Form HC-7 "Prepaid Health Care Plan Review Application" - Hawaii

What Is Form HC-7?

This is a legal form that was released by the Hawaii Department of Labor & Industrial Relations - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2008;
  • The latest edition provided by the Hawaii Department of Labor & Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HC-7 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Labor & Industrial Relations.

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Download Form HC-7 "Prepaid Health Care Plan Review Application" - Hawaii

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FORM HC-7
(Rev. 3/08)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
PREPAID HEALTH CARE PLAN REVIEW APPLICATION
_______________________________
(Date)
Contractor:
_________________________________________
Address:
_________________________________________ Phone No.: _____________
_________________________________________ Fax No.: _______________
Name of Plan: _______________________________________________________________**
(As marketed and filed with the Department of Labor and Industrial Relations)
Type of Plan (see Section 393-12): (Check one)
Reimbursement

Service

Plan submitted for approval under: (Check one)
Section 393-7(a)

Section 393-7(b)*

*Must include certification that the employer has agreed to contribute at least
one-half of the cost of the coverage for dependents.
To assist us in making determinations under Section 393-7(c), please complete the applicable
attached sheets {Form HC-7(a-1) or Form HC-7(a-2)}. Explain any variations. In addition,
please include a directory of the PPO, EPO or HMO Network, if applicable.
Will you be able to have a representative present when the council is discussing your plan?
Yes. How many days notice do you require? __________________________

No

**TEN copies of plan must be submitted with evidence of HAWAII STATE INSURANCE
COMMISSIONER’S approval or the signed statement that the plan does not require approval.
FORM HC-7
(Rev. 3/08)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
PREPAID HEALTH CARE PLAN REVIEW APPLICATION
_______________________________
(Date)
Contractor:
_________________________________________
Address:
_________________________________________ Phone No.: _____________
_________________________________________ Fax No.: _______________
Name of Plan: _______________________________________________________________**
(As marketed and filed with the Department of Labor and Industrial Relations)
Type of Plan (see Section 393-12): (Check one)
Reimbursement

Service

Plan submitted for approval under: (Check one)
Section 393-7(a)

Section 393-7(b)*

*Must include certification that the employer has agreed to contribute at least
one-half of the cost of the coverage for dependents.
To assist us in making determinations under Section 393-7(c), please complete the applicable
attached sheets {Form HC-7(a-1) or Form HC-7(a-2)}. Explain any variations. In addition,
please include a directory of the PPO, EPO or HMO Network, if applicable.
Will you be able to have a representative present when the council is discussing your plan?
Yes. How many days notice do you require? __________________________

No

**TEN copies of plan must be submitted with evidence of HAWAII STATE INSURANCE
COMMISSIONER’S approval or the signed statement that the plan does not require approval.
FORM HC-7
(Rev. 3/08)
Page 2
The Hawaii Prepaid Health Care (PHC) Act, Chapter 393, HRS, requires employers to
provide coverage to eligible employees. An employee is deemed eligible if the employee
works at least twenty hours per week and earns a monthly wage of at least 86.67 times the
Hawaii minimum hourly wage. Coverage commences after four consecutive weeks of
employment. Employers/Contractors are not allowed to deny eligible employees coverage
based upon other factors, such as, pre-existing health conditions.
As a Contractor of Approved Health Care Plans we agree to abide by the following guidelines:
1.
Health information on employees, if requested, may not be used to deny coverage nor
retroactively cancel coverage.
2.
Approved plan(s) must be offered to all employers as defined in section 393-3(3).
3.
Approved plans purchased by employers will remain in effect until such time when
the health care contractor files a notice to terminate with and received approval by the
Department of Labor and Industrial Relations (DLIR) or the plans are revoked by the
DLIR for noncompliance with the PHC Act or its related administrative rules.
4.
The Health Care Contractor will permit the DLIR Director or authorized
representative access to the premises and records for the purposes of conducting
audits and/or investigations in the enforcement of the PHC Act.
5.
Health care contractors will comply with all provisions of the PHC Act, Chapter 393,
and its Related Administrative Rules, Chapter 12, Title 12. (Chapter 12, Title 12,
Subchapter 3 specifically applies to health care contractor requirements, which can be
referenced on DLIR’s website at www.hawaii.gov/labor)
____________________________________________________________________________
Authorized Signature
Date
____________________________________________________________________________
Print Name
Title
____________________________________________________________________________
Name of Health Care Contractor
____________________________________________________________________________
Address
___________________________
__________________________
Telephone Number
Fax Number
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