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CITY OF

BALTIMORE

DEPARTMENT OF

HUMAN RESOURCES





TABLE OF CONTENTS

SECTION

TOPIC

Section 1

New and Important Information

1

Retiree Contacts Phone Numbers & Websites

2

Information About Your Benefits for 2021

3

Administrative Information

4

Enrollment Process

5

Qualifying Life Events and Status Changes

7

Documentation for Newly Added Dependents & Family

Status Changes

9

Medicare Information

10

Important Medicare Information

11

Notice of Creditable Coverage

15

Medicare Beneficiary Identifier (MBI/HIC)

18

Retiree Contribution Schedule

19

Graduated Retiree Contribution Schedule

20

Graduated Retiree Contribution Schedule FAQs

21

Section 2

Section 3

2021 Retiree Medical Plan Rate Chart Monthly Deduction

Retiree Contribution for Retirees 15+ Years

2021 Retiree Medical Plan Rate Chart Monthly Deduction

Retiree Contribution for Retirees 10-14 Years

2021 Retiree Medical Plan Rate Chart Monthly Deduction

Retiree Contribution for Retirees 5-9 Years

Section 4

PAGE

22

23

24

Retiree Prescription Drug Coverage Premium

25

Medical Plan Comparison Chart (Non-Medicare)

26

Comparing Medical Plan Benefits

27

Retiree Benefit Plan Without Medicare

27

Dependent Benefit Plan Without Medicare of a Retiree

With Medicare

33

Table of Contents I

TABLE OF CONTENTS

(continued)

Section 5

Section 6

Medical Plan Comparison Chart (Medicare)

36

Comparing Medical Plans

37

Retiree Benefit Plans With Medicare

37

Rx, Dental, Vision & Life Insurance

40

Rx Copays CareFirst: High Option

41

Rx Copays CareFirst: Standard Option

42

Rx Copays Aetna & Kaiser: MAPD

43

National Vision Administrators (NVA)

44

United Concordia: Dental HMO

45

United Concordia: Dental PPO

47

Retiree Life Insurance Information

48

Table of Contents II

SECTION 1

NEW AND IMPORTANT INFORMATION

Page 1

RETIREE CONTACTS

PHONE NUMBERS & WEBSITES

Insurance Companies

Phone Number

Provider

BlueChoice Advantage (PPO)

(Non-Medicare Retirees)

Aetna Medicare Advantage Plan (PPO)

with Extended Service Area (ESA)

Including Prescription Drug Benefits

Aetna Open Choice (PPO)

(Non-Medicare Beneficiary &

Dependents)

Kaiser Permanente (HMO)

(Non-Medicare Retirees)

Kaiser MAPD (Medicare Retirees)

CareFirst Caremark/CVS

(Non-Medicare Retirees)

National Vision Administrators (NVA)

MetLife

United Concordia Dental

(800) 535-2292



(855) 335-1407

TTY 711



(877) 440-4711



(866) 248-0715



(800) 241-3371



(800) 672-7723

(866) 492-6983

e-

mybenefits



baltimore

(866) 851-7568

Retirement Agencies

Provider

Phone Number

Baltimore City Employee Retirement

(877) 273-7136

System (ERS)

Fire & Police Retirement System

(888) 410-1600

(F&P)

Maryland State Retirement System

(800) 492-5909

Office of Employee Benefits

Provider

Phone Number

7 E. Redwood Street, 20th Floor

(410) 396-5830

Baltimore, MD 21202

(410) 396-5216

Medicare/CMS/ SSA

Provider

Phone Number

(800) MEDICARE

Medicare Service Center

((800) 633-4227)

TTY (877) 486-2048

Local

(410) 786-3000

Centers for Medicare & Medicaid

TTY Toll-Free

Services (CMS)

(866) 226-1819

TTY Local

(410) 786-0727

Social Security Administration

Website

(800) 772-1213

TTY (800) 325-0778

Website





sra.state.md.us/

Website



ogin

Website







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