PremiumCostSharing - UHA Online Employer Services

UHA Customer Form for Federal Reporting under CAA

Group ID 4 or 8-character Group ID

Employer Identification Number (EIN) 9-digit EIN, no dashes

My Groups
Group ID	Employer Identification Number (EIN)	Group Name

Group Name

Group Contact Name

Group Contact Email

Instructions:

Complete the information based on premiums paid by the employee/member and the employer during the 2024 calendar year.
Include only the premium share payments that are for UHA premiums.
Include any premium share payments for UHA COBRA paid directly to the employer, including any COBRA administrative fees charged by the employer to the member.
For UHA COBRA premiums paid directly to UHA by the member and not paid directly to the employer, UHA will account for those payments.
Do not include any premium share payments for coverage made to another insurance carrier.
If there was no premium share paid by the employee and/or employer during a specified month, leave the field(s) blank for that specific month.
Enter the premium share amounts below in dollars and cents.

Description:

Your premium billing statement for each month is shown.
Two examples have been provided. Click the links to expand the examples.

2024 Calendar Year Premium Share Information
Month	UHA Premium From Your Billing Statement*	UHA Premium Share by Employees in Dollars and Cents Paid by Employees with UHA Coverage	UHA Premium Share by Employers in Dollars and Cents Paid by Employer(s)
January	$	$	$
February	$	$	$
March	$	$	$
April	$	$	$
May	$	$	$
June	$	$	$
July	$	$	$
August	$	$	$
September	$	$	$
October	$	$	$
November	$	$	$
December	$	$	$
Total	$	$	$

Example 1. All Active Employees

Aloha Group had three employees that were covered by UHA Health Insurance for the entire 2024 calendar year. Of the 3 employees, 1 employee has a single party plan, and 2 employees have family coverage.

Aloha Group covers 100% of the single party monthly premium of $500.
For family coverage, the monthly UHA premium for family coverage is $1,000; Aloha Group covers $500, and the employee pays the difference of $500.

2024 Calendar Year Premium Share Information
Month	UHA Premium From Your Billing Statement*	UHA Premium Share by Employees in Dollars and Cents Paid by Employees with UHA Coverage	UHA Premium Share by Employers in Dollars and Cents Paid by Employer(s)
January	$	$	$
February	$	$	$
March	$	$	$
April	$	$	$
May	$	$	$
June	$	$	$
July	$	$	$
August	$	$	$
September	$	$	$
October	$	$	$
November	$	$	$
December	$	$	$

Example 2. Active Employees and COBRA Former Employee

Ohana Group had 20 employees that were covered by UHA Health Insurance for the 2024 calendar year. Of the 20 employees, 19 employees had a single-party plan, and 1 employee had family coverage.

Ohana Group covers 100% of the single-party monthly premium of $500.
For family coverage, the monthly UHA premium for family coverage is $1,000; Ohana Group covers $500, and the employee pays the difference of $500.
For the coverage month of June, the one employee with family coverage left the Ohana Group and elected COBRA coverage.
- Ohana Group administers COBRA and charges the former employee a 2% administration fee ($20) on the $1,000 month family premium.
- The total monthly premium paid by the former employee directly to the Ohana Group for their COBRA UHA premium is $1020.00.
  - Note. Only COBRA premiums and the COBRA administrative fee, if applicable, that were directly paid by the former employee or member to the employer group should be reported in the table below.

2024 Calendar Year Premium Share Information
Month	UHA Premium From Your Billing Statement*	UHA Premium Share by Employees in Dollars and Cents Paid by Employees with UHA Coverage	UHA Premium Share by Employers in Dollars and Cents Paid by Employer(s)
January	$	$	$
February	$	$	$
March	$	$	$
April	$	$	$
May	$	$	$
June	$	$	$
July	$	$	$
August	$	$	$
September	$	$	$
October	$	$	$
November	$	$	$
December	$	$	$

UHA is committed to compliance with the Consolidated Appropriations Act (CAA), signed into federal law on December 27, 2020. The CAA requires employer group health plans and insurers to report data annually regarding prescription drugs and health care spending to the federal Departments of Health and Human Services, Labor, and Treasury through a secure web portal.

As part of CAA’s Prescription Drug Data Collection (RxDC) reporting requirements, UHA is collecting premium information on behalf of employer group health plans with UHA coverage. This includes the share paid by employees, and the employer, towards their UHA monthly premium during the 2024 calendar year.

To ensure compliance with the reporting requirements, employer groups must provide the information requested in the 2024 Calendar Year Premium Share Information form. This will help ensure UHA is able to file the required information.

Please provide this information for your employer group, no later than April 25, 2025.

UHA will submit all applicable reports and required narrative responses for all employer groups to CMS by the June 1, 2025 deadline.

If you have any questions, please contact your dedicated Client Services representative or the UHA Client Services Team at 808-532-4000 extension 358 or via email at [email protected].

Information regarding this federal requirement is available at https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/prescription-drug-data-collection.

Sincerely,

Malcolm Leong
VP of Client Services and Sales