"Direct Pay Enrollment Form - Health Benefits" - Maryland

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STATE OF MARYLAND
DIRECT PAY ENROLLMENT FORM
JANUARY 2022-DECEMBER 2022 HEALTH BENEFITS
PERSONAL DATA
PLEASE PRINT CLEARLY
EMPLOYEE/FORMER EMPLOYEE/RETIREE INFORMATION
FORMER DEPENDENT INFORMATION
(if different from employee’s information)
Name: __________________________________________________
Name: __________________________________________________
LAST
FIRST
MI
LAST
FIRST
MI
Address: _____________________________ Apt/Condo: ________
Address: _____________________________ Apt/Condo: ________
City: _______________________ State: _____Zip Code: ________
City: _______________________ State: _____Zip Code: ________
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
Personal E-mail: _________________________________________
Personal E-mail: _________________________________________
Work E-mail: ____________________________________________
Work E-mail: ____________________________________________
W#: W __ __ __ __ __ __ __
Social Security Number: __ __ __ /__ __ / __ __ __ __
Social Security Number: __ __ __ /__ __ / __ __ __ __
Date of Birth: __ __/__ __/__ __ __ __
MM /DD/ YYYY
Date of Birth: __ __/__ __/__ __ __ __
Sex:
LEGAL MARITAL STATUS:
Male
MM /DD/ YYYY
Single
Widowed
Female
Sex:
LEGAL MARITAL STATUS:
Married
Divorced
Male
Single
Widowed
Limited Divorce/Legal Separation
Female
Married
Divorced
Limited Divorce/Legal Separation
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
Change in Family Status
Part-Time Employee (Less than 50%)
(See Benefits Guide for documentation requirements)
Note: Request must be made within 60 days of the date of the qualifying event
LAW-MILITARY (Unpaid Leave of Absence - Military)
Add dependent because of:
Training
Active Duty
Marriage
Date: ___________
Effective Date of LAW-MILITARY: __________
Birth/Adoption/Appointed Permanent Legal Guardian
End Date of LAW-MILITARY: __________
Date: __________
LAW-OJI (Unpaid Leave of Absence – On the Job Injury)
Other/Reason: ________________________________________
Effective Date of LAW-OJI: __________
ALL Required dependent documentation must be attached
End Date of LAW-OJI: __________
when adding a dependent
(May not exceed 2 years - proof of payment from IWIF or
Remove dependent because of:
worker’s comp required.)
Divorce/Limited Divorce/Legal Separation Date: ___________
Open Enrollment - Effective January 1st
Death
Date __________ (Attach copy of Death Certificate)
New Enrollment
Dependent no longer eligible
Date: _______________
Cancel all Coverage in all Plans/Reason:
Reason: _____________________________________________
___________________________________________________
Other: _______________________________________________
COMPLETED AND SIGNED ENROLLMENT FORMS MAY BE MAILED TO:
Form must be signed by the Agency Benefit Coordinator for the status LAW_Military and LAW-OJI
Employee Benefits Division
Hours of Operations: Monday - Friday 8:30 a.m. - 4:30 p.m.
EBD Use Only:
Enrollment Unit
____ Reviewed
Phone: 410-767-4775 or 1-800-307-8283 / Fax: 410-333-5191 /
301 W. Preston Street, Room 510
Email: enrollment.ebd@maryland.gov
____ Processed
Baltimore, Maryland 21201
____ Audited
Health benefits information and forms are available on our website: www.dbm.maryland.gov/benefits
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STATE OF MARYLAND
DIRECT PAY ENROLLMENT FORM
JANUARY 2022-DECEMBER 2022 HEALTH BENEFITS
PERSONAL DATA
PLEASE PRINT CLEARLY
EMPLOYEE/FORMER EMPLOYEE/RETIREE INFORMATION
FORMER DEPENDENT INFORMATION
(if different from employee’s information)
Name: __________________________________________________
Name: __________________________________________________
LAST
FIRST
MI
LAST
FIRST
MI
Address: _____________________________ Apt/Condo: ________
Address: _____________________________ Apt/Condo: ________
City: _______________________ State: _____Zip Code: ________
City: _______________________ State: _____Zip Code: ________
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
Personal E-mail: _________________________________________
Personal E-mail: _________________________________________
Work E-mail: ____________________________________________
Work E-mail: ____________________________________________
W#: W __ __ __ __ __ __ __
Social Security Number: __ __ __ /__ __ / __ __ __ __
Social Security Number: __ __ __ /__ __ / __ __ __ __
Date of Birth: __ __/__ __/__ __ __ __
MM /DD/ YYYY
Date of Birth: __ __/__ __/__ __ __ __
Sex:
LEGAL MARITAL STATUS:
Male
MM /DD/ YYYY
Single
Widowed
Female
Sex:
LEGAL MARITAL STATUS:
Married
Divorced
Male
Single
Widowed
Limited Divorce/Legal Separation
Female
Married
Divorced
Limited Divorce/Legal Separation
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
Change in Family Status
Part-Time Employee (Less than 50%)
(See Benefits Guide for documentation requirements)
Note: Request must be made within 60 days of the date of the qualifying event
LAW-MILITARY (Unpaid Leave of Absence - Military)
Add dependent because of:
Training
Active Duty
Marriage
Date: ___________
Effective Date of LAW-MILITARY: __________
Birth/Adoption/Appointed Permanent Legal Guardian
End Date of LAW-MILITARY: __________
Date: __________
LAW-OJI (Unpaid Leave of Absence – On the Job Injury)
Other/Reason: ________________________________________
Effective Date of LAW-OJI: __________
ALL Required dependent documentation must be attached
End Date of LAW-OJI: __________
when adding a dependent
(May not exceed 2 years - proof of payment from IWIF or
Remove dependent because of:
worker’s comp required.)
Divorce/Limited Divorce/Legal Separation Date: ___________
Open Enrollment - Effective January 1st
Death
Date __________ (Attach copy of Death Certificate)
New Enrollment
Dependent no longer eligible
Date: _______________
Cancel all Coverage in all Plans/Reason:
Reason: _____________________________________________
___________________________________________________
Other: _______________________________________________
COMPLETED AND SIGNED ENROLLMENT FORMS MAY BE MAILED TO:
Form must be signed by the Agency Benefit Coordinator for the status LAW_Military and LAW-OJI
Employee Benefits Division
Hours of Operations: Monday - Friday 8:30 a.m. - 4:30 p.m.
EBD Use Only:
Enrollment Unit
____ Reviewed
Phone: 410-767-4775 or 1-800-307-8283 / Fax: 410-333-5191 /
301 W. Preston Street, Room 510
Email: enrollment.ebd@maryland.gov
____ Processed
Baltimore, Maryland 21201
____ Audited
Health benefits information and forms are available on our website: www.dbm.maryland.gov/benefits
ENROLLMENT FOR JANUARY 2022-DECEMBER 2022
DEPENDENT INFORMATION
PLEASE PRINT
Dependent means your eligible: (a) spouse, or (b) dependent child(ren) (including biological child, adopted child, stepchild, grandchild, step grandchild, legal ward). See Benefits Guide
for a complete listing of eligible dependents and the dependent documentation requirements.
PLEASE PRINT YOUR DEPENDENT INFORMATION BELOW AND ATTACH ALL REQUIRED DEPENDENT DOCUMENTATION. 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.
• Proof of prior employer-sponsored coverage may be required.
• 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 2022-DECEMBER 2022
Medical Benefits - Available to LAW/Part-Time
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE MEDICAL PLAN:
New Enrollment
Individual Only
CareFirst BC/BS EPO
Change in plan
Individual & One Child
CareFirst BC/BS PPO
Addition or removal of dependent
Individual & Spouse
Kaiser IHM*
No, I do not want to enroll in
Individual & Family
UnitedHealthcare EPO
this benefit
End Stage Renal (ESRD)
UnitedHealthcare PPO
Cancel current coverage
(Complete Medicare Information below)
Bargaining Unit I members only (SLEOLA) on LAW:
CareFirst BC/BS EPO Mod-I
CareFirst BC/BS POS Mod-I
CareFirst BC/BS PPO Mod-I
*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.
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.
If you or a dependent have Medicare, please 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
Effective Date
Effective Date
Effective Date
MEDICARE DUE TO ( ):
WITH MEDICARE
(with suffix)
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
Age 65
Disabled
ESRD
Employee
Spouse
Child
Child
Prescription Drug Coverage - Available to LAW/Part-Time
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
New enrollment
No, I do not want to enroll in this benefit
Individual Only
Individual & Spouse
Addition or removal of dependent
Cancel current coverage
Individual & One Child
Individual & Family
Dental Coverage - Available to LAW/Part-Time
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE DENTAL PLAN:
New enrollment
Individual Only
United Concordia DPPO
Change in plan
Individual & One Child
Delta Dental DHMO
Addition or removal of dependent
Individual & Spouse
For the DHMO Plan: You must select a primary
Dentist office once enrolled. Call plan or see plan
No, I do not want to enroll in this benefit
Individual & Family
website for details.
Cancel current coverage
Accidental Death and Dismemberment Benefits - Available to LAW/Part-Time
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE BENEFIT AMOUNT:
New enrollment
Individual 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
Flexible Spending Account - Healthcare - Available to LAW
*For Employees Who Had Flexible Spending Accounts During Active Status during the January 2022-December 2022 plan year.
THIS IS NOT A PRE-TAX BENEFIT WHILE IN DIRECT PAY STATUS AND SERVICES MUST BE INCURRED BY MARCH 15, 2023.
Healthcare Spending Account
I want to continue my Healthcare Spending Account for January 2022-December
Cancel my Healthcare Spending Account. Expenses incurred
2022. Note: COBRA enrollees will be billed for the same total deduction amount
prior to the cancellation date may be reimbursed up to the limit
as an active employee plus a 2% fee on a post-tax basis.
of your Healthcare FSA.
ENROLLMENT FOR JANUARY 2022-DECEMBER 2022
Life Insurance - Available to LAW/Part-Time
APPLICANT LIFE INSURANCE
Please select a benefit amount in increments of $10,000, up to $300,000:
STOP: If you choose an amount greater than $50,000, you must fill out a Life
Yes, I want to enroll as a new enrollee in Life Insurance.
Insurance Evidence of Insurability form. The life insurance vendor will contact you
Yes, I want to continue my current level of coverage.
about completing this form. Amount over $50,000 will not be effective until we receive
Yes, I want to continue my Life Insurance, but at a different amount.
approval from our life insurance carrier.
No, I do not want to enroll in this benefit.
Fill in the Benefit Amount
Cancel all Life Insurance (applicant and dependent).
$ n n n
, n
0 0 0 0
0
0
0
0
n
n
Coverage available in increments of $10,000 only
DEPENDENT
Choose a coverage amount in increments of $5,000 up to 1/2 of the amount chosen for yourself, up to $150,000.
STOP: If you choose an amount greater than $25,000, you must fill out a Life Insurance Evidence of Insurability form. The life
LIFE INSURANCE
insurance vendor will contact you about completing this form. Amount over $25,000 will not be effective until we receive approval
from our life insurance carrier.
Life Insurance on Spouse
Life Insurance on Child(ren)
Yes, I want Life Insurance for my spouse.
Yes, I want Life Insurance on my child(ren).
Yes, I want to continue my spouse’s Life Insurance
Yes, I want to continue my child(ren)’s Life Insurance
Yes, I want to continue my spouse’s Life Insurance, but at a different amount.
Yes, I want to continue my child(ren)’s Life Insurance, but at a different amount.
No, I do not want to enroll in this benefit.
No, I do not want to enroll in this benefit.
Cancel Life Insurance on my spouse.
Cancel Life Insurance on child(ren)
$ n n n , n
$ n n n , n
0 0 0
0
0
0
0 0 0
0
0
0
n
n
n
n
Please fill in the Benefit amount:
Please fill in the Benefit amount:
Applicant and Agency Signatures
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
representative before signing this application.
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 &
Management 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 elections except during an Open Enrollment period or as the result of a qualifying change in family
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 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 any coverage 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 am 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 canceled, I will be required to repay any claims and insurance premiums, 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/retiree). 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 _______________________________________________________________________________
____________________________
YOUR SIGNATURE
Date
X _______________________________________________________________________________
____________________________
AGENCY SIGNATURE - Agency Must Sign
Date
Agency Code: _____________________ _____________________________________ ______________________________________
Work Phone Number (Ext.)
Fax Number
Check Dist. Code: _____________________
_________________________________________________
Agency Benefit Coordinator Email Address
DIRPEF21
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