[PPT] - New Hire Enrollment Presentation Hawaii Employer-Union Health PowerPoint Presentation

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New Hire Enrollment Presentation

Hawaii Employer-Union Health Benefits Trust Fund

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Who We Are Premiums and Contribution Health Plan Options Health Plan Selection Making Changes 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

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 2

SLIDE 3

Who We Are

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SLIDE 4

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. 4

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State of Hawaii

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Hawaii Employer-Union Health Benefits Trust Fund

EUTF Active Employee Open Enrollment

II Election Period: April 1 - 30, 2020

C, All Informational Sessions will be conducted via webinar

2020 OPEN ENROLLMENT FOR ACTIVE EMPLOYEES

Health Plan Options

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SLIDE 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 Premium and employer contribution amounts Hawaii E mployer-Union Health Benefits Trust Fund (EUTF)

Rev. 1115/2020

Open Enrollment

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

EUTF Online Resources Website: eutf.hawaii.gov

Active Employee Tab
EUTF Active Reference Guide

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SLIDE 8

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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SLIDE 9

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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15

SLIDE 12 EFFECTIVE JULY 1, 2019 HAWAII EMPLOYER-UNION HEALTH BENEFITS TRUST FUND ACTIVE EMPLOYEES BU"s 00, 01 , 02, 03, 04, 05, 06. 07, 08, 09, 10, 11, 12, 13, 14 BU's 00, 01 , 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14: ALL EMPLOYERS BU 05: FOR HAWAII PUBLIC CHARTER SCHOOLS, STATE OF HAWAII HSTA VEBA EMPLOYEES WHO OPTED TO TRA~SFER TO EUTF PLANS OR BU 05 EMPLOYE.ES HIRED ON OR AFTER JA~UARY 1, 2011 Soml-Monlhly Monthly Monthly Typo of Employ•• Employao Employar Percent Banaflt Plan Enrollment Contribution Contribution Contribution EmoloV<>r Total MEDICAL PLANS PPO - 90/10 Plan - HMSA Medical and Chiropractic, Se~ 1 3.42 386.84 . 0 49.6% $767. Two-Partv 470.11 940.22 923.72 49.6% S1 ,863.94 CVS Caremark Prescription Drug Familv 599.60 1.199.20 1.177.36 49.5% S2.376.56 PPO - 80/20 Plan - HMSA Medical and Chiropractic, Se~ 126.50 253.00 380.50 60.1% $633.50 Two-Partv 307.49 614.98 923.72 60.0% S1 .538.70 CVS Caremark Prescrlplloo Orug Famllv 392.16 784.32 1.177.36 60.0% S1 .961.68 PPO - 75125 Plan - HMSA Medical and Chiropractic, Se~

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62.54 335.82 84.3% $398. T Partv 75.94 151.88 815.44 .3% $967.32 CVS Caremark Prescrlplloo Orug Famllv .80

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.3% $404.14 Pam, .10 1 .20 82 .88 .3% <982.08 Prescription Drug and Chiropractic Familv 98.35 196.70 1,056.16 84.3% S1 ,252.86 Self 6.57 13.14 19.70 60.0% $32.84 Supplemental MEdlcal and Prescriplloo Drug - H MA T Partv 13.73 2 .46 41.16 68.62 Familv 15.08 30.16 45.22 .0% 5.38 ET Se~ 6.93 13.86 20.78 60.0% $34.64 HDS Dental Two-Partv 13.86 27.72 41.56 60.0% $69.28 Familv 22.79 45.58 68.38 60.0% $113.96 IS INP

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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

Premiums and Contribution

Listed by employer and

bargaining unit

Benefit plan option
Type of enrollment
Monthly employee contribution

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SLIDE 13

Health Plan Selection

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SLIDE 14

Health Plan Selection

Employer-Union Health Benefits Trust Fund

State of Hawaii

Things to Consider

PREMIUMS

The monthly amount paid for your health insurance shared between the employer and employee. Deductibles do not apply to all plans or all services. They cannot be paid in advance and are renewed

DEDUCTIBLE

annually. Deductibles must be paid each calendar year on a claim-by-claim basis before benefits subject

to the deductible become available.

CALENDAR YEAR

Calendar Year - January 1st to December 31st Includes medical and prescription drug benefits.

PLAN YEAR

Plan Year – July 1st to June 30th Includes dental and vision benefits.

IN-NETWORK

In-network - Physicians, hospitals, pharmacies, and other providers contracted with your health insurance.

OUT-OF-NETWORK

Out-of-network - Providers are not contracted with your health insurance carrier.

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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Who We Are Health Plan Options Premiums and Contribution Making Changes Enrollment n Health Plan Selectio

SLIDE 15

Health Plan Selection

Employer-Union Health Benefits Trust Fund

State of Hawaii

Who We Are Health Plan Options Enrollment Health Plan Selection Premiums 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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SLIDE 16

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 $4,642 $3,036

Coinsurance 10% $40 Coinsurance 20% $80

$750

Coinsurance 25% $100 Coinsurance less than $2,500 MOOP

$0 $0

Coinsurance less than $2,000 MOOP

$0

$0 $4,642 $3,036 $0 $750 $300

Coinsurance less than $5,000 MOOP

$850 $300

Total Estimated Annual Cost:

$4,682 $3,116

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. 23

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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 $ 4,642 $3,036

Coinsurance 10% $1,910

$750

Coinsurance 20% $2,500 Coinsurance 25% $4,700

Coinsurance 20%

$3,820

$0 $0 $4,642 $3,036

Coinsurance 25%

$6,856

$18,800 X 25% $4,700

$0 $750 $0 $0

Coinsurance + deductible reaches $5,000 MOOP

$300

Coinsurance exceeds $2,500 MOOP

$5,536 $5,750

The HMSA 80/20 PPO Plan for Self-only offers Rick the most savings in this scenario

Coinsurance less than $2,000 MOOP

Total Estimated Annual Cost:

$6,552

*Annual employee premium contribution amounts are estimates. Please note that amounts vary each plan year. 24

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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* $2,921 $761

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:

$2,921 $3,261

*Annual employee premium contribution amounts are estimates. Please note that amounts vary each plan year. 25

Total estimated annual savings under the Kaiser Comprehensive plan: $340

SLIDE 19

Enrollment

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SLIDE 20

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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SLIDE 21

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
Children are covered until age 26 for medical and prescription drug plans
For dental and vision coverage, children are covered until age 19, or until age 24 if

unmarried and a full-time student

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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SLIDE 22

29

Health Plan Selection Making Changes Enrollment Form

Hawaii Employer-Union Health Benefits Trust Fund

EUTF ACTIVE EMPLOYEE

: h.bmit1lri1fmm1:i)'l'lur ci••ran•• affi•:. DOE :mc,lD:)1::1 ~ :mil ta: DOE-Ell1J

EC-1 HEAL TH BENEFITS ENROLLMENT FORM

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Complele ea:;!, ,ewoo lhorou,hly, p/ea,e p,inl c/ea,ly Enrollment Type {Yo11ml.l!ir checkonebax): NewH~re Qualifyi~g Event Open Enrollment □ New Hire Of" Qualifying Event Date: ______ Qualifying Eve,nt De.scription: __________ , S-Ocial Sewri!y No. ~::9a1 ~ La

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Do nor skip cfJis secrion. Read !he ~C-1 EnrQIJmenr R>m1 ln.sUUC'Dorn;" and com~ere lnis secrion before rnovi"ng on. Mark one oprioo Option #'1 0 Cove~ starts da:t of the eveni. Premil.l1'1 contributions gan 1" day of the pay perioo il wt-=:h the effactilte date of OJWr~e OOCU'S. (If 00 option is .seJec.~ optAln #:1 wil1' be u.sed) Option #2 0 Coverage and premimi contri005ons mrt 1"' d~ of the firsi pay period Dlm,;ng event date. (1"' or the 16"' of lhe monlh) Option #3 0 Coveras1e and premUT'I comribuf1011s · 5t3rt 1"' di:iV of the second pay peood k;lo,,'t'in~ eveM date. fl " or the 1~

f the m:inth)

U• · i}l13 ■ #1H•l: ■ 3ai#N1NfiRPl:lt•lUet:lftBJ 1 tiJ 1 Medical Chiro and Prescriotion Dru a Select one: HM SA PP0-90J10 Medical. Chiro and CVS Prescription Drug □ Caooel'Waive □ Self □ Two-Parr-1 □ Family S381l.84 $1!40.22 $1.1SQ.20 HM SA PP0-80/20 Medical. Chiro and CVS Prescription Drug □ CaooeWhive □ Self □ Two-Part-/ □ Family ""'3.00 M14.98 '7S4.32 HM SA PP0-7SJ25, Medical. Ctjro.and CVS Prescription Drug □ Caooel 11 Naive □ Self □ Two-Part)' □ Family !lil2.M $151.88 $193.60 HM SA I-NO Medical, Chiro and CVS Prescription Drug □ CancelllJVaiive □ Self □ Two-Parr, □ Family W12.84 $1,197.78 $1,527.80 Kaiser I-NO Comprehensive Medical. Chiro and Prescription Drug □ CancelllJVaiive □ Self □ Two-Parr, □ Family S243.46 S,92.52 $756.94 Kaiser IND Standard Medical. Ct.iro and Pr~cription Drug □ CaooeWhive □ Self □ Two-Part-/ □ Family !lil3.46 $154.20 $196.70 HMA S~plemental Medical and Prescription Drug □ CallCel'IJVaiive □ Self □ Two-Parr-1 □ Family (M11st l!~'le a:11er!l;ie izaer • !I nan·EUTF l"~!ltm pl!ln tc, ~ !!lllft4e to, a11~nt111

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"27.46 S30.16 Dental Sele<:! one: Hawaii Dental Service □ CaBCelflJVainle □ Self □ Two-Part)' □ Family $13.M '/iZl.72 S46.ti8 Vision Select one: Vision Service Plan □ Cance1'11Vaiive □ ~, □ Two-Part)' □ Family $4,36 $5.70 Life Select one: Securian □ CancelllJVainle □ Self Premium Conversion Plan for Srate Err.,1= onlv □ CancelllJVainle □ Enroll

Enrollment Form

State of Hawaii

Employer-Union Health Benefits Trust Fund

Who We Are Health Plan Options Premiums and Contribution

EUTF Enrollment

EC-1 Enrollment Form

Available at: eutf.hawaii.gov
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

SLIDE 23

Employee Data

30

SLIDE 24

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EUTF'

ACTIVE EMPLO'YEE EC-1 HEAL TH B! ENEI FITS ENR. OLLMENT FORM

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□ N :ew ffrie Of" Qua.1ifying Event Date: ______

Qualilyi111, g Event [)escripti:on:

: _________ _ Social Secu ~

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. X X X

SLIDE 25

Hawaii Employer-Union Health !Benefits lrust I

Fu11d

. ACTIVE EI MPLOYEE

EC-1 HEALTH BENEFITS E.

NROLLI MENT FOI RM

Ail Bar ainin Units Exce t BU12

Submit 'this rm lo your personnell oflree_ DOE , employees. submit to:: IDO:E-EBU PO Box:2360 alw llLI Hll, 96804

I Enrol ment Type· r {dteck one): rOpen Enrollment New tUre or

1Qual'lfyi111g Event Date-

: QuaHifying Event. Description:

EMPLOYEE DATA

Full Nam _ Sod s~ur1 ity o.

r EUli ID No,

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Resid'.en.c- e I M\,fling

Address: -----------------

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Marilial Status: S ng e Married ZfpCode Dormtstic Pal1ner

M dr, es s:

Gender.

IMama-g;e Dame: ______

_ ! Home Cell Poon@•

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Poon@•

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S:pouse.lPartmn Name:

SSN'. City Slate 'Zip Code B rlihdate:

Male

Femala Email:

fJ"rlihdat.e:

Enrol

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ent P t Proced cedures s

x

01 - 01 - 2020

Kealoha John K

555-55-5555

555 Kealoha Street Honolulu HI 96800

06 19 1960

x

02 14 1980

(808) 555-5555

(808) 123-4567 Johnkkealoha808@email.com

Jane Kealoha 555-12-3456 2/01/1965

SLIDE 26

Coverage and Start date

33

SLIDE 27

COVERAGE. START DATE

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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

SLIDE 28

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16 17 18 19

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Option 1*

Coverage begins on the date
f hire or event date.
Contribution start date will be

the first day of the pay period in which the event occurs.

*If no selection is made option 1 will be used

Pay Period April May

Hire date Coverage Start Date Contribution Start Date

SLIDE 29

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Pay Period April May

Option 2

Coverage and contributions begin
n the first day of the first pay

period following the event.

Hire date Coverage Start Date Contribution Start Date

SLIDE 30

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14 15 16 17 18 19 20

21 22 23 24 25 2.

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Pay Period May April

Option 3

Coverage and contributions begin
n the first day of the second pay

period following the event.

Hire date Coverage Start Date Contribution Start Date

SLIDE 31

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.

38

SLIDE 32

Plan selection

39

SLIDE 33

PLAN SELECTION EFFECTIVE 7/1/19 THROUGH 6/30/20

Medical, Chiro and Prescription Drug Select one:

HMSA PPO-90/10 Medical, Chiro and CVS Prescription Drug

□

Cancel/Waive

□

Self

D Two-Party

□

Family $386.84 $940.22 $1.199.20 HMSA PPO-80/20 Medical, Chiro and CVS Prescription Drug

□

Cancel/Waive

□

Self

D Two-Party

□

Family $253.00 $614.98 $784.32 HMSA PPO-75/25 Medical, Chiro and CVS Prescription Drug

□

Cancel/Waive

□

Self

D Two-Party

□

Family $62.54 $151.88 $193.60 HMSA HMO Medical, Chiro and CVS Prescription Drug

□

Cancel/Waive

□

Self

D Two-Party

□

Family $492.84 $1 ,197.78 $1,527.80 Kaiser HMO Comprehensive Medical, Chiro and Prescription Drug

□

Cancel/Waive

□

Self

D Two-Party

□

Family $243.46 $592.52 $756.94 Kaiser HMO Standard Medical, Chiro and Prescription Drug

□

Cancel/Waive

□

Self

D Two-Party

□

Family $63.46 $154.20 $196.70 HMA Supplemental Medical and Prescription Drug

□

Cancel/Waive

□

Self

D Two-Party

□

Family (Must have coverage under a non-EUTF health plan to be eligible for Supplemental) $13.14 $27.46 $30.16

Dental Select one:

Hawaii Dental Service

D Cancel/Waive p

Self

p

Two-Party

□

Family $13.86 $27.72 $45.58

Vision Select one:

Vision Service Plan

D Cancel/Waive

□

Self

□

Two-Party

□

Family $2.36 $4.36 $5.70

Life Select one:

Securian

□

Cancel/Waive

□

Self

Premium Conversion Plan for State Employees only

□

Cancel/Waive

□

Enroll

Enrollment Form

State of Hawaii

Employer-Union Health Benefits Trust Fund

Who We Are Health Plan Options Premiums and Contribution Health Plan Selection Enrollment Form Making Changes

X X X X X 40 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.

SLIDE 34

Dependent Information

41

SLIDE 35

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

.

r 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' Hawaii 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[lrr \!isicn [P~ - ', p1ease :::

1 iti oertific9fion from the schooE rieg~

strnr ori nsilionel clearinghouse i · · they arie a I ime sfudent De(,· "lee eligibi ity in atio 1 is availab

OOI" e at eutf.h<aM'raii·

.g;o...-

X X X X

Kealoha, Jane, K 2/1/1965 555-12-3456

Spouse F

Complete all dependent (including spouse and children) information and indicate plan selection if adding/removing dependents

Proof Documents

Marriage/Civil Union/ Domestic Partnership Documents
Birth Certificate required if adding dependent children
Student Certification

SLIDE 36

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)

*New, effective July 1, 2019

43

SLIDE 37

Other Insurance Information

44

SLIDE 38 , Employee·s Name: State and County Cootribution.s:- No per.-;on may be enrolkd in any EUfF benefit plan as both a retiree/active, empJoJ children be enmJ1ed c m more than one ~ 'ir.,,e/ar;.five em()lovee pl aft {dual endment}. / . n addificm. i f vou a n d ~ .:spow;e,i MJ~es. the ems,loyer's oontmufion cannot ex~ a falf'i~ rHan oontJibution in accordaw;;e v.ittl C h apter 87 A . J 3

3

6 DEPENDENT I N F O R M A T I O N C

m

ple te depe n d e ,nt (includ i ng spouse and chil d ren) i n f

,

m a t ion and indi c a:e p\an selection if add'ing/rl C

n

t i n ue Add Delete Last Nan-le. First, M d i l e Initial Birth date S S N R e l a 1 i~ Ger □ □ □ □ □ □ □ □ □ □ If depende-nts are age 19 to 23 and covered under yam dental and/orvis.Dn pt ms. ple- a s e slt!mit certification clearinghouse D d icaring they a.re a ,... m ,e st

udent. De-tailed

e ligi b i i t y in"ormation is a._.ailable o OTHER I N S U R A N C E I N F O R M A T I O N tf y

u

0< any of your depelldenls .are c:ov~ d u n der a n

t

h e r n

-E

UTF Ile.a/th plan(.s) Type of Plan: {e..g . m e<lical, dental) Name of the Plan: (e.g. 1-fMSA, Q u e s t) Subscriber! EMPLOYEE S I G N A T U R E I am e. l i gible f O f " the coverage requested and decllre at the individuals listed on this endnent funn are e l e d i

n

s made on this application , :ue in effea as long a s I contnle to meet EUTF"s 1:- f i gibility requi'emer the provisioos Of EUTF",s plan RES. I undE-rStand thaE if I waive CO'i'erage for myself or my ~ pendents ti' Plan unle-ss eligble at the next Open Enrollment peri::id

r

earlier.· there is a mid-year Special Enrollrne,

marriage. bnh
r

ad

ption. I

have read the b e ne-fit

materials. m dim.1and the limitations and

q u .af.'ficatia to abide by the tams and conditions of the benefit plans elected. I authorize my employer or finance off deductions, adjustrne.nt:s or cance l l ations from my ,salaJY, wag.es, or other compensation "or the monthly appicable la. w

s. RES and regulations.

A pera)n who knowingly makes a fa e statE1Tient in connedion Wth an applicatioo fer any benefit mai A dcitionaly, knowin~ m a ) ;ing a false sta~enc may subject a person to tel'Tllmation Cl€ e,vdfflEfli d a g : l f f ' to mffl e diately notify the f und in writing of any changes that would reSdl in the loss er change benefici a r y " s bene

. I unde,stand that the f und reserves the

r i g ht c

terminate benefits and to see-.

'k resUtl'ig from my failure to pro - e written notice within forty-five (-45) dar-, of the event that caused I to terminate 00\lerage in the event of non-pa)'l'Tlm · payment is appicable. This ·orm sup~ edes a EUTf CO"Jerage.. I hereby declare that !he above statemmts are true to the best of my knowledge a penalties for perjury. Employee s;gnature Official Use Onl --- D epartment I 0# Department Division'Scooo Date Received in Office D P O Phone N u m b e r I I

A

~ r,ee) Printed Name Date ct DPO I

Other Insurance Information Other Insurance Information

If you or your dependents are covered under another health plan, you are required to complete this section. The information that you provide does not determine how your benefits are coordinated. Coordination of Benefits rules are determined by the health benefit plans and follow the guidelines of the National Association of Insurance Commissioners (www.naic.org).

SLIDE 39

Employee Signature

46

SLIDE 40

052 0285 Charter School Aloha School 03 04 15 2018 586-9999 586-8888

Debbie Kalama Debbie Kalama

OTHER INSURANCE INFORMATION

I you or

.any of your d'.ep;ena@rrrls :ne cover,

ed ru MBr

.anothil'r on-EL.llTF lil@allh p J1i S, , pro dl!!l data ib€11ow.

T iPl3> ,

ct l"lan: (e.,g~

mooicaJL dent.al)

iN.ame of he Plan: (e.g._HMSA, Qu881)

Subso

Jibers

me(.sj:

EMPlOYEE Sl,

GNATURE

I am e'ligib:le b lire 00\lerage requested declare imiii:llllals

ecll

·s. enroll

i . I umlerst3nd ililai the benefit e'ledicm

em

llir.l

,app

·- nae

in effied ,a!I 1

mg as. I

oliilinue 1D mee'i EIJTf's eli

" lriy requiremen!Ei. a ntil I

·,

1D cilange 1hEm 51..1 • ,

.1he J:ml,liEi

□ m

f EIJTf's. plilfl rulE'!I. I have read 1he

hen . mate -

nderuand the f -

s. arJ!ll qua

·-

s. of lire El.Jiff benefits. Pfl'-lraITT am al!Jee . :abide by .

terms, and o

i ti □ l i t!I

f

plalil!I ,

e6eded. I

ai ltn:rize my

,

J:EYE!r a

m

ile offiCEr

1D makE the J:fl!"IB.x: □ r afte r 1:.3!1 d'educiioos.. arljll!i · nls. □ r caooellalicm an my salaiy, wa!!ll!'!l, □ r

Jrer CDmp£flS,al:iJn far the

'I ffll)ID)•ee oonbi ·- n in ,

aoooo:lance, · ti app

le ws.,

s. and reg

· ras.

A

perscn 'lftl lm

□ wifl

makel, ai

Sla'iEmenl noon · · an a, i:pir.atioo a

I may be slmjecl i o. iqlriSC11ment and · lill!SL Ad

i li □ naly ,

rfl!Min!#t a

ratse, slate

· may 51..11:Qed a person 1D terminalioo of, enm

ial ol

Jie ermlm

,, □

r civ:il

dama!lle!i. I

ayree i o. mneclia'i Fuool in milin!ll of

anychangE'!i tha'i

wo.uld r, esulb n

lire lass: or cfl.alifg:e of eli!lliJi . of mya' :, ol'

my d'epemlent-beneooicllJ's bane s.. I uoo'erataoo Iha! lire IRt!nd feSE!ll'eS Ire lighrl 1D termiraate bene aool I 0. seek

remvel)! of anv □ verpayme

nl

f heme

r, esull:ii!ll frcm my ure i o. j:ml,fide

e m1 □ tiCE

mlhin th" · I~ ) days oil/re event lhat caused the

, change a ale' i I'/-EUTF retains

lire ri;Jhrl ,

emlina'le- 00\'EfB!JI!' in ·

8118m'I of no.n-pa)m

,, if psym

is. a,

Jlllii;a . This ~rsedes. all fi::Jrms. and stmlie.s.iJrng pre\'i:Jllls'ly made b EUTf aga I

lterB>'J' d'ecia-re i

ha! lire above s.tatementi are ,

11113

ilhe

sli ol my

edge am

and I Ulld

tha'i I an s.u • , i o. pen lies far perjisy.

Dale

I

John Kealoha

01/01/2020

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.

SLIDE 41 HAWAII EMPLOYER-U ION HEALTH BENEFITS TRUST FUND ,01cs21: SARAH ALOHA 123 • IAHAl.0 STR£FT HOXOLl.1.li, HI 96$05

GeaOS-21!

°""

ia&-rno

lF-.. toa)ffl,0018
...i

p 01te.t XX XX, xxxx !!Br 9999999

..la-r~Bod&•mdF""""•

11.,.....u

.... u This Confirmat ion No tice details the enrollment changes that were made to your account. Please carefully review its contents to ma.ke sure it does not contain any erron . You have a one-time

pportunity to correct errors tha.t you made in selecting yourcoverage.s (e .g. plan, tier level and

dependents) on youreruollrnent form by notifyi,,g EUTFwithin 15 caJ.ndar day, fzom the date of this notice . Any approved changes will be made retroactively to the effective da.te of the clw,,ges as noted below. You will be responsible for any additional premiums. Please submit your corrections in writing: by completing: the attached Corrective Action Requ.est

Form. Keep a copy of

the Corrective Action Request Form for your records . If the EUTF does not hear fzom you in writi,,gwithin 15 caJ.ndarday, fzom the date of this notice, the clw\ge(s) will remain in effect as indicated. Any additional clwlge, to your plans will not be allowed until the next Open Enrollment period, wtless you experience a. mid-year qualifying event that pennits clw\ges under the EUTF Administrative Rules. \'ovllfuli1Plu£aroll11uau· uo!OI 31 ~IS l'!mT)-p< 8-&Plm C:O.w,i•T)-p< =· P,yP.nod lb:, - :PCP EsoD

::.a

OlllWll soo

~I!

PPO- (W 10),., Oato

S.lf 01 Jl~Oll SIOl ll Ocul Ocul S.!! 01 ll'lOll 5,6j) \'...,. \"woa S.lf OlllWll Sl.21 Pr-Dr,,s PPOPr.,.._Dr,. S.l! OlllWll Sl' 6S l.l!t

Lt!t~

S.lf 01 Jl-:015 soo .,u,~: AHKf aaa n.u.>.A r.u1v ta<· IDGH rtun bOD 4: "" to'l'tn t. \'oar Total Pa, Ptriod Otdacdoa: SllUO

n.

EliTF :,;~

rPm-..;Rol dt,cn

bow)'Cllf ~ im«IIIIDOCI 111,1)' be~ &Dd duclol<d &Dd boo.\· )'OU ca:, gt: l<C<ss 10 tbt c!..-...al>Ol> h " ll'tlbb~

c!Clt a! <Whl\\'llJ.go\'. P1<U< m

><1< ,t cat•!ull)·

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

Confirmation Notice

Once your enrollment is processed, a confirmation notice will be mailed to the address indicated on the EC-1 form. Use the corrective action form provided with the confirmation notice to notify the EUTF of any errors. Please keep this notice for your records if everything is accurate.

48

SLIDE 42

Making Changes

49

SLIDE 43

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.

50

SLIDE 44

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

51

SLIDE 45

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

52

SLIDE 46 , S· .i.l:,n:,il tl,i• f='-" :raur ~;•• ;a,i;l. gSi"'· Hawaii Employer-Union Health Benefits Trust Fund 0 0,:E :n:1~!..,-.::1 n:'::n:ii, m: DOE-El!":J

EUTF ACTIVE EMPLOYEE EC-1 HEAL TH BENEFITS ENROLLMENT FORM

m,illilllil,i!l1lliiG.t!!l!i

Comple.'e e;cli ,ecoon !/>oroughl /, please pmf d early Enrollment Type (Yo11 m11or check one bax): New H ~re Qual ifyiil.g Event Open Enrollment □ New Hire or Qualifying Eve:nt Date: ______ Qualifying Eve-nt De.scription: __________ , Social Security No. Ft.I Legal _____________________

r EUTF ID f'loc

N31rF- l.a.st F~f M.I.. Q!y S.'-'e M31rita/ Sta11E:

Since :i M3rried
M..rrial)e Date: ___l_____l

Home Cell Phone: ' \ Phare: Spo1..EelPartner ~ N"Jre.: fr~ WIN o.: a!l\:1\'Jg fCIH spoo:se- or pa!UleJ Do nor okip mro oecrion. Read me --EC-1 ~ Option 'ltl ::J Cove~ starts da:, of ~ he event OOCU'S. (lfnoopfion i:s.seJec.fed; ~ Option #2 □ Cove~ and premium ron1ri005r: Optioo #3 ::J Covera;ie and premiLrn romriOOflc Medical Chiro and Presc.ripti HM SA PP0-90M0 Medical, CfMro and CVS P HM SA PPO-Stl,120 Medical. CfMro and CVS P HMSA PP0-75,125 Medical. CfMro and CVS P HM SA tNO Medical, Chiro and CVS Prescri Kaiser I-MO Co~rehensive Mecftcal. Chiro Kaiser I-MO Standard Medical. CfMro and Pr HMA s_.,plemental Medical and Prescriptio (MU5l h.:ve CC'i'Ull;je ~ er ,ll n11n·EUTF l'" .;ellltn llllln Dental Select one: 1-la.waii Dental Seniice

Vision Select one:

Vision Service Plan Life Select one: Securian SARAH ALOHA 123 • WW.O STREIT

HO.'Oll.1. •. HI S

HAWAII EMPLOYER,U 1 HEALTH BENEFIT TRU FUND Due: xx xx. xxxx HBr 99m99

¼-r~

Bade•""' F

B-l!

13 This Confirmation Notice details the enrollment changes that were made lo yo, carefully review its contents lo make sure it does not contain a.ny errors. You~

pportunity to correct errors that you made in sel,,ctin; yow: cover~• (e.i;. pl

dependents) on yow: enrollment fonn by notifyu,g: EUTFwithin 15 calendar da this notice. Any approved changes will be made relroactiwly lo the effectiw d as noted below. You will be responsibl,, for a.ny additional premDlltlS. PJ,,ase submit yow: corrections in writing by compl,,tin; the attached CorrectiV<

Fonn. Keep a copy of

the Conectiw Action Request Fann for yow: records. I'. not hear from you in writin;wilhin 15 calendar days from the dale of this notic will remain in effect as indicated. Any additional changes to yow: plans will nol ru,xl Open Enrollment period, wtless you experience a mid-year qualifyu,g: even changes under the EUTF Administratiw Rules.

53

Who We Are Premiums and Contribution Health Plan Options Health Plan Selection Making Changes 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

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

SLIDE 47

Mahalo

54