Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
RCUH Health Insurance Waiver Form – MID YEAR CHANGES (Voluntary or Involuntary)
Employee Name: RCUH Employee ID #:
You are being provided this form due to one of the following reasons: (1) You have voluntarily cancelled your health insurance through RCUH mid plan year, (2) You have become re-eligible to re-enroll into health insurance through RCUH due to an employee change (i.e. Increase in FTE above 50% FTE), or (3) You returned from Leave of Absence and decided not to re-enroll into RCUH’s health insurance. (4) You have met the 30 hours/week and 130 hours/month requirement under the ACA but have waived coverage.
In compliance with the Patient Protection Affordable Care Act (PPACA), you are required (PRIOR TO YOUR EMPLOYEE CHANGE) to complete this form if you have cancelled or waived health care coverage with RCUH. Under the Affordable Care Act, individuals are required to obtain health insurance or pay a tax penalty, unless an exception applies. This is known as the Individual Shared Responsibility Payment. Individuals can meet their obligation to obtain coverage in many ways, including by participating in an employer-sponsored coverage, purchasing insurance in the Federal Health Insurance Marketplace (HealthCare.gov), or by obtaining government health insurance such as Medicare Part A, Medicare Advantage plans, or Medicaid. More information about the Individual Shared Responsibility Payment can be obtained from the Internal Revenue Service’s website: (http://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Questions-and-Answers-on-the-Individual-Shared- Responsibility-Provision)
I have cancelled or waived coverage from RCUH’s group health care plan because:
I (and if applicable, my eligible beneficiaries) prefer not to have coverage. (I am declining health insurance entirely.)
I (and if applicable, my eligible beneficiaries) have coverage with another party (i.e. parent, spouse, domestic partner, civil
union partner, or my own coverage purchased directly from a health insurance carrier).
I (and if applicable, my eligible beneficiaries) have or will have coverage through the Federal Health Insurance Marketplace (HealthCare.gov). I understand that by cancelling or waiving coverage through RCUH that I (and if applicable, my eligible beneficiaries) will not be eligible for a federal subsidy if applying through the Federal Health Insurance Marketplace since I was offered medical coverage through RCUH.
I (and if applicable, my eligible beneficiaries) have coverage such as Medicare, Medicaid, TRICARE, COBRA, Veterans Program, or other coverage recognized by the Secretary of Health and Human Services as minimum essential coverage.
By signing this waiver form I am acknowledging the following:
 I understand that RCUH has given me an opportunity to enroll in RCUH’s Group Health Insurance coverage for myself and my eligible beneficiaries but I am voluntarily declining enrollment as indicated above.
 I understand that by declining RCUH’s Group Health Insurance, I can only enroll during RCUH’s Open Enrollment Period or due to a Qualifying Event as defined by RCUH’s Policy 3.520 RCUH Health Plans.
 I further understand that providing inaccurate information or falsifying the information contained in this form may result in disciplinary action including and up to termination of employment.
Signature of Employee: Date: / /
Why am I required to have health coverage?
The ACA requires nearly everyone have health insurance that meets minimum standards and is affordable. Under the ACA, employees and employers are subject to Shared Responsibility provisions that with some exceptions require employees and / or employers pay a penalty when health insurance coverage is not maintained. Shared Responsibility Provisions – Effective beginning tax year 2014
 Employees: Under the Individual Shared Responsibility Provision, you, your children, and anyone else that you claim as a dependent on your taxes are required
to have health insurance that meets minimum standards. Individuals who do not maintain health insurance coverage will have to pay a penalty to the IRS.
 RCUH: Under the Employer Shared Responsibility Provision, employers who do not offer affordable health coverage that provides a minimum level of coverage
to their full-time employees and their qualified dependents will have to a penalty to the IRS.
Further Information regarding the Individual Mandate:
http://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision
RCUH Form B-5Wa 08/29/15 Rev 05/06/16
Instructions: Provide the completed signed form to RCUH and retain a copy for yourself.