2021 Retiree Benefits Enrollment Form 10 - Human Resources

City of Baltimore Department of Human Resources 7 E Redwood St, 20th Floor Baltimore, MD 21202

ENROLLMENT FORM DEADLINE __________________________

2021 RETIREE BENEFITS ENROLLMENT FORM

Event: Retirement

Effective Date:

Event: Open Enrollment

Effective Date:

INSTRUCTIONS: Step 1: Review your 2021 Retiree Benefits Booklet and 2021 Medical & Prescription Drug Plan Rate Charts before making your elections.

Step 2: Review Your Current Retiree and Dependent Information. If you want to enroll eligible dependents, please provide the information requested in the spaces provided below. Attach a copy of the Medicare card, if enrolled, if the information is missing or incorrect. 00# Last Name: ________________ First Name: ________________MI:__ Social Security Number:______________ Date of Birth: ______________ Gender: ______ Relationship: __________________________ Medicare #:__________________ Medicare Part A Date:_______________ Medicare Part B Date:________________ (If enrolled, attach copy of Medicare card.)

01# Last Name: ________________ First Name: ________________MI:__ Social Security Number:______________ Date of Birth: ______________ Gender: ______ Relationship: __________________________ Medicare #:__________________ Medicare Part A Date:_______________ Medicare Part B Date:________________ (If enrolled, attach copy of Medicare card.)

02# Last Name: ________________ First Name: ________________MI:__ Social Security Number:______________ Date of Birth: ______________ Gender: ______ Relationship: __________________________ Medicare #:__________________ Medicare Part A Date:_______________ Medicare Part B Date:________________ (If enrolled, attach copy of Medicare card.)

03# Last Name: ________________ First Name: ________________MI:__ Social Security Number:______________ Date of Birth: ______________ Gender: ______ Relationship: __________________________ Medicare #:__________________ Medicare Part A Date:_______________ Medicare Part B Date:________________ (If enrolled, attach copy of Medicare card.)

Step 3 - A: Review the 2021 Medical Plan Rate Chart to determine your medical plan option, coverage level and cost. Then elect (X) for the medical plan you and your dependents, if any, are eligible for based on the Medicare status of each person and write the monthly medical plan cost in the spaces below.

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____BlueChoice Advantage PPO High Option with United Concordia DHMO Dental Plan

____Kaiser Permanente HMO/ without Medicare

(All Non-Medicare Members Only) Monthly Cost:

____BlueChoice Advantage PPO Standard Option with United Concordia DHMO Dental Plan

MonthlyCost: ______________________

____Kaiser Permanente HMO/Medicare Advantage* with Kaiser's DHMO Dental

(All Non-Medicare Members Only)

(Non-Medicare & Medicare Parts A&B Members)

MonthlyCost: ______________________

MonthlyCost: ______________________

____Aenta MAPD Plan without United Concordia DHMO Dental

(All Medicare A&B Members Only)

____I Want to Opt-Out of my Medicare Advantage Plan

Monthly Cost: ______________________

____AETNA MAPD(Non-Med) Plan with United Concordia DHMO Dental Plan & AETNA MAPD without DHMO Dental Plan

*Kaiser Permanente is Zip Code specific and requires a Primary Care Physician (PCP).

(Combination of Non-Medicare & Medicare A&B Members)

Monthly Cost: ______________________

Important Information About the BlueChoice Advantage PPO & AETNA MAPD Plans:

Members that elect the BlueChoice Advantage PPO High/Standard Option Plan and become eligible for Medicare Parts A&B due to attaining age 65 will automatically be enrolled in the Aenta MAPD Plan with no dental coverage. If you or your dependents become eligible for Medicare Parts A&B due to a disability determined by the Social Security Administration, a copy of the Medicare card must be submitted to Employee Benefits in order to initiate the enrollment into the Aetna MAPD Plan.

Members enrolled in the MAPD Supplemental Plan are not entitled to dental coverage.

Important Information About the Kaiser Permanente Medicare Advantage Plan:

Members that elect the Kaiser Permanente HMO Plan and become Medicare eligible must notify the Office of Employee Benefits that you are enrolled in both Medicare Parts A&B. Please send our office a copy of your Medicare ID Card. Once we receive the Medicare Card, we will enroll you in the Kaiser Medicare Advantage Plan (MAPD). Upon enrollment in the Kaiser Medicare Advantage Plan, you will receive an Opt-Out letter in the mail from Kaiser. If you want to remain in the Kaiser MAPD plan, you don't have to do anything, you will remain enrolled.

If you should decide that you do not want to be enrolled in the MAPD plan offered by Kaiser, then you must notify the office of Employee Benefits immediately at 410-396-1780/1781. You may also submit your request to opt out in writing to the Office of Employee Benefits, 7 E. Redwood Street, 20th floor, Baltimore MD 21202.

Step 3 ? B: Indicate below whom you want to enroll in the medical plan elected on the reverse including yourself by writing the 2-digit employee/dependent number (from Step 2 next to the employee/dependent name) in the spaces provided below.

Medical & Dental: (Example) 00

/______/______/______/______/______/______/______/______/______/

Step 4 - A: Review the 2021 Prescription Drug Plan Rate Chart to determine your prescription drug plan option, coverage tier and cost. You and your dependents must be enrolled in a Baltimore City medical plan in order to have prescription drug coverage. (If you elect BlueChoice Advantage PPO Standard Option medical plan, you may only elect the CareFirst CVS (Standard Option) prescription drug plan or No Coverage. If you elect any other medical plan, you may only elect the CareFirst CVS (High Option) prescription drug plan or No Coverage.) Then elect (X) for the prescription drug plan for you and your dependents, if any.

_____CareFirst CVS High Option

_____CareFirst CVS Standard Option

_____No Coverage

Step 4 ? B: Indicate below whom you want to enroll in the prescription drug plan elected above including yourself by writing the 2-digit retiree /dependent number (from Step 2 next to the employee/dependent name) in the spaces provided below.

Prescription Drug: (Example) 00 /

/

/

/

/

/

/

/

/

/

Step 5 - A: Review the Vision benefit in your 2021 Retiree Benefits Booklet. If eligible, elect (X) for the vision plan below.

_____ National Vision Administrators (NVA)

_____ No Coverage

Step 5 - B: Indicate below whom you want to enroll in the vision plan elected above including yourself by writing the 2- digit retiree/dependent number (from Step 2 next to the retiree/dependent name) in the space provided below.

Vision (If eligible): (Example) 00 /

/

/

/

/

/

/

/

/

/

Step 6: Documentation is required for newly added dependents to show proof of relationship. Refer to the Required Documentation Form for Ongoing Enrollment.

Step 7: The City of Baltimore requires all retired members covered under a Baltimore City medical plan to enroll in Medicare Part B through Social Security Administration (SSA) at the time they become eligible for Medicare Part A. Once enrolled in Part B, they must remain enrolled in order to receive the maximum possible benefit. Attach a copy of the Medicare card for you and/or your dependent(s) if you or your dependents are enrolled in Medicare Parts A&B and the information, we have on file is missing or incorrect.

Step 8: Provide your contact information in the spaces provided below.

Phone # (Home): _______________

Phone # (Cell): ______________

Email: ____________________

Step 9: Sign and date this enrollment form. Mail this form and a copy of your required documentation (such as court- certified marriage certificates, birth certificate, etc.) for newly added dependents and Medicare card for members enrolled in Medicare Part A&B, if applicable, to Office of Employee Benefits, 7 E. Redwood Street, 20th Floor, Baltimore, MD 21202 by you enrollment form deadline.

Signature:

Date:

Step 10: If you have any questions, please contact the Office of Employee Benefits between 8:30 AM EST and 4:30 PM EST at 410-396-5830 and select option 2 (City Retirees) or 3 (BCPSS Retirees) and then option 1 to speak to an Employee Benefits Specialist.

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