Form Dirpef14 - Direct Pay Enrollment Form 2015 Health Benefits Page 3
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4ENROLLMENT FOR JANUARY 2015-DECEMBER 2015
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:
Mark the event that applies to you:
Mark the event, if different, that applies to your dependent:
MAXIMUM PERIOD OF TIME ELIGIBLE
MAXIMUM PERIOD OF TIME
QUALIFYING EVENT
QUALIFYING EVENT
FOR CONTINUATION*
ELIGIBLE FOR CONTINUATION*
18 months or until eligible for group coverage
36 months or until eligible for group coverage
1. Terminated employee (other than for
6. Spouse or child of a State employee/retiree
through another source including Medicare
through another source including Medicare
gross misconduct)
who has elected Medicare as the only coverage
and the spouse or child is not eligible for
Medicare
18 months or until eligible for group coverage
36 months or until eligible for group coverage
2. Resigned
7. Previously dependent child of an employee/
through another source including Medicare
through another source including Medicare
retiree who is no longer eligible by reason of
age or death of employee
18 months or until eligible for group coverage
36 months or until eligible for group coverage
3. Laid off employee
8. Death of a State employee/retiree
through another source including Medicare
through another source including Medicare
* The period of continuation of coverage is the number of months listed, or until
18 months or until eligible for group coverage
4. Employee whose hours have been
through another source including Medicare
reduced
eligible for coverage elsewhere, whichever is less.
Indefinitely or at the time of remarriage or until
5. Divorce or legally separated spouse
eligible for group coverage through another
of a current State employee/retiree
source including Medicare
Medical Benefits - Available to COBRA, 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
Bargaining Unit I members only (SLEOLA) on LAW:
Cancel current coverage
(Complete Medicare Information below)
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 (P):
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 COBRA, 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 COBRA, 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
No, I do not want to enroll in this benefit
Individual & Family
Dentist office once enrolled. Call plan or see plan
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 COBRA and LAW
*For Employees Who Had Flexible Spending Accounts During Active Status during the January 2015-December 2015 plan year.
THIS IS NOT A PRE-TAX BENEFIT WHILE IN DIRECT PAY STATUS AND SERVICES MUST BE INCURRED BY MARCH 15, 2016.
Healthcare Spending Account
I want to continue my Healthcare Spending Account for January 2015-December
Cancel my Healthcare Spending Account. Expenses incurred
2015. 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.
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