Hawaii Employer-Union Health Benefits Trust Fund

(Watch video on Acquisition of Coverage)

EVENT DESCRIPTION: Employee or dependent gets coverage from another plan and wishes to cancel EUTF or HSTA VB plans

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days from effective date of gaining coverage elsewhere

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Letter from carrier or employer detailing type of coverages enrolled in (i.e., medical, drug, dental, vision), effective date of coverage, and names of covered insured and/or dependents

EFFECTIVE DATE: If coverage is gained on the 1st of the month, EUTF coverage ends last day of the month preceding. If coverage is gained 16th of the month, EUTF coverage ends on the 15th of the month.

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: Employee may enroll in the supplemental health benefit plan effective the first day of the pay period following the cancellation of their EUTF coverage.

EVENT DESCRIPTION: Employee wishes to add newborn to EUTF plans

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 180 days from date of birth

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Birth certificate and Social Security Number must be submitted within 45 days from date of submission of EC-1/EC-1H enrollment form.

EFFECTIVE DATE: Employee can choose: birth date, beginning of next pay period after birth date, or beginning of 2nd pay period after birth date

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No plan changes allowed if already enrolled. May enroll in plans if not already enrolled or may add dependents if already enrolled.

EVENT DESCRIPTION: To cover child

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): EUTF receives the order directly from the Child Support Enforcement Agency (CSEA). No EC-1/EC-1H is required if employee is already enrolled in EUTF plans

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Child Support Enforcement Agency (CSEA) notice, Birth certificate, and Social Security Number.

If enrolling a dependent age 19 through 23 in Dental and/or Vision coverage, student certification from an accredited school/college on school letterhead with registrar’s signature confirming full-time status or an enrollment certificate from the National Student Clearinghouse. Transcripts not accepted.

EFFECTIVE DATE: Effective date on CSEA notice

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: Plan changes allowed if required by court order. May enroll in plans if not already enrolled or may add dependents if already enrolled.

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): As soon as reasonably practical

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Death certificate or copy of obituary as soon as available

EFFECTIVE DATE: Date of death or last day of pay period in which date of death occurs for dependents.

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: N/A

(Watch video on Demographic Changes)

EVENT DESCRIPTION: Making demographic changes such as address changes or legal name changes

WHEN ADDRESS CHANGE FORM OR EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Employees are responsible for notifying the EUTF for any demographic changes such as address changes or legal name changes as soon as possible.

DOCUMENTATION REQUIREMENTS: No additional documentation required for address changes. Proof documents are required for legal name changes such as copies of court order or letter from the Lieutenant Governor’s office.

EFFECTIVE DATE: Effective date will be as stated on Address Change form or submitted proof documents.

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No plan changes or enrollments allowed.

(Watch video on Divorce)

EVENT DESCRIPTION: Employee must terminate coverage for former spouse or civil union partner.

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days of date of divorce. If EC-1/EC-1H filed more than 45 days after date of divorce, employee shall be responsible for paying the employer contribution premiums retroactive to the divorce date.

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Pages 1 and 2 of divorce decree, along with signature page.

EFFECTIVE DATE: First day of the first pay period following the divorce.

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No

EVENT DESCRIPTION: Employee wishes to add child to EUTF plans

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days from date of guardianship

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Guardianship decree, Birth certificate, and Social Security Number

EFFECTIVE DATE: Employee can choose: Date of guardianship, beginning of next pay period after date of guardianship, or beginning of 2nd pay period after date of guardianship

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No plan changes allowed if already enrolled. May enroll in plans if not already enrolled or may add dependents if already enrolled.

(Watch video on LWOP)

EVENT DESCRIPTION: For leave of absence without pay lasting more than 30 days, employee may waive all plans excluding life insurance or continue coverage by paying his/her share of premiums.

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days from beginning of LWOP to waive plans. To reenroll after LWOP EC-1/EC- 1H must be submitted within 45 days of return from LWOP

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Form L-1 completed by employer

EFFECTIVE DATE: If employee cancels plans, first day of the pay period following the date LWOP begins

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No

EVENT DESCRIPTION: Employee must terminate coverage for former spouse and step-children.

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days from date of legal separation. If EC-1/EC-1H is filed more than 45 days after date of legal separation, employee shall be responsible for paying the employer contribution premiums retroactive to the legal separation date.

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Court document establishing legal separation, including any pages regarding health benefits to children

EFFECTIVE DATE: First day of the pay period following the legal separation

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No

(Watch video on Loss of Coverage)

EVENT DESCRIPTION: Employee and/or dependent lost coverage from a non-EUTF plan, and wishes to enroll in EUTF plans

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days from loss of other coverage

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Loss of coverage letter from previous employer/carrier detailing type of coverages lost (i.e., medical, dental, drug, vision), date of loss of coverage, and names of any covered dependents.

If adding Dependents:

• Spouse or Partner:
  • Marriage, Civil Union certificate or Domestic Partnership documents and Social Security Number, if not previously submitted to the EUTF
• Dependent Child:
  • Birth certificate and Social Security Number
  • If enrolling a dependent age 19 through 23 in Dental and/or Vision coverage, student certification from an accredited school/college on school letterhead with registrar’s signature confirming full-time status or an enrollment certificate from the National Student Clearinghouse. Transcripts not accepted.

EFFECTIVE DATE: Day following loss of coverage from other plan

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No plan changes allowed if already enrolled. May enroll in plans if not already enrolled or may add dependents if already enrolled. If proof document notification date is outside of the initial 45-day enrollment period, the employee will be given 45 days from the notification date to submit EC-1/EC-1H form and required documents. Those losing coverage from a Medicaid plan have 60 days from event date to submit EC-1/EC-1H form and required documents. The effective date of coverage will be the Event Date.

EVENT DESCRIPTION: Employee wishes to enroll new spouse in EUTF plans

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days from date of marriage

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Marriage certificate

If adding dependents:

• Birth certificate and Social Security Number
• If enrolling a dependent age 19 through 23 in Dental and/or Vision coverage, student certification from an accredited school/college on school letterhead with registrar’s signature confirming full-time status or an enrollment certificate from the National Student Clearinghouse. Transcripts not accepted.

EFFECTIVE DATE: Employee can choose: Date of marriage, beginning of next pay period after date of marriage or beginning of 2nd pay period after date of marriage

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No plan changes allowed if already enrolled. May enroll in plans if not already enrolled or may add dependents if already enrolled.

EVENT DESCRIPTION: Employee wishes to enroll new civil union partner in EUTF plans

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days from date of civil union

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Civil Union certification (on-line proof accepted), Affidavit of Dependency and Social Security Number submitted within 45 days from the civil union date.

If adding Dependents:

• Birth certificate and Social Security Number
• If enrolling a dependent age 19 through 23 in Dental and/or Vision coverage, student certification from an accredited school/college on school letterhead with registrar’s signature confirming full-time status or an enrollment certificate from the National Student Clearinghouse. Transcripts not accepted.

EFFECTIVE DATE: Employee can choose: Date of civil union, beginning of next pay period after date of civil union, or beginning of 2nd pay period after date of civil union

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No plan changes allowed if already enrolled. May enroll in plans if not already enrolled or may add dependents if already enrolled.

(Watch video on Domestic Partnership Enrollment)

EVENT DESCRIPTION: Employee wishes to enroll new domestic partner in EUTF plans

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days from date of notarized signature (event date is considered date of notarization)

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Notarized Declaration of Domestic Partnership, Affidavit of Dependency (notarized if IRS qualified) and two sets of documents must also be provided which include any combination of documents that list both you and your domestic partner’s name and address or separate documents from each party with the same address (i.e. utility bill, bank statement, rental agreement, etc.). The verification documentation is in addition to the required declaration and affidavit, along with the EC-1/EC-1H form.

If adding Dependents:

• Birth certificate and Social Security Number
• If enrolling a dependent age 19 through 23 in Dental and/or Vision coverage, student certification from an accredited school/college on school letterhead with registrar’s signature confirming full-time status or an enrollment certificate from the National Student Clearinghouse. Transcripts not accepted.

EFFECTIVE DATE: Employee can choose: Date of notarization of Declaration of Domestic Partnership, beginning of next pay period after notary date, or beginning of 2nd pay period after notary date

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No plan changes allowed if already enrolled. May enroll in plans if not already enrolled or may add dependents if already enrolled.

EVENT DESCRIPTION: New employee wishes to enroll in EUTF plans

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days of date of new hire

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*:
If adding Dependents:

• Spouse or Partner:
  • Marriage, Civil Union certificate or Domestic Partnership documents and Social Security Number
• Dependent Child:
  • Birth certificate and Social Security Number
  • If enrolling a dependent age 19 through 23 in Dental and/or Vision coverage, student certification from an accredited school/college on school letterhead with registrar’s signature confirming full-time status or an enrollment certificate from the National Student Clearinghouse. Transcripts not accepted.

EFFECTIVE DATE: Employee can choose:

• New hire date
• Beginning of next pay period after new hire date
• Beginning of 2nd pay period after new hire date

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: N/A

EVENT DESCRIPTION: Employee wishes to add child in dental or vision plan because child became a full-time student and is between the ages of 19 through 23

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days from date of school start date

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: If enrolling a dependent in Dental and/or Vision coverage, student certification from an accredited school/college on school letterhead with registrar’s signature confirming full-time status or an enrollment certificate from the National Student Clearinghouse. Transcripts not accepted.

EFFECTIVE DATE: Employee can choose:

• Date child becomes full time student
• Beginning of next pay period after becoming full time student
• Beginning of 2nd pay period after becoming full time student

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No

EVENT DESCRIPTION: Employee must terminate domestic partner and domestic partner’s
dependents

WHEN EC-1/EC-1H MUST BE SUBMITTED TO EMPLOYER (Personnel Office): Within 45 days of termination of partnership. If EC-1/EC-1H is filed more than 45 days after date of termination of domestic partnership, employee shall be responsible for paying the employer contribution premiums retroactive to the termination of​ domestic partnership date.

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-1/EC-1H*: Declaration of Termination of Domestic Partnership

EFFECTIVE DATE: First day of the pay period following the date of the termination of the domestic partnership

CHANGES ALLOWED TO PLANS OR TO ENROLL IN PLANS OR ADD DEPENDENTS?: No