COBRA ENROLLMENT FORM
JANUARY 2024-DECEMBER 2024 HEALTH BENEFITS
PERSONAL DATA
PLEASE PRINT CLEARLY
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
Change in Family Status (See Benefits Guide for documentation requirements)
Note: Request must be made within 60 days of the qualifying event
Add dependent because of:
Marriage Date: ___________
Birth/Adoption/Appointed Permanent Legal Guardian
Date: __________
Other/Reason: ________________________________________
ALL Required dependent documentation must be attached
when adding a dependent
Remove dependent because of:
Divorce/Limited Divorce/Legal Separation/Dissolution of
Domestic Partnership Date: ___________
Death Date __________ (Attach copy of Death Certificate)
Dependent no longer eligible Date: _______________
Reason: _____________________________________________
Other: _______________________________________________
COBRA Date of Qualifying Event: __________
Are you on Medicare? Yes No
Open Enrollment - Effective January 1st
Cancel all Coverage in all Plans/Qualifying Event:
___________________________________________________
STATE OF MARYLAND
Name: __________________________________________________
Address: _____________________________ Apt/Condo: ________
City: _______________________ State: _____Zip Code: ________
Home Phone: ( __ __ __) __ __ __ - __ __ __ __
Work Phone: ( __ __ __) __ __ __ - __ __ __ __
Cell Phone: ( __ __ __) __ __ __ - __ __ __ __
Personal E-mail: _________________________________________
Work E-mail: ____________________________________________
Social Security Number: __ __ __ /__ __ / __ __ __ __
Date of Birth: __ __/__ __/__ __ __ __
MM /DD/ YYYY
Sex: Male LEGAL MARITAL STATUS:
Female Single Widowed
Married Divorced
Limited Divorce/Legal Separation
COMPLETED AND SIGNED ENROLLMENT FORMS MAY BE SENT BY EMAIL OR REGULAR MAIL TO:
Employee Benefits Division
301 W. Preston Street, Room 510
Baltimore, Maryland 21201
Phone: 410-767-4775 or 1-800-307-8283 / Fax: 410-333-5191 /
Email: [email protected]
LAST FIRST MI
Health benefits information and forms are available on our website: www.dbm.maryland.gov/benefits
COBRA POLICY HOLDER INFORMATION/FORMER DEPENDENT
Name: __________________________________________________
Address: _____________________________ Apt/Condo: ________
City: _______________________ State: _____Zip Code: ________
Home Phone: ( __ __ __) __ __ __ - __ __ __ __
Work Phone: ( __ __ __) __ __ __ - __ __ __ __
Cell Phone: ( __ __ __) __ __ __ - __ __ __ __
Personal E-mail: _________________________________________
Work E-mail: ____________________________________________
W#: W __ __ __ __ __ __ __
Social Security Number: __ __ __ /__ __ / __ __ __ __
Date of Birth: __ __/__ __/__ __ __ __
MM /DD/ YYYY
Sex: Male LEGAL MARITAL STATUS:
Female Single Widowed
Married Divorced
Limited Divorce/Legal Separation
LAST FIRST MI
EMPLOYEE/FORMER EMPLOYEE/RETIREE INFORMATION
A
D
C
LAST NAME FIRST NAME, MI SEX
DATE OF
BIRTH
MM/DD/YYYY
RELATIONSHIP SOCIAL SECURITY NO.
( ) COVER THIS DEPENDENT FOR:
MEDICAL DRUG DENTAL
ENROLLMENT FOR JANUARY 2024-DECEMBER 2024
DEPENDENT INFORMATION
PLEASE PRINT
Dependent means your eligible: (a) spouse, (b) domestic partner, (c) dependent child(ren), or (d) domestic partner dependent children. All dependent children include biological, adopted,
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 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.
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.
• Proof of prior employer-sponsored coverage may be required.
Mark the event that applies to you: Mark the event, if different, that applies to your dependent:
QUALIFYING EVENT
MAXIMUM PERIOD OF
TIME ELIGIBLE FOR
CONTINUATION*
QUALIFYING EVENT
MAXIMUM PERIOD OF
TIME ELIGIBLE FOR
CONTINUATION*
1. Terminated employee (other than for
gross misconduct)
18 months or until eligible for
group coverage through another
source including Medicare
6. Spouse or child of a State employee/
retiree who has elected Medicare as
the only coverage and the spouse or
child is not eligible for Medicare
36 months or until eligible for
group coverage through another
source including Medicare
2. Resigned
18 months or until eligible for
group coverage through another
source including Medicare
7. Previously dependent child of an
employee/retiree who is no longer
eligible by reason of age or death of
employee
36 months or until eligible for
group coverage through another
source including Medicare
3. Laid off employee
18 months or until eligible for
group coverage through another
source including Medicare
8. Death of a State employee/retiree
36 months or until eligible for
group coverage through another
source including Medicare
4. Employee whose hours have been
reduced
18 months or until eligible for
group coverage through another
source including Medicare
12. Personal Leave
18 Months or until eligible for
group coverage through another
source including Medicare
5. Divorce or legally separated spouse of
a current State employee/retiree
Indefinitely or at the time of
remarriage or until eligible for
group coverage through another
source including Medicare
13. Suspension
18 Months or until eligible for
group coverage through another
source including Medicare
COBRA - Consolidated Omnibus Budget Reconciliation Act and Other Continuation Coverage
You and your eligible dependents may continue health coverage if the loss of coverage is due to one of the following qualifying events:
* The period of continuation of coverage is the
number of months listed, or until eligible for coverage elsewhere, whichever is less.
Medical Benefits
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 & Domestic Partner UnitedHealthcare EPO
this benefit Individual & Family UnitedHealthcare PPO
Cancel current coverage End Stage Renal Disease (ESRD)
(Complete Medicare Information below)
ENROLLMENT FOR JANUARY 2024-DECEMBER 2024
Dental Coverage
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
website for details.
No, I do not want to enroll in this benefit Individual & Domestic Partner
Cancel current coverage
Individual & Family
Prescription Drug Coverage
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 & Domestic Partner Individual & Family
Individual & One Child
If you or a dependent have Medicare, please write in name, Medicare number, and effective date of Medicare coverage. Medicare Part A&B enrollment is required for full
claims coverage.
*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.
Medical plans do not include Prescription Drug or Dental coverage. Separate selections are required (see below).
NOTE: Vision benefits are included if enrolled in a medical plan.
NAMES OF INDIVIDUALS
WITH MEDICARE
MEDICARE
NUMBER
PART A
(Hospital Claims)
Effective Date
MM/DD/YYYY
PART B
(Medical Claims)
Effective Date
MM/DD/YYYY
PART D
(Prescription Drug)
Effective Date
MM/DD/YYYY
MEDICARE DUE
TO ( ):
Age 65
Disabled
ESRD
Employee
Spouse
Domestic Partner
Child
Child
ENROLLMENT FOR JANUARY 2024-DECEMBER 2024
COBRAEF24
COBRA Policy Holder Signature
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. Details can be found at
mymdbenefits.com. 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 or the continuation period has expired, whichever is earlier.. 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 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 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, with the exception of a domestic partner or domestic partner’s child(ren), is my true tax dependent.
X _______________________________________________________________________________ ____________________________
COBRA Policy Holder Signature Date
Flexible Spending Account - Healthcare
-
Domestic partners and the dependent children of domestic partners are not eligible for FSA reimbursement
*For Employees Who Had Flexible Spending Accounts During Active Status during the January 2024-December 2024 plan year.
THIS IS NOT A PRE-TAX BENEFIT WHILE IN DIRECT PAY STATUS AND SERVICES MUST BE INCURRED BY MARCH 15, 2025.
Healthcare Spending Account
I want to continue my Healthcare Spending Account for January 2024-December
2024. Note: COBRA enrollees will be billed for the same total deduction amount
as an active employee plus a 2% fee on a post-tax basis.
Cancel my Healthcare Spending Account. Expenses incurred
prior to the cancellation date may be reimbursed up to the limit
of your Healthcare FSA.
NOTE: All claims must be submitted for reimbursement. Debit card will not be active.
