Worker's Compensation | Temporary Disability Insurance | Prepaid Healthcare

I. Workers' Compensation FAQ's

EMPLOYER'S SECTION

WHO IS REQUIRED TO PROVIDE WC COVERAGE?  

Any employer, other than those excluded below, having one or more employees, full-time or part-time, permanent or temporary, is required to provide WC coverage for the employees.

Excluded employment includes voluntary or unpaid workers for a religious, charitable, educational or nonprofit organization; student workers performing services for a school, university or college club in return for room, board or tuition; duly ordained, commissioned or licensed minister, priest or rabbi; domestic workers earning less than $225 (cash) per calendar quarter; domestic workers of public welfare recipients; certain twenty-five percent stockholders; all fifty percent stockholders; and real estate salespersons and brokers paid solely on a commission basis. An employer may, however, elect to cover the excluded employees.

Federal laws cover workers employed by the federal government and workers engaged in fishing, maritime and longshoring activities.

Each employer shall post and maintain in places readily accessible to employees a printed statement concerning benefit rights, claims for benefits, and such other matters relating to the administration of the workers' compensation law. Each employer shall furnish within three working days of notice of injury to each injured employee a copy of the brochure, Hawaii Workers' Compensation Law (Highlights).

An employer may secure WC coverage by:

• Purchasing insurance from a carrier authorized to transact WC insurance in this State. Hawaii has no State Fund from which employers can purchase WC insurance.

• Becoming a self-insured employer who pays statutory benefits directly to its employees. The employer must be approved to self-insure by showing proof to the Director of Labor and Industrial Relations of its solvency and ability to pay benefits or by depositing securities. (Form WC-21 Application for WC Self-Insurance Authorization)

You may obtain a temporary DOL account number assigned by this Division known as a "Z"-number. If you need a Z-number, call the Insurance Section.

I AM AN EMPLOYER AND MY EMPLOYEE HAS ASKED ME TO FILL OUT FORM WC-14, "EMPLOYEE'S WAGE REPORT FOR FIFTY-TWO WEEKS PRIOR TO DATE OF INJURY." I PAY MY EMPLOYEES EVERY TWO WEEKS. HOW AM I TO REPORT THIS INFORMATION ON THE FORM?

It does not matter if your payroll frequency is bi-weekly or semi-monthly, complete the form according to your pay periods. It is important you indicate the beginning and ending dates of each pay period. Besides providing payroll information, please make sure you complete the entire Form WC-14.

EMPLOYEE'S SECTION

Most employees who suffer from any injury or illness, which results from work or working conditions, are covered. However, under the law, certain kinds of employees are not covered as described above in WHO IS REQUIRED TO PROVIDE WC COVERAGE?

Hawaii's federal workers must file their WC claim through the Office of Workers' Compensation Programs (OWCP), U. S. Department of Labor, District No.13, 71 Stevenson Street, Box 3769, San Francisco, CA 94119-3769. The phone number is (415) 744-6610.

If you are injured on the job, you should report the date, time and circumstances of your injury immediately to your employer or supervisor. Your employer should file Form WC-1, "Employer's Report of Industrial Injury/Illness" with its WC carrier and this Division within seven working days after the employer has knowledge of the injury causing absence from work for one day or more or requiring medical treatment beyond ordinary first aid.

If your employer fails to file Form WC-1, you should contact this Division or on the neighbor-island, the nearest Department of Labor and Industrial Relations District Office and file Form WC-5, "Employee's Claim for Workers' Compensation Benefits."

Each employer shall post and maintain in places readily accessible to employees a printed statement concerning benefit rights, claims for benefits, and such other matters relating to the administration of the workers' compensation law. Each employer shall furnish within three working days of notice of injury to each injured employee a copy of the brochure, Hawaii Workers' Compensation Law (Highlights).

You may obtain medical treatment from a physician of your choice. However, you may be under the care of only one attending physician. Your attending physician may refer you to other specialist(s) with the approval of your employer's insurance carrier.

You may change your attending physician once, but you must notify the insurance carrier before making the change. Any other changes in attending physician require approval from the insurance carrier before the change. You should tell your physician that this is an industrial injury. Ask the physician to send the medical reports and bills to your employer's insurance carrier. You should be able to obtain the name of your employer's insurance carrier from your employer.

Within seven days after the date of first attendance or services rendered, any physician, surgeon or hospital shall make an initial report, Form WC-2, "Physician's Report" to this Division and the insurance carrier and at appropriate intervals to verify your continued treatment.

If your claim is accepted, the WC carrier should pay for all required medical care, services, and supplies, as the nature of the injury reasonably requires.

If your physician does not have Form WC-2, "Physician's Report," you may give him a copy.

1. 1. Temporary Total Disability (TTD)
   
   If you are unable to work because of an industrial injury, after a three-day waiting period, you may receive temporary wage replacement benefits equal to 66 2/3% of your average weekly wage, but no more than the maximum weekly benefit amount annually set by this Division.
   
   The weekly compensation for TTD is set and fixed according to your wages or the maximum amount existing the year you were first injured. For example, the maximum weekly benefit amount for the year 2008 is $696.00. In other words, if you were injured anytime in 2008, your weekly TTD benefit payment will either be two thirds of your average weekly wages or $696.00, whichever is less.

2. 2. Permanent Partial Disability (PPD)
   
   After you reach the point of stability or maximum medical recovery, you may be sent to a physician to evaluate the extent of your permanent impairment. The evaluation will be used to determine the amount of your PPD award. The PPD is an indemnity benefit and is payable even if you have returned to work.

3. 3. Permanent Total Disability (PTD)
   
   If you are permanently unable to do any kind of work, you may be eligible for PTD benefits. Whether you are eligible for PTD benefits is determined at a hearing held by this Division.

4. 4. Disfigurement
   
   If an injury results in a permanent disfigurement, you may be entitled to additional compensation. Disfigurement includes scars, deformity, and discoloration. Laceration scars and surgical scars are reviewed six months from date of occurrence; however, burn scars are evaluated after one year. At the appropriate six-month or twelve-month timeframe, you may call this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you, to request your disfigurement be evaluated.

5. 5. Death Benefits
   
   Where an industrial injury results in death, the surviving spouse and dependent minor children (including full-time students up to 21 years of age) are entitled to weekly benefits as provided in the WC law. Funeral expenses up to 10 times the maximum weekly benefit rate and burial expenses up to 5 times the maximum weekly benefit rate are also allowed.




6. 6. Vocational Rehabilitation
   
   Should your injury prevent you from returning to your usual occupation, you may be eligible for vocational rehabilitation services. You, as the injured worker, may select your own certified provider of rehabilitation services. The carrier does have a right to challenge your right to vocational rehabilitation services. You may obtain a current list of certified providers from your WC carrier.

7. 7. Concurrent Employment Benefits
   
   If you have two or more jobs and cannot work because of an injury you sustained on one of those jobs, you may be eligible for additional benefits from the WC Special Compensation Fund. To determine your eligibility for this benefit, Form WC-14, "Employee's Wage Report for Fifty-Two Weeks Prior to Date of Injury," must be completed by each of your employers and submitted to this Division or on the neighbor-island, the Department of Labor & Industrial Relations District Office nearest you, with your written request for concurrent benefits.

If you have already reported your injury to your employer or supervisor, and your employer has not filed a claim, you may file Form WC-5, "Employee's Claim for Workers' Compensation Benefits" with this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you.

You may file Form WC-5, "Employee's Claim for Workers' Compensation Benefits" with this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you.

You may be eligible for Temporary Disability Insurance (TDI) benefits while your WC claim is being investigated. Ask your employer for the name of the TDI insurance carrier and file a TDI claim.

You may be eligible for concurrent benefits from the WC Special Compensation Fund. Have all your employers complete Form WC-14, "Employee's Wage Report for Fifty-Two Weeks Prior to Date of Injury," and submit the completed WC-14s with your written request for concurrent benefits to this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you.

Call the WC insurance carrier to request a re-opening. If your request is denied, you may file Form WC-5, "Employee's Claim for Workers' Compensation Benefits" with this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you.

No. The WC law does not require an employee to hire an attorney. Whether or not you decide to hire an attorney is a personal decision. If you have complaints about the attorney you hired, those complaints are addressed by the Office of Disciplinary Council at (808) 521-4591 and not the Department of Labor & Industrial Relations, Disability Compensation Division.

WHAT IF I HIRE AN ATTORNEY?

Your attorney should provide a Letter of Representation to you and this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you. Your attorney will represent you in all maters with the carrier/employer and this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you. Any attorney fees have to be approved by this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you . Attorney fees usually are a lien upon any workers' compensation benefits due you.

WC INSURANCE CARRIER'S SECTION

The insurance carrier must be authorized to write WC policy in Hawaii, and the Notice of Insurance must be signed by an authorized representative of the insurance carrier. The WC carrier then acts on behalf of and assumes the liability of the employer during the life of the policy.

Any carrier wishing to terminate a policy before the expiration date must serve a minimum ten-day notice of intent to cancel on the employer and this Division.

An employer is prohibited from having the employee pay for any portion of the WC premium.

II. Temporary Disability Insurance FAQ'S

EMPLOYER'S SECTION

Other than those excluded (refer to section 392-5 of the law for exclusions), all employers are required to provide TDI, or sick leave benefits, when their eligible employees are unable to work because of a nonwork-related illness or injury. The State does not pay TDI benefits; instead, it makes sure every employer covered by the law provides benefits to the eligible employees. As for the cost of providing TDI coverage, the employer may pay for the entire cost or share the cost with the employees eligible for coverage, in which case the employer may deduct one-half the premium cost but not more than 0.5% of the employees' weekly wages up to the maximum of $4.21 per week for 2008, which is set annually by this Division (refer to the Maximum Wage Base and Weekly Benefit Amount). Example: An employee's weekly wage is $300. The premium cost is 80 cents per $100 of covered wages. Since the employer cannot charge the employee more than one-half the premium cost, the employee's share is $1.20. To further determine whether this amount is within statutory limit, calculate 0.5% of the employee's weekly wage of $300, which equals $1.50. The $1.20 premium cost withheld from employee per week is within the statutory limit.

An employer may adopt one or more of the following methods of providing TDI benefits:

1. a. By purchasing insurance, called an "insured" plan, from an authorized insurance carrier. To purchase a TDI policy, refer to the List of Authorized TDI Insurance Carriers.

2. b. By adopting a sick leave policy, called a "self-insured" plan, which must be approved by this Division. A self-insured employer pays benefits directly to its disabled employees. As a self-insurer, the employer must show proof of financial solvency and ability to pay benefits by:


1. Furnishing this Division with the latest audited financial statements for review. Following the initial approval, the audited financial statements must be submitted annually for continued approval of the employer's self-insured plan, or

2. Depositing securities, or

3. Posting surety bonds in an amount determined pursuant to sections 12-11-69 and 12-11-70, Hawaii Administrative Rules.

3. c. By a collective bargaining agreement that contains sick leave benefits at least as favorable as required by the TDI Law.


All plans must be submitted (Form TDI-13 and Form TDI-15) to this Division for review and approval before they can be put into effect. The benefits provided by an employer's plan will fall into one of the following categories:

a. Statutory benefits, meaning benefits that follow the minimum standards as set forth in Sections 392-22, 392-23, 392-24 and 392-41 of the law.

b. Equivalent benefits, meaning benefits "as favorable as" statutory benefits, as determined by this Division. (To view or download the Equivalency Tables, click here.)

c. Better-than-statutory benefits, meaning benefits that are superior to statutory benefits.

 

EMPLOYEE'S SECTION

To be eligible for TDI benefits, you must have at least 14 weeks of Hawaii employment during each of which you were paid for 20 hours or more, and earned not less than $400 in the 52 weeks preceding the first day of disability. The 14 weeks need not be consecutive nor with only one employer.

You must also meet the following conditions in addition to the eligibility requirements described above:

• a. Your injury or illness is not work related; not caused by your job.

• b. Your injury or illness prevents you from performing your regular duty.

• c. Your disability is certified by and you are under the care of a licensed physician, surgeon, dentist, chiropractor, osteopath, naturopath, or an accredited practitioner of a faith-healing group.

• d. You must be in current employment to qualify for benefits. You are considered to be in current employment if you were employed immediately before the date you suffered your injury or illness, or if you were separated from your job, your disability occurred within two weeks from your last day of work. Current employment includes the period you were receiving vacation or sick leave pay, TDI benefits or workers' compensation benefits for temporary total disability.

Any employee who meets the eligibility requirements must be provided with TDI coverage by the employer. If you were in concurrent employment or had more than one job, whether full-time or part-time, you may qualify for TDI benefits from each employer if you meet the eligibility requirements.

Some employees are excluded from coverage (refer to section 392-5 of the law for exclusions) such as the employees of the federal government, certain domestic workers, insurance agents and real estate salespersons paid solely on a commission basis, individuals under 18 years of age in the delivery or distribution of newspapers, certain family employees, student nurses, interns and workers in other categories specifically excluded by the law.

Besides the exclusions mentioned above, you are not eligible for benefits if:

• a. You performed work for pay for any day during your period of disability.

• b. You were denied unemployment insurance benefits because of a work stoppage due to a labor dispute.

• c. Your injury was willfully and intentionally self-inflicted or it was received while committing a criminal offense.

• d. You received or will receive unemployment insurance, workers' compensation or federal disability benefits.

• e. You knowingly made a false statement or failed to disclose information in order to obtain benefits.

• f. You filed your claim beyond 90 days from the commencement of your disability period with no valid reason.

Your employer's plan determines how much benefit you will receive each week, how long you will be paid and whether you have to serve a waiting period.

• a. If your employer has a statutory plan, i.e. a plan that provides benefits according to minimum benefit standards, you are entitled to:

• 1. Cash benefits of 58% of your average weekly wages rounded to the next higher dollar, but not more than the maximum weekly benefit amount annually set by the Disability Compensation Division. Example: The maximum weekly benefit for 2008 is $489. Based on 58% of your average weekly wage, your weekly benefit amount for 2008 will range from a minimum of $1 to a maximum of $489.

• 2. Benefits from the eighth day of disability; in other words, there is a seven-consecutive-day waiting period.

• 3. A maximum of 26 weeks of benefit payments during a benefit year.

• b. If your employer has a sick leave plan which differs from statutory benefits and has been approved by this Division as an equivalent or better-than-statutory plan, your weekly benefit amount, duration of payments, and whether or not a waiting period is required will be determined by the plan. Ask your employer for details of the plan.

TDI benefits paid or payable to you are solely to partially replace the wage loss resulting from your inability to work. Your employer or insurance carrier is prohibited from receiving benefit assignments, in whole or in part, to pay for a debt or obligation you incurred. Benefits are also exempt from levy, execution, attachment, and garnishment except for child support with a Family Court order, as allowed under Section 571-52, HRS.

If you suffered a nonwork-related sickness or injury, you should follow the procedures described below:

• a. Notify your employer immediately of your disability.

• b. Ask for Form TDI-45, Claim for TDI Benefits, from your employer. A TDI claim must be filed within 90 days after commencement of the disability period.

• c. Complete Part A, Claimant's Statement, of the claim form.

• d. Take the form to your physician to certify your disability on Part C, Doctor's Statement.

• e. Have your employer complete Part B, Employer's Statement.

• f. Mail the form to your employer's TDI insurance company if your employer is not self-insured.

• g. Your employer or the insurance carrier will notify you of your entitlement to benefits.

The law requires that you file your claim within 90 days from the date you were disabled. If you file your claim after 90 days, you may lose part of your benefits unless good cause can be shown. If you file your claim more than 26 weeks after your disability, you will not be entitled to any benefits. To avoid partial or complete loss of benefits, file your claim within 90 days.

WHAT ARE SUBROGATION RIGHTS?

Occasionally, there may be doubt as to whether a disabling injury or sickness had anything to do with work. A work-related disability is covered under the workers' compensation law, while a nonwork-related disability should be filed as a TDI claim.

If you filed a workers' compensation claim and it is being denied or controverted, you can then file a TDI claim, and your employer or the insurance carrier must pay the TDI benefits first provided you meet the eligibility requirements as described above. If you were subsequently awarded workers' compensation benefits for the same disability, your employer or the TDI insurance carrier has the right to subrogate your workers' compensation benefits to the extent of the TDI benefits already paid to you earlier.

Subrogation may also extend to benefits resulting from a legal action on liability if such benefits are awarded subsequently for the same disability covering the same disability period. Here is an example of what subrogation is:

Suppose while walking in a restaurant, you slipped on wet pavement and suffered a broken ankle. During your disability, you received TDI benefits from your employer or the insurance carrier. As a result of a suit you filed against the restaurant or of an agreement concluded between you and the restaurant, you received a cash settlement, which compensated you for wages lost during your disability. Since your employer or the insurance carrier paid you TDI benefits to replace your lost wages, the employer or the insurance carrier has the right to claim from the cash settlement or to require reimbursement from you for the amount of TDI benefits paid you.

WHAT IS THE TDI SPECIAL FUND AND WHO MAY FILE CLAIM AGAINST IT?

A TDI Special Fund for disability benefits was established in 1969 through assessments imposed on all employers subject to the TDI Law. According to the law, this Fund can only be used to pay benefits to:

a. Employees whose employers have failed to provide TDI coverage or who have gone bankrupt.

b. Unemployed claimants who, while receiving unemployment insurance (UI) benefits, became disabled and were held ineligible for further UI benefits solely due to the disability.

If you fall in either one of the above categories at the time you became disabled, immediately notify this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you.

WHAT IS THE TIMEFRAME FOR THE EMPLOYER TO COMPLETE PART B OF THE CLAIM FORM?

The Hawaii TDI law does not provide a specific timeframe within which the employer must complete Part B. If, however, your employer does not fill out Part B in a timely manner (for instance, within a week or so), you may contact the Investigation Section or the Department of Labor and Industrial Relations District Office nearest you for assistance.

WHAT IF I AM DENIED BENEFITS OR DISAGREE WITH MY WEEKLY BENEFIT AMOUNT?

Your employer or insurance carrier is required to send you a written notice (three copies of Form TDI-46) if your claim is denied. If you disagree with the denial, you may appeal by explaining why you disagree on the notice and send two copies to this Division in Honolulu or the Department of Labor & Industrial Relations field office nearest you. You have 20 calendar days from the mailing date of the denial notice to appeal.

You may also appeal to this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you if you disagree with the amount of benefits paid you by your employer or the TDI insurance carrier. Bring evidence such as pay slips or check stubs to prove you are entitled to more benefits. This Division will notify you of the time and place of the appeal hearing. An impartial referee will hear your case.

WHILE ON TDI, CAN MY EMPLOYER TERMINATE MY EMPLOYMENT?

The Hawaii TDI law does not specifically indicate that it is unlawful to suspend any employee solely because that employee has suffered a nonwork-related disability. However, you may contact the Civil Rights Commission at 586-8636 for more information.

IF MY EMPLOYER DOES NOT HAVE A TDI POLICY FOR THE EMPLOYEES, WHAT RECOURSE DO I HAVE?

You may contact the Investigation Section in Honolulu or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you for assistance.


IF I AM A STATE OR COUNTY EMPLOYEE, AM I ENTITLED TO RECEIVE TDI BENEFITS AS WELL?

Basically, the sick leave provided by the employer is the TDI benefits for a state or county employee. However, if your combined total of used and unused sick leave credits within a benefit year is less than three weeks prior to the disability, you may be entitled to additional TDI benefits.

INSURANCE CARRIER'S SECTION

WHAT IS A TDI INSURANCE POLICY?

Every TDI policy issued by an authorized TDI insurance carrier covers the entire liability of the employer to its employees. The classes of employees covered must be specifically indicated in the policy and the Certification of Issuance (Form TDI-62) shall contain the following information:

• Insurer's name

• Employer's (insured) name

• Employer's business name (d.b.a.) if different from above

• Department of Labor (DOL) account number of insured

• Policy or rider form number

• Effective date of coverage

• Classes of employees covered or excluded

• Benefits provided

The Form TDI-62 should be submitted within thirty days after purchase of insurance to this Division in triplicate, signed by an officer of the insurance carrier or its authorized representative. If accepted, two copies of the Form TDI-62 will be stamped "Accepted" and returned to the carrier, who will forward one copy to the policyholder.

When canceling an insurance policy, the following guidelines should be observed:

• A minimum 10-day notice of intent to cancel on a specified date and the reason therefor must be filed with and served on this Division and the employer.

• If the reason for cancellation is "coverage provided by a new carrier," cancellation date can be the effective date of the new policy provided the new carrier has already filed a TDI-62 with this Division.

A self-insurer who terminates self-insured status with the approval of this Division may have the security deposit returned after 24 months from termination as specified in Section 12-11-72 of the Hawaii Administrative Rules.

III. Prepaid Healthcare FAQ'S

EMPLOYER'S SECTION

WHO IS REQUIRED TO PROVIDE PHC COVERAGE?

Other than those excluded (refer to section 393-5 of the law for exclusions), all employers with one or more employees, whether full-time or part-time, permanent or temporary, are required to provide PHC coverage to their eligible employees in Hawaii.

WHO IS EXCLUDED FROM PHC COVERAGE?

Some workers are excluded from health care coverage (refer to Section 393-5 of the law for exclusions) such as:

• (1) individuals who work less than twenty hours per week;

• (2) Federal, State, and County employees;

• (3) agricultural seasonal workers;

• (4) insurance or real estate salespersons paid solely by commission;

• (5) individuals working for son, daughter, or spouse; and

• (6) children under age 21 working for father or mother.

HOW DOES AN EMPLOYER PROVIDE PHC COVERAGE?

An employer may obtain health care coverage by:

• 1) purchasing an approved health care plan from a health care contractor or a Hawaii licensed insurance carrier;

• 2) adopting an approved self-insured health care plan (Form HC-4, Form HC-61); or

• 3) purchasing an insured plan of its choice. The employer selects the health care contractor and the plan type.

As a self-insurer, the employer must show proof of financial solvency and ability to pay benefits by furnishing this Division with the latest audited financial statements for review. Following the initial approval, the audited financial statements must be filed annually for continued approval of the employer's self-insured plan.

All health care plans must be approved by the Department of Labor and Industrial Relations as meeting prescribed minimum standards. Such determination is made by the Director under the advisement of a seven-member Prepaid Health Care Advisory Council consisting of representatives from the medical and public health professions, from consumer interests, and from the prepaid health care protection industry.

WHAT IS PREMIUM SUPPLEMENTATION FUND AND WHO MAY BENEFIT FROM IT?

The Prepaid Health Care (PHC) Premium Supplementation Fund was established in 1974 by general fund appropriation and used to defray the cost of providing health care benefits for employers with less than eight employees entitled to and covered under the PHC Act. To qualify for premium supplementation, the employer must meet the criteria as outlined in the Form HC-6a or section 393-45 of the law and file a claim (Form HC-6) with the Audit Section of this Division within two years after the close of the employer applicant's taxable year.

The Fund may also reimburse health care expenses to employees of bankrupt and noncompliant employers. Benefits paid from the Fund shall be recovered from those defaulting employers.

EMPLOYEE'S SECTION

WHO IS ELIGIBLE FOR PHC BENEFITS?

If you work twenty hours or more per week for four consecutive weeks and earn a monthly wage of at least 86.67 times the current Hawaii minimum hourly wage ($7.25 effective January 1, 2007), you are deemed eligible. You must be provided with health insurance at the earliest enrollment date of your employer's health care contractor.

WHEN DOES MY HEALTH CARE COVERAGE BEGIN?

Coverage commences after you have worked four consecutive weeks, at the earliest time the health care contractor can provide coverage. Usually, it is the first of the month following the month during which you met the eligibility criteria.

If I HAVE TWO JOBS, WHICH EMPLOYER IS TO PROVIDE PHC COVERAGE?

If you work concurrently for two or more employers, you are required to designate the principal and secondary employer and file notification (Form HC-5) with your employers who, in turn, will file the notification with this Division. The principal employer shall be the employer who pays you the most wages; only in cases where the employer who does not pay the most wages employs you for at least 35 hours per week do you determine which of the employers shall be the principal employer. The designated principal employer is required to provide coverage pursuant to the law (393-6, 393-16). Your determination of principal employer is binding for one year or until change of employment occurs. Whenever you elect to make a change with respect to the status of each, notification (Form HC-5) must be filed.

Your employer is prohibited from coercing, interfering, or influencing you in making a determination of principal employer.

IF I ALREADY HAVE HEALTH COVERAGE ELSEWHERE, DO I HAVE TO BE COVERED AGAIN BY MY EMPLOYER'S PLAN?

You can elect to be exempt from coverage under your employer's health care plan if:

• 1) You are 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;

• 2) You are covered as a dependent under a qualified health care plan;

• 3) You are a recipient of public assistance or covered by a State-Legislated health care plan governing medical assistance; or

• 4) You are a follower of a religious group that depends upon prayer or other spiritual means for healing.

To claim an exemption, you must complete and submit Form HC-5 to your employer who must, in turn, file the document with this Division. The exemption notification (Form HC-5) is binding for one year and must be renewed every December 31.

IF I CANNOT WORK DUE TO A DISABILITY, IS MY EMPLOYER REQUIRED TO CONTINUE MY HEALTH INSURANCE?

In the event you are disabled and unable to work, your employer is obligated to enable you to continue health care coverage by continuing the employer's share of the premium costs for three additional months following the month during which you became disabled, or for the period for which your employer has undertaken payment of your regular wages, whichever is longer. You must maintain your portion of the premium payments; otherwise, coverage may be terminated.

HOW MUCH CAN MY EMPLOYER CHARGE FOR MY HEALTH INSURANCE?

Your employer may elect to pay the entire premium amount or share the cost with you. For single coverage, your employer must pay at least one-half the premium cost; however, your contribution cannot exceed 1.5% of your monthly gross wages. In the event your allowable share constitutes less than one-half of the premiums, your employer is liable for the entire remaining portion. Your employer is permitted to withhold your contribution from your wages each pay period. You cannot agree to pay a greater share from wages except for the purpose of paying for the added cost of providing prepaid health care benefits for your dependents under the same plan.

HEALTH CARE CONTRACTOR'S SECTION

WHO IS A HEALTH CARE CONTRACTOR?

A prepaid health care contractor may fall in one of three groups:

• (1) any medical group or organization which provides health care benefits under a prepaid health care plan;

• (2) any nonprofit organization which defrays or reimburses in whole or in part the expenses of health care under a prepaid health care plan; or

• (3) any insurer who defrays or reimburses in whole or in part the expenses of health care under a prepaid health care plan.

For required health benefits that the prepaid health care plans must offer to meet standards as prescribed by law, please call the Plans Acceptance Branch.

Back to top of page