25 26 27

    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

  • 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

  • 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

  • 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.

    37

  • Plan selection

    38

  • 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

    39

    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.

    X

  • Dependent Information

    40

  • I

    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

  • 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)

    42

  • Other Insurance Information

    43

  • ,

    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

  • Employee Signature

    45

  • 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.

  • 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

  • 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

  • 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

  • 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

  • :

    - ,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

  • Mahalo

    53

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