"Contractual/Variable Hour Employees Health Benefits Enrollment and Change Form" - Maryland

Contractual/Variable Hour Employees Health Benefits Enrollment and Change Form is a legal document that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland.

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STATE OF MARYLAND
CONTRACTUAL / VARIABLE HOUR EMPLOYEES
HEALTH BENEFITS ENROLLMENT AND CHANGE FORM FOR JANUARY 2021-DECEMBER 2021
PERSONAL DATA
PLEASE PRINT CLEARLY
Name: ____________________________________________________________________________________________________________
LAST
FIRST
MI
Address: _______________________________________________________________________________Apt/Condo: ________________
City: _______________________________________________ State: _______________________ Zip Code: _______________________
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
Sex:
Legal Marital Status:
Male
Single
Limited Divorce/Legally Separated
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Female
Married
Widowed
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
Divorced
Personal E-mail: ________________________________________________
TO BE COMPLETED BY AGENCY BENEFITS COORDINATOR
Work E-mail: ___________________________________________________
Agency Code: __________
Check Dist. Code: ___________
(if applicable)
W#: W __ __ __ __ __ __ __
Date of Birth: __ __ /__ __ / __ __ __ __
M M / D D /
Y Y Y Y
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
New Hire Date: ____________
Change in Family Status (See Benefits Guide for documentation requirements)
Note: Request must be made within 60 days of the date of the qualifying event.
Job Change Date: ____________
Add dependent because of:
Open Enrollment - Effective January 1st
Marriage
Date: ____________
Birth/Adoption/Appointed Permanent Legal Guardian
Date: ___________
Cancel all Coverage in all Plans/Reason: _________________
Other Reason: _______________________________________
____________________________________________________
Remove dependent because of:
Divorce/Limited Divorce/Legal Separation
Date: ____________
Death
Date: ____________ (Attach copy of Death Certificate)
Dependent no longer eligible
Date: ____________
Reason: _______________________________________________________
Other Change: ____________________________________________________
COMPLETED AND SIGNED ENROLLMENT FORMS MUST BE GIVEN TO YOUR AGENCY BENEFITS COORDINATOR
If you are enrolling dependents,
all required dependent documentation must be attached.
If eligible, the State subsidy applies only to medical and prescription
coverage. Employee pays full premium for all other coverage elected.
EBD Use Only:
____ Reviewed
Health benefits information and forms are available on our website:
____ Processed
www.dbm.maryland.gov/benefits
____ Audited
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STATE OF MARYLAND
CONTRACTUAL / VARIABLE HOUR EMPLOYEES
HEALTH BENEFITS ENROLLMENT AND CHANGE FORM FOR JANUARY 2021-DECEMBER 2021
PERSONAL DATA
PLEASE PRINT CLEARLY
Name: ____________________________________________________________________________________________________________
LAST
FIRST
MI
Address: _______________________________________________________________________________Apt/Condo: ________________
City: _______________________________________________ State: _______________________ Zip Code: _______________________
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
Sex:
Legal Marital Status:
Male
Single
Limited Divorce/Legally Separated
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Female
Married
Widowed
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
Divorced
Personal E-mail: ________________________________________________
TO BE COMPLETED BY AGENCY BENEFITS COORDINATOR
Work E-mail: ___________________________________________________
Agency Code: __________
Check Dist. Code: ___________
(if applicable)
W#: W __ __ __ __ __ __ __
Date of Birth: __ __ /__ __ / __ __ __ __
M M / D D /
Y Y Y Y
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
New Hire Date: ____________
Change in Family Status (See Benefits Guide for documentation requirements)
Note: Request must be made within 60 days of the date of the qualifying event.
Job Change Date: ____________
Add dependent because of:
Open Enrollment - Effective January 1st
Marriage
Date: ____________
Birth/Adoption/Appointed Permanent Legal Guardian
Date: ___________
Cancel all Coverage in all Plans/Reason: _________________
Other Reason: _______________________________________
____________________________________________________
Remove dependent because of:
Divorce/Limited Divorce/Legal Separation
Date: ____________
Death
Date: ____________ (Attach copy of Death Certificate)
Dependent no longer eligible
Date: ____________
Reason: _______________________________________________________
Other Change: ____________________________________________________
COMPLETED AND SIGNED ENROLLMENT FORMS MUST BE GIVEN TO YOUR AGENCY BENEFITS COORDINATOR
If you are enrolling dependents,
all required dependent documentation must be attached.
If eligible, the State subsidy applies only to medical and prescription
coverage. Employee pays full premium for all other coverage elected.
EBD Use Only:
____ Reviewed
Health benefits information and forms are available on our website:
____ Processed
www.dbm.maryland.gov/benefits
____ Audited
ENROLLMENT FOR JANUARY 2021-DECEMBER 2021
DEPENDENT INFORMATION
PLEASE PRINT
Dependent means your eligible: (a) spouse, or (b) dependent child(ren) (including biological child, adopted child, stepchild, grandchild, step grandchild, other child relative, legal ward).
See Benefits Guide for a complete listing of eligible dependents and the dependent documentation requirements.
Please provide your dependent information below. PLEASE PRINT. THIS FORM MUST BE FILLED OUT COMPLETELY (INCLUDING SOCIAL SECURITY NUMBER
AND DATE OF BIRTH) TO ENSURE YOUR DEPENDENTS ARE ENROLLED IN THE PLANS YOU SELECT. Please use this section for additions (A), deletions (D) or
changes (C) to your existing dependent information for Open Enrollment or a qualifying event.
A
DATE OF
( )
COVER THIS DEPENDENT FOR:
D
LAST NAME
FIRST NAME, MI
SEX
BIRTH
RELATIONSHIP
SOCIAL SECURITY NO.
C
MM/DD/YYYY
MEDICAL
DRUG
DENTAL
Special Notifications:
• Biological, adopted and step children age 26 and over must have become disabled prior to reaching age 26 in order to be eligible for continued coverage.
• Grandchildren, step grandchildren, legal wards and other child relatives age 25 and over must have become disabled prior to reaching age 25 in order to be eligible for
continued coverage.
ENROLLMENT FOR JANUARY 2021-DECEMBER 2021
Medical Benefits
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE MEDICAL PLAN:
New Enrollment
Employee Only
CareFirst BC/BS EPO
Change in plan
Employee & One Child
CareFirst BC/BS PPO
Addition or removal of dependent
Employee & Spouse
Kaiser IHM*
No, I do not want to enroll in
Employee & Family
UnitedHealthcare EPO
this benefit
End Stage Renal (ESRD)
UnitedHealthcare PPO
Cancel current coverage
(
Complete Medicare Information below)
*Members and/or dependents eligible for Medicare due to age, disability, or End Stage Renal Disease (ESRD) are not eligible to enroll in the
Kaiser medical plan.
If you or a dependent have Medicare, write in name, Medicare number, and effective date of Medicare coverage.
PART A
PART B
PART D
MEDICARE
(Hospital Claims)
(Medical Claims)
(Prescription Drug)
NAMES OF INDIVIDUALS
NUMBER
MEDICARE DUE TO ( ):
Effective Date
Effective Date
Effective Date
WITH MEDICARE
(with suffix)
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
Age 65
Disabled
ESRD
Employee
Spouse
Child
Child
NOTE: Vision and Mental Health/Substance Abuse benefits are included if enrolled in a medical plan.
Medical plans do not include Prescription Drug or Dental coverage. Separate selections are required.
Prescription Drug Coverage
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
New enrollment
Employee Only
Addition or removal of dependent
Employee & One Child
Employee & Spouse
No, I do not want to enroll in this benefit
Cancel current coverage
Employee & Family
Dental Coverage
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE DENTAL PLAN:
New enrollment
Employee Only
United Concordia DPPO
Change in plan
Employee & One Child
Delta Dental DHMO
Addition or removal of dependent
Employee & Spouse
For the DHMO Plan: You must select
No, I do not want to enroll in this benefit
Employee & Family
a primary Dentist office once enrolled.
Call plan or see plan website for details.
Cancel current coverage
Accidental Death and Dismemberment Benefits
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE BENEFIT AMOUNT:
New enrollment
Employee Only coverage
$100,000
Change of benefit amount
Family coverage
$200,000
Addition or removal of dependent
$300,000
No, I do not want to enroll in this benefit
Cancel current coverage
Life Insurance Plan
EMPLOYEE
OPTIONS-Choose only one
Choose a Coverage Amount in increments of $10,000 up to $300,000:
Yes, I want to enroll as a new enrollee in Life
STOP-If you choose an amount greater than $50,000, you must fill out a Life Insurance
Insurance.
Evidence of Insurability form. The life insurance vendor will contact you about completing
I am currently enrolled in Life Insurance and
this form. Amount over $50,000 will not be effective until we receive approval from our life
making a change.
insurance carrier.
No, I do not want Life Insurance for myself.
Fill in the amount of Benefit
Cancel Life Insurance.
$ n n n
, n
0 0 0 0
0
0
0
0
n
n
Spouse and Child Life Insurance continued on next page
ENROLLMENT FOR JANUARY 2021-DECEMBER 2021
Life Insurance Plan (continued)
SPOUSE
SECTION 2: SPOUSE INSURANCE
NOTE: You cannot enroll your family members unless you, the employee, are enrolled. You cannot select an amount for your dependents greater than
50% of the amount selected for yourself.
OPTIONS-Choose only one
Choose a Coverage Amount in increments of $5,000 up to 1/2 of the amount
chosen for yourself, up to $150,000:
Having selected Life Insurance for myself, I
wish to have Life Insurance on my spouse.
STOP-If you choose an amount greater than $25,000, you must fill out a Life Insurance
Evidence of Insurability for your spouse. The life insurance vendor will contact you about
I currently have Life Insurance for my spouse
completing this form. Amount over $25,000 will not be effective
and am making a change.
until we receive approval from our life insurance carrier.
No, I do not want Life Insurance on my spouse.
Fill in the amount of Benefit
$ n n n , n
0
0 0 0
0
0
Cancel Life Insurance on my spouse.
n
n
CHILDREN
SECTION 3: CHILD(REN) INSURANCE
NOTE: You cannot enroll your family members unless you, the employee, are enrolled. You cannot select an amount for your dependents greater than
50% of the amount selected for yourself.
OPTIONS-Choose only one
Choose a Coverage Amount in increments of $5,000 up to 1/2 of the amount
Having selected Life Insurance for myself, I
chosen for yourself, up to $150,000:
wish to have Life Insurance for my child(ren).
STOP-If you choose an amount greater than $25,000, you must fill out a Life Insurance
I currently have Life Insurance for my child(ren)
Evidence of Insurability for each covered child. The life insurance vendor will contact you about
and am making a change.
completing this form. Amount over $25,000 will not be effective until we receive approval from
No, I do not want Life Insurance on my
our life insurance carrier.
child(ren).
Fill in the amount of Benefit
Cancel Life Insurance on my child(ren).
$ n n n , n
0
0 0 0
0
0
n
n
Employee Signature
Please enroll me for the benefits indicated on this form. I understand the benefits and limitations provided by the various plans. To the extent deemed necessary
by the Plan Administrator for the proper administration of my coverages, I authorize the release of all medical records and related information pertaining to me or
my dependents. The personal information provided on this enrollment form is warranted to be complete, accurate, and in accordance with Department of Budget and
Management (DBM) regulations. The Mandatory Insurer Reporting Law 42 U.S.C. 1395y(b)(7) requires group health plans to report SSNs in order for Medicare
to coordinate payments with other insurance benefits. Please refer to our Notice of Privacy Practices in the Benefit Guide and on our website for more detailed
information. I understand that I cannot cancel or change my enrollment except during an Open Enrollment period or as a result of a change in status
permitted by COMAR 17.04.13.04 and IRS Section 125.
I understand that the benefits program offered by the State is subject to modifications and changes and that the benefits I have chosen on this enrollment form are only
in effect for the current plan year. The State of Maryland reserves the right to modify any of the benefits provided and gives no assurances, expressed or implied, that any
coverage obtained hereunder will continue beyond the end of the current plan year. I certify that neither I nor my covered dependents are covered under another
State of Maryland employee’s or retiree’s membership for which I or they are enrolled on this form.
I certify that I and any dependents listed for coverage are eligible for coverage. I understand that enrollment in benefits to which I or my dependents are not entitled
is considered fraud. In all cases I am responsible for the accuracy of my benefits, coverage levels and premiums. I further understand that if I willfully misrepresent
the eligibility of myself or my dependents on my benefits application, or fail to take the necessary action to remove ineligible dependents, or in any way obtain benefits to
which I am not entitled, my benefits will be cancelled. I may be required to repay any claims and insurance premiums which have been paid inappropriately, and I may face
criminal investigation and prosecution.
I further solemnly affirm under the penalties of perjury under applicable state laws that any dependent information I have provided is true and accurate. I understand
that willful falsification of information contained in this attestation can result in referral of the matter for investigation and prosecution, the termination of enrollment
and coverage of the person identified as my dependent, and the termination of coverage for myself (the employee). I understand that a civil action may be brought
against me for any losses, including reasonable attorney fees because of a false statement contained in this attestation, and that other serious consequences may result.
I further attest and agree that if a dependent’s status changes and the dependent is no longer eligible, I will notify my Agency Benefit Coordinator or the Employee
Benefits Division immediately to remove this dependent from my coverage. I also agree to provide the required documentation as outline in the current plan year’s
Benefits Guide to substantiate the information I have provided, and affirm that each enrolled dependent is my true tax dependent.
X __________________________________________________
_____/______/_______
Employee Signature
Date
NOTE: If you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact the plan’s member
service department before signing this application. Plan phone numbers are listed on the inside front cover of the Benefits Guide.
Agency Signature -
Agency Must Sign Here FORMS WILL NOT BE PROCESSED WITHOUT AN AGENCY SIGNATURE
I hereby certify that I have reviewed the form and all accompanying documents for accuracy.
X __________________________________________________
_____/______/_______
(_____) _______________
______________________
Agency Benefits Coordinator
Date
Work Phone Number (Ext.)
Department
__________________________________________________
(_____) _______________
Agency Benefits Coordinator Email Address
Fax Number
CEF20
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