BENEFITS DISCLOSURES & FORMS
Please review these important disclosures and forms about your health care benefits.
Health Insurance Marketplace Notice
To assist you as you evaluate options for you and your family, this notice provides some basic information about the Health Insurance Marketplace and health coverage offered through your employment.
If you prefer a paper copy, please contact the ProService Benefits Service Team at 808-394-4175.
Summary Plan Description
As your health care Plan Administrator, we are providing additional information about your plans in accordance with the Employee Retirement Income Security Act of 1974 (ERISA).
Your Summary Plan Description (SPD) includes information pertaining to all the health and welfare benefit plans provided by ProService Hawaii; however, some medical, vision, prescription drug, dental and/or chiropractic plan information may or may not apply to you depending on the health plan elections made by you and your worksite employer.
If you prefer a paper copy, please contact the ProService Benefits Service Team at 808-394-4175.
Section 125
In accordance with Section 125 of the Internal Revenue Service Code, you may pay for your selected benefits with pre-tax dollars, which in most cases would reduce your income taxes. As a courtesy to employees, we automatically deduct the employee portion for your selected benefits from your paycheck pre-tax.
If you do not wish to participate in this pre-tax program, you may decline by submitting a completed Section 125 Form within 30 days of your health care plan effective date.
General Notice of COBRA Continuation Coverage Rights
The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that may allow plan participants to continue medical coverage under specified circumstances where such group coverage would otherwise be lost.
COBRA applies if your worksite employer employed more than twenty (20) employees on a typical business day during the preceding calendar year. If you qualify for COBRA, you or your covered dependents must apply for and pay the required premium before the deadline for payment in order to continue coverage. COBRA coverage can be extended for 18, 29, or 36 months, depending on the particular "qualifying event" that gave rise to COBRA. To learn more about COBRA, read the COBRA Notice.
Hawaii Prepaid Health Care Information
Your worksite employer provides health care benefits in accordance with the State of Hawaii Prepaid Health Care Act and ProService is the administrator of your worksite employer’s benefit plans.
Employees are eligible for health care benefits on the first day of the month following the month in which they worked twenty (20) or more hours for four (4) consecutive weeks with your Employer.
Employees may be required to pay up to one-half of the premium for single coverage, provided that the cost does not exceed 1.5% of their gross monthly wages. Employees may also be required to pay for the additional cost of their dependent coverage. Please read the complete notice for more information.
Prescription Drug Coverage and Medicare
Please read the complete notice to learn more about your current prescription drug coverage with ProService and your options under Medicare’s prescription drug coverage.
If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. This information can help you decide whether or not you want to join a Medicare drug plan.
Group Term Life & Accidental Death and Dismemberment Insurance
As a valued employee, you may be eligible to receive Group Term Life & Accidental Death and Dismemberment Insurance when you participate in a health care plan through ProService.
Please complete the Beneficiary Designation/Change Form and send it to the Benefits Service Center using one of these ways:
- Email: ola@proservice.com
- Fax: 808-394-6592 or toll-free at 888-783-8333
Children’s Health Insurance Program (CHIP) Notice
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace.
For more information, visit www.healthcare.gov.
Primary Care Provider Designation Patient Protection Notice
Kaiser and HMSA HPA generally require the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. Until you make this designation, Kaiser or HMSA HPH designates one for you. For children, you may designate a pediatrician as the primary care provider. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact HMSA at 800-776-4672 or Kaiser at 800-966-5955.
You do not need prior authorization from Kaiser or HMSA HPH or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the HMSA at 800-776-4672 or Kaiser at 800-966-5955.
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(808) 394-4175
For assistance with your benefits, please contact the Benefits Team between Monday - Friday, 8:00 am - 5:00 pm.