Wes Moore, Governor
Aruna Miller, Lieutenant Governor
Helene Grady, Secretary
Marc L. Nicole, Deputy Secretary
Together, we are working toward a healthier community.
January 2024 - December 2024
Th ki d
h l hi i
What’s New in
2024
• 2024 Premium Rates
• Domestic Partner
Eligibility (see page 40)
• Healthcare FSA increase
to $3,050
• Visit mymdbenets.com
for additional information
on all our plans!
Health Benefits
Guide to your
Awareness • Ownership • Accountability • Improvement
EMPLOYEE BENEFITS DIVISION
301 West Preston Street
Room 510
Baltimore, MD 21201
410-767-4775
Fax: 410-333-7104
1-800-30-STATE (1-800-307-8283)
Email us at: [email protected]
Twitter: MdEBDWellness
http://www.dbm.maryland.gov/benefits
HELPFUL CONTACTS
State Retirement Pension System 410-625-5555 or 1-800-492-5909 www.sra.state.md.us
Social Security Administration 1-800-772-1213
www.ssa.gov
Medicare 1-800-Medicare
www.medicare.gov
SPS Benefits System* 410-767-4112
https://wd5.myworkday.com/stateofmaryland/d/home.htmld
Instructions (Job Aids) for SPS Benefits System 410-767-4775
https://dbm.maryland.gov/sps/
PLANS/ACCOUNTS INFORMATION
PLAN PHONE WEBSITE
MEDICAL PLANS
CareFirst BlueCross BlueShield EPO, PPO 1-800-225-0131 1-800-735-2258 (TTY) www.carefirst.com/statemd
Kaiser Permanente IHM 1-855-839-5763 1-855-839-5763
(TTY) MD Relay 711
my.kp.org/maryland
UnitedHealthcare Choice EPO, ChoicePlus PPO 1-800-382-7513 (TTY) MD Relay 711
www.uhcmaryland.com
PRESCRIPTION DRUG PLAN
CVS Caremark (844) 460-8767 (800) 863-5488 (TTY) https://info.caremark.com/stateofmaryland
DENTAL PLANS
Delta Dental DHMO 1-844-697-0578 www.deltadentalins.com/statemd
United Concordia DPPO 1-888-MD-TEETH
(1-888-638-3384)
www.unitedconcordia.com/statemd
FLEXIBLE SPENDING ACCOUNTS
P&A Group 1-844-638-1900 md.padmin.com
TERM LIFE INSURANCE PLAN
MetLife 1-866-574-2863 https://metlife.com/stateofmd
ACCIDENTAL DEATH AND DISMEMBERMENT PLAN
Metlife 1-866-574-2863 https://metlife.com/stateofmd
*MDOT, Judiciary, General Assembly, University and DHS employees should contact your agency help desk for login assistance.
Availability of Summary Health Information
As an employee, the health benets available to you represent a signicant component of your compensation package. They also provide
important protection for you and your family in case of illness or injury.
The State of Maryland oers a series of health coverage options. Choosing a medical plan is an important decision. To help you make an informed
choice, we make available a number of documents including our Guide to Your Health Benets (Guide) and a Summary of Benets and Coverage
(SBC). The SBC summarizes important information about any of the medical plan options available to you in a standard format to help you
compare options. The Guide provides a more detailed description of all of the health benets options available to you, not just the medical plans.
The SBCs are available on our website at www.dbm.maryland.gov/benets. A paper copy is also available, free of charge, by calling the Employee
Benets Division at 410-767-4775 or 1-800-307-8283.
12024 Health Benets Guide
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THIS GUIDE IS NOT A CONTRACT
This guide is a summary of general benets available to State of Maryland eligible employees and retirees
through the State Employee and Retiree Health and Welfare Benets Program (the Program). Wherever
conicts occur between the contents of this guide and the contracts, rules, regulations, or laws governing
the administration of the various programs, the terms set forth in the various program contracts, rules,
regulations, or laws shall prevail. Space does not permit listing all limitations and exclusions that apply to
each plan. Before using your benets, call the plan for information. Benets provided can be changed at
any time without the consent of participants.
Revised 09/01/2023
TABLE OF CONTENTS
What’s New for 2024! ......................................................................3
Wellness Plan .................................................................................4
Medical Benets ............................................................................6
Prescription Drug Benets ............................................................20
Dental Benets ............................................................................26
Flexible Spending Accounts ...........................................................29
Term Life Insurance ......................................................................33
Accidental Death and Dismemberment ..........................................36
Eligibility .....................................................................................37
When Coverage Begins ............................................................................. 37
Enrolling Eligible Dependents ................................................................... 39
Eligibility by Employee/Retiree Type.......................................................... 42
Qualifying Status Changes ........................................................................ 49
Leave of Absence ...................................................................................... 51
When Coverage Ends................................................................................. 54
COBRA Continuation of Coverage .............................................................. 55
Medicare and Your State Benets ............................................................. 57
Important Notices & Information ..................................................63
Benets Appeal Process ............................................................................ 75
Nondiscrimination and Accessibility Requirements Notice ........................ 76
Denitions ................................................................................................ 78
2 2024 Health Benets Guide
The State of Maryland provides a generous benet package to eligible employees and retirees with a wide
range of benet options from healthcare to income protection. The following chart outlines your benet
options for the plan year January 1, 2024 - December 31, 2024.
For details about
each specic plan,
review the sections
in this guide or
see the inside of
the front cover for
contact information
for each of the
plans.
Benet Options
Plan Options Coverage Who Is Eligible*
Medical PPO Plans
• CareFirst BlueCross BlueShield
• UnitedHealthcare
EPO Plans
• CareFirst BlueCross BlueShield
• UnitedHealthcare
IHM
• Kaiser
Provide benets for a variety of
medical services and supplies.
Benet coverage levels vary by plan;
review the information carefully.
Medical plans include routine vision
services and behavioral health
coverage.
• Active Full-time State/
Satellite employees*
• Part-time State employees
• State retirees**
• ORP retirees**
Prescription Drug
• CVS Caremark
• SilverScript EGWP
Provide benets for a variety of
prescription drugs. Some limitations
(quantity limits, prior authorization,
and step therapy) apply for certain
drugs.
Plan wraps around Medicare Part
D for Medicare eligible retirees and
dependents.
• Active Full-time State/
Satellite employees*
• Part-time State employees
• State retirees
• ORP retirees
Dental
DPPO
• United Concordia
DHMO
• Delta Dental
Provide benets for a variety of
dental services and supplies.
• Active Full-time State/
Satellite employees*
• Part-time State employees
• State retirees
• ORP retirees
Flexible Spending
Accounts
P&A Group
• Healthcare
• Dependent Daycare
Allow you to set aside money on a
pre-tax basis to reimburse yourself
for eligible healthcare or dependent
daycare expenses.
• Active Full-time State
employees*
Term Life MetLife
Coverage for you in increments of
$10,000 up to $300,000
Coverage for dependents in
increments of $5,000 up to 50% of
your coverage
Pays a benet to your designated
beneciary in the event of your
death. You are automatically the
beneciary for your dependent’s
coverage.
May be subject to medical review.
• Active Full-time State/
Satellite employees*
• Part-time State employees
• State retirees***
• ORP retirees***
Accidental Death
and
Dismemberment
MetLife
Coverage amounts for yourself and/
or your dependents: $100,000,
$200,000, or $300,000.
Pays a benet to you or your
beneciary in the event of accidental
death or
dismemberment.
• Active Full-time State/
Satellite employees*
• Part-time State
employees
* To be eligible you must meet the eligibility requirements as outlined in the Eligibility section of this guide. Amount of
state subsidy, if any, varies by what category of employee (including contractuals) or retiree you are.
** For retirees and their dependents who are Medicare-eligible, all medical plans are secondary to Medicare Parts A & B
regardless of whether the individual has enrolled in each.
*** Only retirees who are enrolled in life insurance as an active employee at the time of retirement may continue life insurance
coverage in retirement.
OR
Visit our Benets
Microsite
mymdbenets.com
32024 Health Benets Guide
What’s New for 2024?
• Online benets enrollment is mandatory for active and contractual employees who wish
to make or change benets elections for plan year 2024.
• Wellness activities carryover in 2024. See pages 4-5 for details on how to reduce your
costs this calendar year.
• There are no changes to the prescription coverage provided to Medicare eligible retirees
in 2024.
• Healthcare FSA annual amount will increase to $3,050.
• FSA’s require an annual election
– Healthcare funds may be used for employees and their eligible family members
– Dependent care funds may be used for daycare expenses for dependents under the
age of 13
• Flu shots are available at most pharmacies nationwide at no cost!
• Domestic Partner Eligibility
– lived together for at least 12 months
– not married to anyone else nor have another domestic partner
– at least 18 years of age and mentally competent to consent to contract
– reside together in the same residence and intend to do so indenitely
– have an exclusive mutual commitment similar to that of marriage
– are jointly responsible for each other’s common welfare and share nancial
obligations
– visit dbm.maryland.gov/benets for full details
4 2024 Health Benets Guide
Notice Regarding Wellness Plan
The wellness plan administered under the Program is voluntary. Employees, non-Medicare eligible
retirees and spouses or domestic partners who are enrolled in a medical plan are eligible to participate.
The wellness plan is administered in accordance with all federal laws and regulations to the extent
they are applicable to the Program, including but not limited to the Americans with Disabilities Act, the
Genetic Information Nondiscrimination Act, the Health Insurance Portability and Accountability Act, and
the Aordable Care Act. If you choose to participate in the wellness plan, you will be asked to complete
a voluntary health risk assessment or “HRA” that asks a series of questions about your health-related
activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes,
or heart disease). You will also be asked to select a primary care physician (PCP) and complete an age/
gender appropriate preventive screenings for the plan year. You are not required to participate in any of
the wellness activities in order to participate in the Health Benet Program.
However, those employees who choose to participate in the wellness plan and complete all of the
wellness plan activities will receive the following incentives during the 2024 plan year:
• $0 copays for PCP visits and
• a $5 reduction in Specialist copays for:
• Complete one of the recommended screenings
• Complete an annual eye exam
Maximum reduction = $10
The data from your HRA and the results of an annual physical may be used to provide you with
information to help you understand your current health and potential risks. Additionally, you may receive
oers of other services such as free video visits with your PCP lab screens for certain chronic conditions,
health coaching, and/or disease management assistance.
Protections from Disclosure of Medical Information
We are required by law to maintain the privacy and security of your personally identiable health
information. Although the wellness plan under the Program may use aggregate information it collects to
design a program based on identied health risks in the workplace, the Program will never disclose any of
your personal information either publicly or to the employer, except as necessary to respond to a request
from you for a reasonable accommodation needed to participate in the wellness plan, or as expressly
permitted by law. Medical information that personally identies you that is provided in connection with
the wellness plan will not be provided to your supervisors or managers and may never be used to make
decisions regarding your employment.
Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the
extent permitted by law to carry out specic activities related to the wellness plan, and you will not be
asked or required to waive the condentiality of your health information as a condition of participating
in the wellness plan or receiving an incentive. Anyone who receives your information for purposes of
providing you services as part of the wellness plan will abide by the same condentiality requirements.
The only individual(s) who will receive your personally identiable health information are your PCP and
associated personnel and health coach as appropriate and if elected in order to provide you with services
under the wellness plan.
In addition, all medical information obtained through the wellness plan will be stored electronically and
encrypted. Health information obtained through the wellness plan will be maintained separate and apart
from any personnel records unrelated to the Program. Appropriate precautions will be taken to avoid any
Wellness Plan
2023 wellness
activities will
carryover through
Plan Year 2024.
52024 Health Benets Guide
data breach, and in the event a data breach occurs involving information you provide in connection with
the wellness plan, we will notify you immediately.
You may not be discriminated against in employment because of the medical information you provide
as part of participating in the wellness plan, nor may you be subjected to retaliation if you choose not to
participate.
If you have questions or concerns regarding this notice, or about protections against discrimination
and retaliation, please contact – Employee Benets Division at compliance.ebd@maryland.gov or
410.767.4775.
For information concerning the 2024 Wellness Plan activities, go to the Employee Benets Wellness
website at www.dbm.maryland.gov/benefits and click on the Wellness tab at the top of the screen.
There you will nd the 2024 Wellness Plan Activities and additional wellness resources available to you.
6 2024 Health Benets Guide
Medical Benets
The State oers several comprehensive medical plan options—all designed to reduce your out-of-pocket
cost for most medically necessary services and promote wellness. Please note that prescription
coverage must be elected separately. Members of the State Law Enforcement Ocers Labor Alliance
(SLEOLA) please refer to the SLEOLA Addendum for medical coverage options and rates.
Choosing a Medical Plan
You have ve medical plans from which to choose:
Two PPO options:
• CareFirst BlueCross BlueShield PPO
• United Healthcare PPO
Two EPO options:
• CareFirst BlueCross BlueShield EPO
• United Healthcare EPO
One IHM option:
• Kaiser Permanente IHM
You have the option to enroll in a PPO, EPO or IHM Plan. Although they each have dierent provider
networks, all plans cover the same services (such as preventive care, specialty care, lab services and
x-rays, hospitalization and surgery, routine vision care, and mental health/substance abuse treatment).
Below is more information about each plan.
Preferred Provider Organization (PPO) Plan
With a PPO plan, you can see any doctor you want, whenever you want. However, the PPO plan has a
national network of doctors, hospitals and other healthcare providers that you are encouraged to use.
These “in-network” providers have contracts with the PPO plan and have agreed to accept certain fees for
their services. Because their fees are lower, the plan saves money and so do you. You pay more for care if
you use out-of-network providers.
PPO plans are available through Carerst BlueCross BlueShield and United Healthcare. Both cover the
same services, treatments and products. However, the cost of coverage and the provider networks are
dierent. See the charts in this section to compare these two plans.
Exclusive Provider Organization (EPO) Plan
With an EPO plan, the Plan pays benets only when you see an in-network provider (except in an
emergency) within a national network. However, your out of pocket costs are lower. An EPO plan only
covers eligible services from providers and facilities that are contracted in the EPO plan network.
EPO plans are available through Carerst BlueCross BlueShield and United Healthcare. Both cover the
same services, treatments and supplies, but the cost for coverage and the provider networks are dierent.
See the chart in this section to compare these two plans.
Integrated Health Model (IHM) Plan
An IHM plan refers to care that allows doctors, hospitals and the plan to work together to coordinate a
patient’s care for a total health approach. It allows for a smooth transition from clinic to hospital or from
primary care to specialty care. This plan option is available through Kaiser Permanente. If you elect this
option, you need to reside in one of the following states; MD, DC, VA, DE, PA or WV and you must visit the
providers and facilities that are part of the Kaiser Permanente network in the Baltimore/DC/VA area only
for all of your care (except in an emergency). This option is only available to our members who are
not Medicare eligible.
There are no
preexisting condition
limitations for any of
the medical plans,
but there are other
exclusions. Please
contact the medical
plans for further
information on
coverage exclusions,
limitations,
determination of
medical necessity,
preauthorization
requirements, etc.
72024 Health Benets Guide
Medical Plan ID Cards
Once you enroll in a medical plan, your ID cards will be sent to the address on le in the SPS Benets
System. Take these cards with you every time you receive medical services. Depending on the type of
medical plan you choose, the way you receive medical services and how much you pay at the time of
service will vary.
Two terms you should know
Allowed Benet
The plan’s allowed benet refers to the reimbursement amount the plan has contractually negotiated
with network providers to accept as full payment. Nonparticipating (out-of-network) providers are not
obligated to accept the allowed benet as payment in full and may charge more than the plan’s allowed
benet. In the charts that follow, if it indicates a service is covered at 90%, you only pay 10% of the
allowed benet up to your out-of-pocket maximum. If it indicates the service is covered at 70% out-of-
network, it means the plan pays 70% of the allowed benet. You are responsible for 30% of the cost of
services or supplies, as well as any additional cost above the plan’s allowed benet, when you receive
services from nonparticipating (out-of-network) providers.
Out-of-Pocket Maximum
When the total amount of copayments and/or coinsurance for you and/or your covered dependents
reaches the out-of-pocket limits noted in the charts, the plan will pay 100% of your copays and/or
coinsurance for the remainder of the plan year (through December 31).
Comparing Medical Plan Benets
The following charts are a summary of generally available benets and do not guarantee coverage. Check
each carrier’s website to nd out if your providers and the facilities in which your providers
work are included in the various plan networks. To ensure coverage under your plan, contact
the plan before receiving services or treatment to obtain more information on coverage limitations,
exclusions, determinations of medical necessity, and preauthorization requirements. In addition, a
summary of coverage from the plan will be available on the Health Benets website. The Summary of
Benets & Coverage provides details on your plan. https://dbm.maryland.gov/benets
If Your Provider
Terminates from
Your Plan’s Network
Providers may decide
to terminate from
a plan’s network
at any time. If your
provider terminates
from your plan, it
is not considered
a qualifying status
change that would
allow you to cancel
or change your plan
election. You will
need to select a new
provider. Changes
to your plan can be
made during any
Open Enrollment.
Coordination of
Benets
Coordination of
Benets (COB) occurs
when a person has
healthcare coverage
under more than
one insurance plan.
All plans require
information from
State employees and
retirees on other
coverage that they
or their dependents
have from another
health insurance
carrier.
8 2024 Health Benets Guide
CareFirst
PPO EPO
TYPE OF SERVICE INNETWORK OUTOFNETWORK INNETWORK ONLY
Annual Deductible
Individual
None $250 None
Family
None $500 None
Yearly Maximum Out-of-Pocket Costs
Coinsurance OOP
90% 70% N/A
Individual
$1,000 $3,000 None
Family
$2,000 $6,000 None
Copayment OOP
Individual
$1,000 None $1,500
Family
$2,000 None $3,000
Total Medical OOP
Individual
$2,000 $3,250 $1,500
Family
$4,000 $6,500 $3,000
Lifetime Benet Maximum
Unlimited
HOSPITAL INPATIENT SERVICES (Preauthorization Required)
Inpatient Care
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Hospitalization
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Acute Inpatient Rehab when
Medically Necessary
90% of allowed benet Not covered 100% of allowed benet
Anesthesia
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Surgery
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Organ Transplant
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
HOSPITAL OUTPATIENT SERVICES
Chemotherapy/Radiation
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Diagnostic Lab Work and X-rays*
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Outpatient Surgery
(Preauthorization Required)
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Anesthesia
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Observation – up to 23 hours
and 59 minutes - presented via
Emergency Department
100% of allowed benet
after $150 copay
100% of allowed benet
after $150 copay
100% of allowed benet
after $150 copay
Observation – 24 hours or
more - presented via Emergency
Department
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Did You Know?
Not all outpatient
surgery requires
preauthorization.
Your medical plan
will advise your
physician when he/
she calls to verify
benets.
92024 Health Benets Guide
CareFirst
PPO EPO
TYPE OF SERVICE INNETWORK OUTOFNETWORK INNETWORK ONLY
THERAPIES (Preauthorization required)
Benet Therapies $30 copay 70% of allowed benet
after deductible
$30 copay
Physical Therapy (PT) and
Occupational Therapy (OT)
PT/OT services must be precertied after the 20th visit, based on medical necessity;
50 days per plan year combined for PT/OT/Speech Therapy.
Speech Therapy Must be precertied from rst visit with exceptions and close monitoring for special situations
(e.g. trauma, brain injury) for additional visits.
COMMON AND PREVENTIVE SERVICES
Physician Oce Visits - Primary
Care
100% after $15 copay 70% of allowed benet
after deductible
100% after $15 copay
Physician Oce Visits – Specialist 100% after $30 copay 70% of allowed benet
after deductible
100% after $30 copay
Physical Exams and
Associated Lab
(Adult and Child)
100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
One exam per plan year for all members and their dependents age 3 and older.
Well Baby Care 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Birth – 36 months: 13 visits total
Routine Annual GYN Exam
(including PAP test)
100% of allowed benet.
Non-routine $15 copay.
70% of allowed benet
after deductible
100% of allowed benet.
Non-routine $15 copay.
Preventive Cancer Screenings
• US Preventive Services Task Force
• Mammography
• Colonoscopy
• Well woman exam
100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Preventative mammogram coverage at age 35+
Diagnostic Cancer Screenings 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Mammogram/Breast and Lung Cancer Screenings paid at 100% of allowed amount
Hearing Examinations
(1 exam every 3 years)
100% after $15 copay – PCP or
$30 copay – Specialist
70% of allowed benet
after deductible
100% after $15 copay – PCP or
$30 copay – Specialist
Hearing Aids
(1 hearing aid per ear every
3 years)
100% of allowed benet for Basic
Model Hearing Aid
70% of allowed benet
after deductible for Basic Model
Hearing Aid
100% of allowed benet for Basic
Model Hearing Aid
Includes Maryland mandated benet for hearing aids for minor children (ages 0-18) eective
01/01/02, including hearing aids per each impaired ear for minor children.
Immunizations 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Immunizations are only covered as recommended by the U.S. Preventive Services Task Force. The
immunization benet covers immunizations required for participation in school athletics and Lyme
Disease immunizations when medically necessary.
Flu Shots 100% of allowed benet Not covered 100% of allowed benet
STI Screening and Counseling
(Including HPV, DNA and HIV)
100% of allowed benet Not Covered 100% of allowed benet
Counseling and screening for sexually active women as mandated by PPACA.
Allergy Testing 100% after $15 copay – PCP or
$30 copay – Specialist
70% of allowed benet
after deductible
100% after $15 copay – PCP or
$30 copay – Specialist
10 2024 Health Benets Guide
CareFirst
PPO EPO
TYPE OF SERVICE INNETWORK OUTOFNETWORK INNETWORK ONLY
EMERGENCY TREATMENT
Ambulance Services –
Emergency Transport and Hospital
Directed Transport Between
Approved Facilities
100% of allowed benet 100% of allowed benet 100% of allowed benet
Ambulance Services –
Non-Emergency Transport
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Emergency Room (ER) Services –
In and Out of Network
100% of allowed benet after
$150 copay
100% of allowed benet after
$150 copay
100% of allowed benet after
$150 copay
Copays are waived if admitted.
If criteria are not met for a medical emergency, plan coverage is 50% of allowed amount, plus the
$150 copay.
Urgent Care Oce Visit 100% after $30 copay 70% of allowed benet
after deductible
100% of allowed benet after
$30 copay
MATERNITY BENEFITS
Maternity Benets** 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Prenatal Care 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Newborn Care 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Breastfeeding Support and
Counseling (per birth)
100% of allowed benet Not Covered 100% of allowed benet
Breastfeeding Supplies (per birth) 100% of allowed benet Not Covered 100% of allowed benet
Covers the cost of rental/purchase of certain breastfeeding pump and pump equipment
through Plan’s Durable Medical Equipment partner(s).
OTHER SERVICES AND SUPPLIES
Acupuncture Services for Chronic
Pain Management
100% after $30 copay 70% of allowed benet
after deductible
100% after $30 copay
Chiropractic Services 100% after $30 copay 70% of allowed benet
after deductible
100% after $30 copay
Cardiac Rehabilitation 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Dental Services Not covered except as a result of accident or injury or as mandated by Maryland or federal law (if
applicable).
Diabetic Nutritional Counseling, as
mandated by Maryland Law
100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Durable Medical Equipment 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Must be medically necessary as determined by the attending physician
Extended Care Facilities 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Skilled nursing care and extended care facility benets are limited to 180 days per calendar year
as long as skilled nursing care is medically necessary. Inpatient care primarily for or solely for
rehabilitation is not covered.
Family Planning 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Contraception 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Includes IUD insertion and tubal ligation. For information on coverage of prescription contraceptives,
please refer to the Prescription Drug section of this guide.
Contraceptive Counseling 100% of allowed benet Not covered 100% of allowed benet
Fertility Testing
(Preauthorization Required)
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
In-Vitro Fertilization (IVF) and
Articial Insemination (per MD
mandate)
90% of allowed benet
(outpatient hospital)
100% after $30 copay
(physician oce)
70% of allowed benet after
deductible
100% of allowed benet
(Preauthorization Required) See carrier’s evidence of coverage documents for details.
Not covered following reversal of elective sterilization.
112024 Health Benets Guide
CareFirst
PPO EPO
TYPE OF SERVICE INNETWORK OUTOFNETWORK INNETWORK ONLY
OTHER SERVICES AND SUPPLIES (continued)
Hospice Care
(Preauthorization Required)
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Home Healthcare
(Preauthorization Required)
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Limited to 120 days per plan year
Medical Supplies 90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Includes, but is not limited to: surgical dressings; casts; splints; syringes; dressings for cancer,
burns or diabetic ulcers; catheters; colostomy bags; oxygen; supplies for renal dialysis
equipment and machines.
Private Duty Nursing 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Whole Blood Charges 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES
Oce Visit $15 copay 70% of allowed benet after
deductible
$15 copay
Inpatient Hospital Care 90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Partial Hospitalization Services 90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Outpatient Services (including
Intensive Outpatient Services)
90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Residential Crisis Services 90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Habilitative Services, which include occupational therapy, physical therapy, speech therapy, and
applied behavior analysis, are covered for children under the age of 19 with congenital or genetic
birth defects including but not limited to autism, autism spectrum disorder, and cerebral palsy.
VISION SERVICES (Adults 19 and older)
Vision – Medical (Services related
to medical health of the eye)
$15 copay (PCP) or $30 copay
(Specialist)
70% of allowed benet after
deductible
$15 copay (PCP) or $30 copay
(Specialist)
Vision – Routine (One per
plan year)
100% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Frames (One per plan year) 100% of allowed benet up to
$45 per frame
70% of allowed benet after
deductible up to $45 per frame
100% of allowed benet up to
$45 per frame
Prescription Lenses 100% of allowed benet up to
the following: Single Vision - $52;
Bifocal - $82; Trifocal - $101;
Lenticular $181
70% of allowed benet up to the
following: Single Vision - $52;
Bifocal - $82; Trifocal - $101;
Lenticular $181
100% of allowed benet up to
the following: Single Vision - $52;
Bifocal - $82; Trifocal - $101;
Lenticular $181
Contact Lenses (in lieu of frames
& lenses)
100% of allowed benet up
to the following: Medically
Necessary - $285; Cosmetic - $97
70% of allowed benet up to the
following: Medically Necessary -
$285; Cosmetic - $97
100% of allowed benet up
to the following: Medically
Necessary - $285; Cosmetic - $97
VISION SERVICES (Dependent children age 18 and under)
Vision – Medical (Services related
to medical health of the eye)
$15 copay (PCP) or $30 copay
(Specialist)
70% of allowed benet after
deductible
$15 copay (PCP) or $30 copay
(Specialist)
Vision – Routine (One per plan
year)
100% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Frames (One per plan year) 100% of allowed benet up to
$45 per frame
70% of allowed benet after
deductible up to $70 per frame
100% of allowed benet up to
$45 per frame
Basic Prescription Lenses 100% priced at charges
Contact Lenses (in lieu of frames
& lenses)
100% of annual supply (2 rells
per plan year)
100% of allowed amount (see
benet summary for details)
100% of annual supply (2 rells
per plan year)
BENEFIT CHART FOOTNOTES
* Laboratory testing services related to diabetes, hypertension, coronary artery disease, asthma and COPD are paid at 100%, including
test strips for diabetics.
** Newborns’ and Mothers’ Health Protection Act Notice. See Page 72 of the booklet.
Medicare COB Retirees or their dependent(s) must enroll in Medicare Parts A & B upon becoming eligible for
Medicare due to age or disability. If the Medicare eligible State retiree and their dependent(s) fail
to enroll in Medicare, the Medicare eligible State retiree and their dependent(s) will be responsible
for any claim expenses that would have been paid under Medicare Parts A or B, had they enrolled
in Medicare. If a retiree or covered dependent’s Medicare eligibility is due to End Stage Renal
Disease (ESRD), they must sign up for both Medicare Parts A & B as soon as they are eligible.
Non-Medicare COB When the State's plan is the secondary payor, payments will be limited to only that balance of claim
expenses that will reach the published limits of the State's plan.
12 2024 Health Benets Guide
UnitedHealthcare
PPO EPO
TYPE OF SERVICE INNETWORK OUTOFNETWORK INNETWORK ONLY
Annual Deductible
Individual None $250 None
Family None $500 None
Yearly Maximum Out-of-Pocket Costs
Coinsurance OOP 90% 70% N/A
Individual $1,000 $3,000 None
Family $2,000 $6,000 None
Copayment OOP
Individual $1,000 None $1,500
Family $2,000 None $3,000
Total Medical OOP
Individual $2,000 $3,250 $1,500
Family $4,000 $6,500 $3,000
Lifetime Benet Maximum Unlimited
HOSPITAL INPATIENT SERVICES (Preauthorization Required)
Inpatient Care 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Hospitalization 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Acute Inpatient Rehab when
Medically Necessary
90% of allowed benet Not covered 100% of allowed benet
Anesthesia 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Surgery 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Organ Transplant 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
HOSPITAL OUTPATIENT SERVICES
Chemotherapy/Radiation 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Diagnostic Lab Work and X-rays* 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Outpatient Surgery
(Preauthorization Required)
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Anesthesia 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Observation – up to 23 hours
and 59 minutes - presented via
Emergency Department
100% of allowed benet
after $150 copay
100% of allowed benet
after $150 copay
100% of allowed benet
after $150 copay
Observation – 24 hours or
more - presented via Emergency
Department
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Did You Know?
Not all outpatient
surgery requires
preauthorization.
Your medical plan
will advise your
physician when he/
she calls to verify
benets.
132024 Health Benets Guide
UnitedHealthcare
PPO EPO
TYPE OF SERVICE INNETWORK OUTOFNETWORK INNETWORK ONLY
THERAPIES (Preauthorization required)
Benet Therapies $30 copay 70% of allowed benet
after deductible
$30 copay
Physical Therapy (PT) and
Occupational Therapy (OT)
PT/OT services must be precertied after the 20th visit, based on medical necessity;
50 days per plan year combined for PT/OT/Speech Therapy.
Speech Therapy Must be precertied from rst visit with exceptions and close monitoring for special situations
(e.g. trauma, brain injury) for additional visits.
COMMON AND PREVENTIVE SERVICES
Physician Oce Visits - Primary
Care
100% after $15 copay 70% of allowed benet
after deductible
100% after $15 copay
Physician Oce Visits – Specialist 100% after $30 copay 70% of allowed benet
after deductible
100% after $30 copay
Physical Exams and
Associated Lab
(Adult and Child)
100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
One exam per plan year for all members and their dependents age 3 and older.
Well Baby Care 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Birth – 36 months: 13 visits total
Routine Annual GYN Exam
(including PAP test)
100% of allowed benet.
Non-routine $15 copay.
70% of allowed benet
after deductible
100% of allowed benet.
Non-routine $15 copay.
Preventive Cancer Screenings
• US Preventive Services Task Force
• Mammography
• Colonoscopy
• Well woman exam
100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Preventative mammogram covered at age 35+
Diagnostic Cancer Screenings 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Mammogram/Breast and Lung Cancer Screenings paid at 100% of allowed amount.
Hearing Examinations
(1 exam every 3 years)
100% after $15 copay – PCP or
$30 copay – Specialist
70% of allowed benet
after deductible
100% after $15 copay – PCP or
$30 copay – Specialist
Hearing Aids
(1 hearing aid per ear every 3
years)
100% of allowed benet for Basic
Model Hearing Aid
70% of allowed benet
after deductible for Basic Model
Hearing Aid
100% of allowed benet for Basic
Model Hearing Aid
Includes Maryland mandated benet for hearing aids for minor children (ages 0-18) eective
01/01/02, including hearing aids per each impaired ear for minor children.
Immunizations 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Immunizations are only covered as recommended by the U.S. Preventive Services Task Force. The
immunization benet covers immunizations required for participation in school athletics and Lyme
Disease immunizations when medically necessary.
Flu Shots 100% of allowed benet Not covered 100% of allowed benet
STI Screening and Counseling
(Including HPV, DNA and HIV)
100% of allowed benet Not Covered 100% of allowed benet
Counseling and screening for sexually active women as mandated by PPACA.
Allergy Testing 100% after $15 copay – PCP or
$30 copay – Specialist
70% of allowed benet
after deductible
100% after $15 copay – PCP or
$30 copay – Specialist
14 2024 Health Benets Guide
UnitedHealthcare
PPO EPO
TYPE OF SERVICE INNETWORK OUTOFNETWORK INNETWORK ONLY
EMERGENCY TREATMENT
Ambulance Services –
Emergency Transport and Hospital
Directed Transport Between
Approved Facilities
100% of allowed benet 100% of allowed benet 100% of allowed benet
Ambulance Services –
Non-Emergency Transport
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Emergency Room (ER) Services –
In and Out of Network
100% of allowed benet after
$150 copay
100% of allowed benet after
$150 copay
100% of allowed benet after
$150 copay
Copays are waived if admitted.
If criteria are not met for a medical emergency, plan coverage is 50% of allowed amount, plus the
$150 copay.
Urgent Care Oce Visit 100% after $30 copay 70% of allowed benet
after deductible
100% of allowed benet after
$30 copay
MATERNITY BENEFITS
Maternity Benets** 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Prenatal Care 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Newborn Care 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Breastfeeding Support and
Counseling (per birth)
100% of allowed benet Not Covered 100% of allowed benet
Breastfeeding Supplies (per birth) 100% of allowed benet Not Covered 100% of allowed benet
Covers the cost of rental/purchase of certain breastfeeding pumps and pump equipment
through Plan’s Durable Medical Equipment partner(s).
OTHER SERVICES AND SUPPLIES
Acupuncture Services for Chronic
Pain Management
100% after $30 copay 70% of allowed benet
after deductible
100% after $30 copay
Chiropractic Services 100% after $30 copay 70% of allowed benet
after deductible
100% after $30 copay
Cardiac Rehabilitation 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Dental Services Not covered except as a result of accident or injury or as mandated by Maryland or federal law
(if applicable).
Diabetic Nutritional Counseling, as
mandated by Maryland Law
100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Durable Medical Equipment 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Must be medically necessary as determined by the attending physician
Extended Care Facilities 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Skilled nursing care and extended care facility benets are limited to 180 days per calendar year
as long as skilled nursing care is medically necessary. Inpatient care primarily for or solely for
rehabilitation is not covered.
Family Planning 100% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Contraception 100% of allowed Benet 70% of allowed Benet
after deductible
100% of allowed Benet
Includes IUD insertion and tubal ligation. For information on coverage of prescription contraceptives,
please refer to the Prescription Drug section of this guide.
Contraceptive Counseling 100% of allowed benet Not covered 100% of allowed benet
Fertility Testing
(Preauthorization Required)
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
In-Vitro Fertilization (IVF) and
Articial Insemination (per MD
mandate)
90% of allowed benet
(outpatient hospital)
100% after $30 copay
(physician oce)
70% of allowed benet after
deductible
100% of allowed benet
(Preauthorization Required) See carrier’s evidence of coverage documents for details.
Not covered following reversal of elective sterilization.
Hospice Care
(Preauthorization Required)
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
152024 Health Benets Guide
UnitedHealthcare
PPO EPO
TYPE OF SERVICE INNETWORK OUTOFNETWORK INNETWORK ONLY
OTHER SERVICES AND SUPPLIES (continued)
Home Healthcare
(Preauthorization Required)
90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Home Healthcare benets are limited to 120 days per plan year
Medical Supplies 90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Includes, but is not limited to: surgical dressings; casts; splints; syringes; dressings for cancer,
burns or diabetic ulcers; catheters; colostomy bags; oxygen; supplies for renal dialysis
equipment and machines.
Private Duty Nursing 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
Whole Blood Charges 90% of allowed benet 70% of allowed benet
after deductible
100% of allowed benet
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES
Oce Visit $15 copay 70% of allowed benet after
deductible
$15 copay
Inpatient Hospital Care 90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Partial Hospitalization Services 90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Outpatient Services (including
Intensive Outpatient Services)
90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Residential Crisis Services 90% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Habilitative Services, which include occupational therapy, physical therapy, speech therapy, and
applied behavior analysis, are covered for children under the age of 19 with congenital or genetic
birth defects including but not limited to autism, autism spectrum disorder, and cerebral palsy.
VISION SERVICES (Adults 19 and older)
Vision – Medical (Services related
to medical health of the eye)
$15 copay (PCP) or $30 copay
(Specialist)
70% of allowed benet after
deductible
$15 copay (PCP) or $30 copay
(Specialist)
Vision – Routine (One per
plan year)
100% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Frames (One per plan year) 100% of allowed benet up to
$45 per frame
70% of allowed benet after
deductible up to $45 per frame
100% of allowed benet up to
$45 per frame
Prescription Lenses 100% of allowed benet up to
the following: Single Vision - $52;
Bifocal - $82; Trifocal - $101;
Lenticular $181
70% of allowed benet up to the
following: Single Vision - $52;
Bifocal - $82; Trifocal - $101;
Lenticular $181
100% of allowed benet up to
the following: Single Vision - $52;
Bifocal - $82; Trifocal - $101;
Lenticular $181
Contact Lenses (in lieu of frames
& lenses)
100% of allowed benet up
to the following: Medically
Necessary - $285; Cosmetic - $97
70% of allowed benet up to the
following: Medically Necessary -
$285; Cosmetic - $97
100% of allowed benet up
to the following: Medically
Necessary - $285; Cosmetic - $97
VISION SERVICES (Dependent children age 18 and under)
Vision – Medical (Services related
to medical health of the eye)
$15 copay (PCP) or $30 copay
(Specialist)
70% of allowed benet after
deductible
$15 copay (PCP) or $30 copay
(Specialist)
Vision – Routine (One per
plan year)
100% of allowed benet 70% of allowed benet after
deductible
100% of allowed benet
Frames (One per plan year)
100% of allowed benet up to
$45 per frame
70% of allowed benet after
deductible up to $70 per frame
100% of allowed benet up to
$45 per frame
Basic Prescription Lenses 100% priced at charges
Contact Lenses (in lieu of frames
& lenses)
100% of annual supply (2 rells
per plan year)
100% of allowed amount (see
benet summary for details)
100% of annual supply (2 rells
per plan year)
BENEFIT CHART FOOTNOTES
* Laboratory testing services related to diabetes, hypertension, coronary artery disease, asthma and COPD are paid at 100%, including
test strips for diabetics.
** Newborns’ and Mothers’ Health Protection Act Notice. See Page 72 of the booklet.
Medicare COB Retirees or their dependent(s) must enroll in Medicare Parts A & B upon becoming eligible for
Medicare due to age or disability. If the Medicare eligible State retiree and their dependent(s) fail
to enroll in Medicare, the Medicare eligible State retiree and their dependent(s) will be responsible
for any claim expenses that would have been paid under Medicare Parts A or B, had they enrolled
in Medicare. If a retiree or covered dependent’s Medicare eligibility is due to End Stage Renal
Disease (ESRD), they must sign up for both Medicare Parts A & B as soon as they are eligible.
Non-Medicare COB When the State's plan is the secondary payor, payments will be limited to only that balance of claim
expenses that will reach the published limits of the State's plan.
16 2024 Health Benets Guide
Kaiser Permanente
IHM
TYPE OF SERVICE INNETWORK ONLY
Annual Deductible
Individual None
Family None
Yearly Maximum Out-of-Pocket Costs
Copayment OOP
Individual $1,500
Family $3,000
Total Medical OOP
Individual $1,500
Family $3,000
Lifetime Benet Maximum Unlimited
HOSPITAL INPATIENT SERVICES (Preauthorization Required)
Inpatient Care 100% of allowed benet
Hospitalization 100% of allowed benet
Acute Inpatient Rehab when Medically Necessary 100% of allowed benet
Anesthesia 100% of allowed benet
Surgery 100% of allowed benet
Organ Transplant 100% of allowed benet
HOSPITAL OUTPATIENT SERVICES (Preauthorization Required)
Chemotherapy/Radiation 100% of allowed benet
Diagnostic Lab Work and X-rays* 100% of allowed benet
Outpatient Surgery 100% of allowed benet
Anesthesia 100% of allowed benet
Observation – up to 23 hours and 59 minutes - presented via Emergency Department 100% of allowed benet after
$150 copay
Observation – 24 hours or more - presented via Emergency Department 100% of allowed benet
THERAPIES (Preauthorization required)
Benet Therapies 100% after $15 copay
Physical Therapy (PT) and Occupational Therapy (OT) PT/OT services must be
precertied after the 20th
visit, based on medical
necessity; 50 days per plan
year combined for PT/OT/
Speech Therapy.
Speech Therapy Must be precertied from
rst visit with exceptions and
close monitoring for special
situations (e.g. trauma, brain
injury) for additional visits.
NOTE: The Kaiser IHM medical plan does not coordinate benets with Medicare Parts A & B for Active Employees, Retirees, and their
dependents who are Medicare eligible.
Kaiser Permanente
has a regional
network. You must
visit a provider
or facility that is
part of the Kaiser
Permanente network
in the Baltimore/
DC/ NVA (Northern
Virginia) area for all
of your care (except
in an emergency).
Did You Know?
Not all outpatient
surgery requires
preauthorization.
Your medical plan
will advise your
physician when he/
she calls to verify
benets.
172024 Health Benets Guide
Kaiser Permanente
IHM
TYPE OF SERVICE INNETWORK ONLY
COMMON AND PREVENTIVE SERVICES
Physician Oce Visits - Primary Care 100% after $15 copay
Physician Oce Visits – Specialist 100% after $15 copay
Physical Exams and Associated Lab (Adult and Child) 100% of allowed benet
Well Baby Care 100% of allowed benet
Routine Annual GYN Exam (including PAP test) 100% of allowed benet.
Non-routine $15 copay.
Mammography Preventive 100% of allowed benet
Screening: one mammogram
per plan year (35+).
Mammography Diagnostic 100% of allowed benet
No age/frequency limitation on
diagnostic mammogram.
Hearing Examinations
(1 exam every 3 years)
100% after $15 copay –
PCP/Specialist
Hearing Aids
(1 hearing aid per ear every 3 years)
100% of allowed benet for
Basic Model Hearing Aid
Includes Maryland mandated
benet for hearing aids for
minor children (Coverage for
children until the end of the
month in which the child turns
19) eective 01/01/02, including
hearing aids per each impaired
ear for minor children.
Immunizations 100% of allowed benet
Immunizations are only
covered as recommended by
the U.S. Preventive Services
Task Force. The immunization
benet covers immunizations
required for participation in
school athletics and Lyme
Disease immunizations
when medically necessary.
Flu Shots 100% of allowed benet
STI Screening and Counseling (Including HPV DNA and HIV) 100% of allowed benet
Counseling and screening
for sexually active women as
mandated by PPACA.
Allergy Testing 100% after $15 copay –
PCP or Specialist
18 2024 Health Benets Guide
Kaiser Permanente
IHM
TYPE OF SERVICE INNETWORK ONLY
EMERGENCY TREATMENT
Ambulance Services – Emergency Transport and Hospital Directed Transport Between Approved Facilities 100% of allowed benet
Ambulance Services – Non-Emergency Transport 100% of allowed benet
Emergency Room (ER) Services –In and Out of Network 100% of allowed benet after
$150 copay
Copays are waived if admitted.
If criteria are not met for a
medical emergency, plan
coverage is 50%
of allowed amount, plus the
$150 copay.
Urgent Care Oce Visit 100% after $15 copay
MATERNITY BENEFITS
Maternity Benets** 100% of allowed benet
Prenatal Care 100% of allowed benet
Newborn Care 100% of allowed benet
Breastfeeding Support and Counseling (per birth) 100% of allowed benet
Breastfeeding Supplies (per birth) 100% of allowed benet
Covers the cost of rental/purchase
of certain breastfeeding pumps
and pump equipment through
Plan’s Durable Medical Equipment
partner(s).
OTHER SERVICES AND SUPPLIES
Acupuncture Services for Chronic Pain Management 100% after $15 copay
Chiropractic Services 100% after $15 copay
Cardiac Rehabilitation 100% of allowed benet
Dental Services Not covered except as a result of
accident or injury or as mandated
by Maryland or federal law (if
applicable).
Diabetic Nutritional Counseling, as mandated by Maryland Law 100% of allowed benet
Durable Medical Equipment 100% of allowed benet
Must be medically necessary as
determined by the attending
physician
Extended Care Facilities 100% of allowed benet
Skilled nursing care and extended
care facility benets are limited
to 180 days per calendar year
as long as skilled nursing care is
medically necessary. Inpatient
care primarily for or solely for
rehabilitation is not covered.
Family Planning and Fertility Testing 100% of allowed benet
Contraception 100% of allowed benet
Includes IUD insertion and
tubal ligation. For information
on coverage of prescription
contraceptives, please refer to
the Prescription Drug section of
this guide.
Contraceptive Counseling 100% of allowed benet
In-Vitro Fertilization (IVF) and Articial Insemination (per MD mandate) 100% of allowed benet
See carrier’s evidence of coverage
documents for details. Not
covered following reversal of
elective sterilization.
Hospice Care 100% of allowed benet
Home Healthcare 100% of allowed benet
Home Healthcare benets are
limited to 120 days per plan year
192024 Health Benets Guide
Kaiser Permanente
IHM
TYPE OF SERVICE INNETWORK ONLY
OTHER SERVICES AND SUPPLIES (continued)
Medical Supplies
100% of allowed benet
Includes, but is not limited
to: surgical dressings; casts;
splints; syringes; dressings
for cancer, burns or diabetic
ulcers; catheters; colostomy
bags; oxygen; supplies for
renal dialysis equipment and
machines.
Private Duty Nursing 100% of allowed benet
Whole Blood Charges 100% of allowed benet
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES
Oce Visit $15 copay
Inpatient Hospital Care 100% of allowed benet
Partial Hospitalization Services 100% of allowed benet
Outpatient Services (including Intensive Outpatient Services) 100% of allowed benet
Residential Crisis Services
100% of allowed benet
Habilitative Services, which
include occupational therapy,
physical therapy, speech therapy,
and applied behavior analysis,
are covered for children under
the age of 19 with congenital or
genetic birth defects including
but not limited to autism, autism
spectrum disorder, and cerebral
palsy.
VISION SERVICES (Adults 19 and older)
Vision – Medical (Services related to medical health of the eye) $15 copay (PCP) or $15 copay
(Specialist)
Vision – Routine (One per plan year) 100% of allowed benet
Frames (One per plan year) Up to $45 per frame
Prescription Lenses Single vision: $52.00, Bifocal:
$82.00, Trifocal: $101.00,
Lenticular: $181.00
Contact Lenses (in lieu of frames & lenses) Medically necessary: $285.00,
Cosmetic: $97.00
VISION SERVICES (Dependent children age 18 and under)
Vision – Medical (Services related to medical health of the eye) $15 copay
Vision – Routine (One per plan year) 100% of allowed benet
Frames
100% of allowed benet
Up to $70 per frame
Basic Prescription Lenses
100% of allowed benet
Single vision: $40, Bifocal: $60,
Trifocal: $80, Lenticular: $100
Contact Lenses (in lieu of frames & lenses)
100% of allowed benet
Medically necessary: $225
Cosmetic: $105
BENEFIT CHART FOOTNOTES
* Laboratory testing services related to diabetes, hypertension, coronary artery disease, asthma and COPD are paid at 100%, including
test strips for diabetics.
** Newborns’ and Mothers’ Health Protection Act Notice. See Page 72 of the booklet.
Non-Medicare COB
When the State’s plan is the secondary payor, payments will be limited to only that
balance of claim expenses that will reach the published limits of the State’s plan.
20 2024 Health Benets Guide
Prescription Drug Benets
The State oers prescription drug coverage through a separate plan; it is not included in your medical
plan. To have prescription drug coverage you must enroll in it.
The prescription drug plan is administered by CVS Caremark. After you elect coverage, you will receive an
ID card to present when you have your prescriptions lled at the participating pharmacy of your choice.
Here are some important features of the program:
• You may use any pharmacy in the CVS Caremark network which includes not only CVS, but also
chain retail pharmacies such as Giant, Walgreens and Walmart in addition to the many independent
pharmacies;
• Your prescription drug coverage has a “mandatory generics” feature. If you purchase a brand name
medication when a generic medication is available, even if the brand name medication is prescribed by
your doctor, you must pay the dierence in price between the brand name and the generic, plus the
applicable copayment;
• CVS Caremark Mail Service Pharmacy is available for prescribed maintenance medications (medications
you take regularly for an ongoing health condition) with no cost for standard shipping;
• There is no copayment for a limited list of generic medications lled at a retail pharmacy and through
the CVS Caremark Mail Service;
• If you are eligible for Medicare, your prescription drug coverage is through the CVS Medicare Part D
EGWP program. When you become eligible for Medicare, you will be enrolled in SilverScript® Employer
PDP sponsored by State of Maryland (SilverScript);
• Active employees represented by Bargaining Unit I (SLEOLA) have a dierent premium schedule and
plan design for prescription drug benets. Please refer to the SLEOLA Addendum or visit the Employee
Benets Division’s website for more information: www.dbm.maryland.gov/benets;
• As part of the ACA, your health plan oers certain preventive service benets at no cost to you. CVS
Caremark works with your health plan to provide these benets.
CVS Caremark can provide you with additional plan information, including participating pharmacy
locations, the preferred drug list and prescription costs. Please see the inside front cover of this guide for
CVS Caremark’s contact information.
Coverage for Generic Drugs
Generic drugs are those drugs approved by the FDA as being as safe and eective as their brand name
counterparts; they are just less expensive.
An Innovative Approach to Diabetes Management
Transform Diabetes Care is a health benet that combines advanced blood glucose testing technology
with coaching to support chronic health conditions like diabetes. It is available at no cost to you as part of
your CVS Caremark prescription benet plan.
What’s included at $0 cost to you:
9 A connected glucose meter
9 As many strips as you need
9 Lancing device, lancets, and carrying case
9 Personalized insights with each reading
9 Anytime access to Certied Diabetes Educators
9 And more
Look for more information about this program at https://info.caremark.com/stateofmaryland.
Prescription coverage
is not included in
any of our medical
plans. It is oered
separately and you
have to enroll in
order to participate.
212024 Health Benets Guide
Preferred Brand Name Medications
Preferred brand name medications are those medications that CVS Caremark has on its formulary (preferred
drug list). CVS Caremark uses an independent panel of doctors and pharmacists to evaluate the medications
approved by the U.S. Food & Drug Administration (FDA) for inclusion on the preferred drug list.
Each prescription medication is reviewed for safety, side eects, ecacy (how well it works), ease of
dosage and cost. Preferred medications are reviewed throughout the year and are subject to change.
You can review and/or print the list at https://info.caremark.com/stateofmaryland. You may also
call CVS Caremark for a copy of the list.
Zero Dollar Copay for Generics Program
To support your eorts to improve your health and help stick with your doctor’s recommended treatment,
you do not pay a copayment for specic generic medications at a retail pharmacy and through the CVS
Caremark Mail Service. The ve drug classes, including some examples of generic medications covered
under this program, are listed in the chart below. Not all generic drugs in these drug classes are covered
under the Zero Dollar Copay for Generics Program.
If you are currently taking a brand name medication in one of these drug classes, please consult with your
doctor to determine if a generic alternative is appropriate.
Zero-Dollar Copayment for Generics Program
DRUG CLASS
USED TO TREAT
GENERIC MEDICATION
HHG CoA Reductase Inhibitors (Statins) High Cholesterol simvastatin (generic Zocor)
pravastatin (generic Pravachol)
Angiotensin Converting Enzyme
Inhibitors (ACEIs)
High Blood Pressure lisinopril (generic Zestril)
lisinopril/HCTZ (generic Zestoretic)
enalapril (generic Vasotec)
enalapril/HCTZ (generic Vaseretic)
Proton Pump Inhibitors (PPIs) Ulcer/GERD omeprazole (generic Prilosec)
Inhaled Corticosteroids Asthma budesonide (generic Pulmicort Respules)
Selective Serotonin Reuptake Inhibitors
(SSRIs)
Depression uoxetine (generic Prozac)
paroxetine (generic Paxil)
sertraline (generic Zoloft)
citalopram (generic Celexa)
Contraception Methods Prevention of Pregnancy Oral Contraceptives, Diaphragm, Levonorgestrel
(Generic Plan B)
Tobacco Cessation Smoking Bupropion (generic Zyban)
Your Cost for Prescription Drugs
Whether you have a prescription lled at a retail pharmacy or CVS Caremark Mail Service Pharmacy, your
copayment depends on the type of medication and the quantity purchased.
Type of Medication
Prescriptions for 1-45 Days
(1 copay)
Prescriptions for 46-90 Days
(2 copays)
Generic $10 $20
Preferred brand name $25 $50
Non-preferred brand name $40 $80
CVS Caremark Mail Service
Mail Service from CVS Caremark delivers your maintenance medications (the prescription medication you
take regularly to treat an ongoing condition) to your home with no cost for standard shipping.
You may rell your mail ordered medications online or by phone.
Visit https://info.caremark.com/oe/stateofmaryland, download the CVS Caremark App, or call
(844) 460-8767 to get started with home delivery service from CVS Caremark Mail Order Pharmacy.
The standards of
quality are the same
for generics as brand
name medications.
The FDA requires
that all medications
be safe and eective.
When a generic
medication is
approved and on the
market, it has met the
rigorous standards
established by the
FDA with respect
to identication,
strength, quality,
purity and potency.
22 2024 Health Benets Guide
Annual Out-of-Pocket Copayment Maximum for Prescription Drugs
The annual out-of-pocket copayment maximum for prescription drugs is separate from your medical
plan’s annual out-of-pocket maximum and is as follows:
• Active Employees: $1,000 per individual and $1,500 per family
• Retirees: $1,500 per individual and $2,000 per family
This means that when the total amount of copayments you and/or your covered dependents pay for
prescription drugs during the plan year reaches the annual out-of-pocket copayment maximum, the plan
will pay 100% of your prescription drug costs for the remainder of the plan year (through December 31).
If you purchase a brand name medication when a generic medication is available, your copayment
will count toward your annual out-of-pocket copayment maximum, but the dierence in cost you pay
between the generic and brand name medication will not count toward the maximum.
Specialty Guideline Management
CVS Caremark ensures the appropriate use of specialty medications. Many specialty medications are
biotech medications that may require special handling and may be dicult to tolerate.
Examples of specialty medications included in this program are for the treatment of rheumatoid arthritis,
multiple sclerosis, blood disorders, cancer, hepatitis C and osteoporosis. Specialty medications will be
reviewed automatically for safety, and clinical appropriateness. Specialty medications will continue to be
limited to a maximum 30-day supply per prescription per ll. Some of these specialty drugs are listed in
the chart below.
For drugs limited to a 30 day supply, you will pay one-third (1/3) of the 90 day copay for up to 30 days’
worth of medication.
Examples of Medications in Specialty Drug Management
Auto-Immune Diseases (such as
Rheumatoid Arthritis, Psoriasis and
Inammatory Bowel Disease)
Cosentyx, Enbrel, Humira, Kevzara, Otezla, Stelara, and Xeljanz
Multiple Sclerosis Glatiramer, Betaseron, Copaxone, Rebif, Acthar HP, Tysabri, Gilenya, Aubagio, Tecdera
Blood Disorder Nplate, Procrit Leukine, Neulasta, Zarxio, Neumega, Proleukin, Hemophilia agents
Cancer Anitor, Gleevec, lressa, Nexavar, Revlimid, Sprycel, Sutent, Tarcva, Tasigna, Temodar, Thalomid,
Treanda, Tykerb, Xeloda, Zolinza, Eligard, Plenaxis, Trelstar, Vantas, Viadur, Zoladex, Thyrogen,
Bosulif, Stivarga, Pomalyst, Cometriq, lclusig, Anitor, Ibrance, and Imbruvica
Hepatitis C Epclusa, Harvoni, Vosevi , Alferon N, Ribavirin
Osteoporosis Forteo, Prolia
Growth Hormones Genotropin, Norditropin
*This list not comprehensive and is subject to change without notice to accommodate new prescription medications and to reect the most
current medical literature.
CVS Specialty emphasizes the importance of patient care and quality customer service. As a CVS Specialty
patient, you will have access to a team of specialists including pharmacists, nurse clinicians, social
workers, patient care coordinators and reimbursement specialists who will work closely with you and
your doctor throughout your course of therapy. CVS Specialty also provides an on-call pharmacist 24
hours a day, 7 days a week. However, you may ll your specialty medications at any pharmacy in the CVS
Caremark network that carries the medication.
232024 Health Benets Guide
Prior Authorization Medications
Some prescription medications require prior authorization before they can be covered under the
prescription drug plan. Your doctor will need to provide more information about why these medications
are being prescribed so CVS Caremark can verify their medical necessity. Prior authorization medications
include, but are not limited to, the following:
• Acne Medications (such as oral isotretinoins, topical tretinoins, Tazorac and Fabior)
• Attention Decit Hyperactivity Disorder Medications in Adults (such as Adderall products, Dexedrine,
Desoxyn, and Ritalin products)
• Anabolic Steroids
• Topical Diclofenac Products (such as Voltaren Gel, Pennsaid, Solaraze)
• Oral and Intranasal Fentanyl Products (such as Actiq, Fentora, Subsys)
• Select Medical Devices and Articial Saliva Products
• Disposable Insulin Pumps
• Atopic Dermatitis (such as Opzelura)
• Vision Enhancement Agents (such as Vuity,Upneeq)
The list of prior authorization medications is subject to change and is available by visiting
https://info.caremark.com/oe/stateofmaryland
Medications with Quantity Limits
Some medications have limits on the quantities that will be covered under the prescription drug plan.
Quantity limits are placed on prescriptions to make sure you receive the safe daily dose as recommended
by the FDA and medical studies. Some medications with quantity limits include, but are not limited to,
the following:
• Erectile dysfunction medications
• Proton pump inhibitors
• Sedative/Hypnotics (e.g., sleeping pills)
• Nasal inhalers
• Migraine Medications
• Opioid and Opioid Combination Products
When you go to the pharmacy for a prescription medication with a quantity limitation, your copayment
will only cover the quantity allowed by the plan. You may still purchase the additional quantities, but you
will pay the additional cost. The cost of the additional quantities will not count toward your annual out-
of-pocket copayment maximum.
The list of quantity limitation medications is subject to change and is available by visiting
https://info.caremark.com/stateofmaryland.
Step Therapy
Step therapy is a process for nding the best treatment while ensuring you are receiving the most
appropriate medication therapy and reducing prescription drug costs.
Medications are grouped into two categories:
• First-Line Medications: These are the medications recommended for you to take rst — usually
generics, which have been proven safe and eective. You pay the lowest copayment for these.
• Second-Line Medications: These are brand name medications. They are recommended for you only if
24 2024 Health Benets Guide
A note about the
communications
you will receive
from Medicare.
Plan coverage
documents and
Explanations of
Benets will only
show the Medicare
Part D benets.
Remember that our
plan wraps around
those benets so
you don’t have to
pay the Part D cost
share that appears in
the communications
you receive from
Medicare.
a rst-line medication does not work. You may pay more for brand name medications.
These steps follow the most current and appropriate medication therapy recommendations. CVS
Caremark will review your records for step therapy medications when you go to the pharmacy to ll
a prescription. If your prescription is for a step therapy medication, the pharmacy will search your
prescription records for use of a rst-line alternative.
If prior use of a rst-line medication is not found, the second-line medication will not be covered. You
will need to obtain a new prescription from your doctor for one of the rst-line alternatives, or have your
doctor request a prior authorization for coverage of the second-line medication.
The list of step therapy medications is subject to change and is available by visiting
https://info.caremark.com/oe/stateofmaryland
Drug Exclusions
Some medications are excluded from coverage, including, but not limited to, the following:
• Over-the-counter vitamins, except those covered under the Aordable Care Act
• Anorectics (any drug used for the purpose of weight loss)
• Bulk compounding ingredients, kits, high cost bases
• Experimental/investigative drugs
• Unapproved Products
Refer to the CVS Caremark’s State of Maryland website for a full list of excluded medications:
https://info.caremark.com/stateofmaryland.
Medicare-Eligible Prescription Drug
If you are a retiree enrolled in Medicare, your prescription drug coverage is provided by SilverScript
Employer PDP sponsored by the State of Maryland. The common name for this type of plan is an Employer
Group Waiver Plan (EGWP). You may see both names in the communications you receive. As a Medicare-
eligible retiree, you qualify for the EGWP as long as:
• You live in the United States;
• You are entitled to Medicare Part A, or you are enrolled in Medicare Part B (or you have both Part A and
Part B); and
• You qualify for retiree health benets from the State of Maryland.
Highlights of this plan include:
• You pay the same copays as noted in this guide for non-Medicare-eligible retirees.
• You have one ID card.
• You don’t deal with Medicare Part D – it’s all handled behind the scenes.
• Many of the prescription drug step therapies, quantity limits and prior authorization requirements
noted in this Section do not apply to you. Refer to your annual Notice of Coverage for information about
what is and what is not allowed.
Those with limited incomes may qualify for Extra Help to pay for their Medicare prescription drug costs. If
you are eligible to receive Extra Help, Medicare could pay up to 75% or more of your drug costs, including
monthly prescription drug premiums, annual deductibles and copayments. For more information about
Extra Help, contact your local Social Security oce or call Social Security at 1-800-772-1213 between 7
a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778.
Most people will pay the standard monthly Part D premium. However, some people pay an extra amount
because of their yearly income. If your income exceeds current limits for individuals, married individuals
252024 Health Benets Guide
ling separately, or married couples, you must pay an extra amount for your Medicare Part D coverage. If
you have to pay an extra amount, the Social Security Administration, not your Medicare plan, will send
you a letter telling you what that extra amount will be. For more information about Part D premiums
based on income, you can visit http://www.medicare.gov on the Web or call 1-800-MEDICARE (1-800-
633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or you may also call the
Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778.
Direct Member Reimbursement
If you or your covered dependent purchase a covered prescription medication without using your
prescription drug card and pay the full cost of the medication, you may be entitled to reimbursement,
subject to plan terms and conditions. Please do the following for your out-of-pocket expenses to be
considered for reimbursement:
• Complete the Prescription Drug Claim Form. Forms are available by calling CVS Caremark (844) 460-
8767 or by going to www.dbm.maryland.gov/benets and clicking on the Prescription Drug
coverage and then the CVS Caremark symbol.
• Attach a detailed pharmacy receipt. This includes medication dispensed, quantity and cost.
• Send the information to CVS Caremark by mail to the address listed on the bottom of the form.
If the amount you paid is equal to or less than your copayment, it is not necessary to send in claims
for reimbursement. The copayment is your responsibility and will not be reimbursed. However, if you
have reached the annual out-of-pocket maximum, the copayment (or a smaller payment amount, if
applicable) will be reimbursable.
Out of Country Claims
(Please note: SilverScript members are not eligible for out-of-country claims reimbursement.)
Out-of-country claims are covered if the drug is FDA approved. Prescriptions lled in the United States
must be lled by a network pharmacy for claims to be covered. The claim request must be submitted
within the prescription ll date for reimbursement to be issued.
Claims
reimbursements
are subject to plan
terms and conditions
and therefore may
not be eligible for
reimbursement.
All claims must be
submitted within
one year of the
prescription ll date.
Please allow 2 to
6 weeks for your
reimbursement
check to arrive at
your address on le.
26 2024 Health Benets Guide
Predetermination
of Benets
You or your dentist
should seek
predetermination
of benets before
a major dental
procedure so you
and your dentist will
know exactly what
will be covered and
what you will need to
pay out-of-pocket.
Dental Benets
Dental coverage is available to all individuals who are eligible for State health benets. You have two
dental plans from which to choose:
• A Dental Preferred Provider Organization (DPPO) plan through United Concordia; or
• A Dental Health Maintenance Organization (DHMO) plan through Delta Dental.
How the Plans Work
The DPPO Plan
United Concordia is committed to providing you quality DPPO benets. Under this plan, you do not have
to select a Primary Dental Oce (PDO) and can receive coverage from any licensed dentist. If you use
one of its Advantage Plus network dentists, you can maximize your benet dollars with their negotiated
discount rates. Some United Concordia dentists have agreed to oer discounts for non-covered services
and services received over your annual max.
No referrals are needed for specialty care. Orthodontia services are only covered for eligible dependent
children (not employees) age 26 or younger.
Orthodontic Treatments in Progress
Switching dentists isn’t always easy—especially when you have a treatment in progress, such as
orthodontia. If you have to switch dentists and need to continue with your treatments in progress, we’ll
switch your services and coverage, while also determining your payable benets.
Out-of-Area Coverage
You never need to worry about where you are if you need dental care as you may receive services from any
dentist, in-network or out. However, if you use an out-of-network dentist, you must submit a claim form
for reimbursement and may be billed for the amount charged that exceeds the allowed benet.
Member Services
When you use an in-network DPPO dentist, the in-network dentist will bill the plan directly for the
amount the plan will pay. You will be billed your share of the cost under the plan. You can access all of
your dental information online any time on My Dental Benets:
• Visit www.UnitedConcordia.com/statemd
• Select My Dental Benets and sign in or create an account, then
• View all your Explanations of Benets (EOBs) under Claims & Deductibles
• You can also view your benets from your mobile device by using the State of Maryland Members App
• Questions regarding the DPPO plan? Call United Concordia at 1-888-638-3384.
DPPO Plan Design
Feature
Benet Coverage (In-Network
and Out-of-Network Services)
Plan Year deductible $50 per individual; $150 per family
Only applies to Class II and Class III services
Plan Year Maximum $2,500 per participant; only applies to Class II and Class III services
Class I: Preventive services, initial periodic and emergency
examinations, radiographs, prophylaxis (adult and child), uoride
treatments, sealants, emergency palliative treatment
Plan pays 100% of allowed benet
Class II: Basic Restorative services, including composite/resin
llings, inlays, endodontic services, periodontal services, oral
surgery services, general anesthesia, prosthodontic maintenance,
relines and repairs to bridges, and dentures, space maintainers
Plan pays 70% of allowed benet after deductible
Class III: Major services, including crowns and bridges, dentures
(complete and partial), xed prosthetics, implants
Plan pays 50% of allowed benet after deductible
Class IV: Orthodontia (for eligible child(ren) only, age 26 or
younger), diagnostic, active, retention treatment
Plan pays 50% of allowed benet, up to $2,000 lifetime maximum
272024 Health Benets Guide
The DHMO Plan
Important note: Before enrolling, we strongly recommend that you contact your primary care dental
facility to be sure that the facility participates in Delta Dental’s DeltaCare® USA network. The plan
cannot guarantee the continued participation of a particular facility or dentist.
Delta Dental is the Program’s DHMO carrier. Delta Dental oers quality, convenience, and predictable
costs through their DeltaCare® USA network.
When you enroll, you’ll select a DeltaCare USA primary care general dentist to provide services. Family
members may select dierent dentists, as many as three per family, for treatment within the covered
service area. You’ll receive most of your dental care from your primary care dentist. If you need treatment
from a specialist, your DeltaCare USA primary care dentist will coordinate a referral for you.
With the DHMO there are no claim forms to complete, no deductibles or annual and lifetime dollar
maximums. Preventive and diagnostic services are covered at low or no costs.
You must visit your selected primary care dentist to receive benets under your plan. If you don’t select a
dentist, Delta Dental will choose one for you near your home address.
To select a primary care dentist:
• Visit deltadentalins.com/statemd and click on “Find a Dentist.”
• Select “DeltaCare USA” as your plan network.
• Once you have selected a dentist, call Delta Dental’s Customer Service at 844-697-0578 with the
dentist’s name and practice number.
Selections of or changes to primary dentists received between the rst and 15th of the month are
eective immediately. Changes received on the 16th through the end of the month will be eective on
the rst of the next month. You can also call Customer Service at 844-697-0578 for help with nding or
changing a dentist.
Continuous orthodontic coverage:
If you or an eligible family member has started orthodontic treatment (banding has taken place) under a
previous plan, you may be able to continue that coverage when you switch to Delta Dental DHMO dentist
through a provision called orthodontic treatment in progress. Please contact Delta Dental at 844-697-
0578 for details.
Out-of-area emergencies:
If you experience an emergency while traveling outside the service area of your network oce, you
may use your out-of-area emergency benet. This benet provides for emergency treatment up to a
maximum allowance of $100. You may initially be required to pay for services upon treatment. To receive
reimbursement, simply submit a copy of the itemized treatment from the attending dentist to Delta
Dental within 90 days of treatment. Depending on the plan benets, copayments may apply.
Online Services Available:
You can access your eligibility and benets information online with a secure, simple Online Services
account:
• Visit deltadentalins.com/statemd
• Select “Register Today” in the “Online Services” box and create your prole. You can choose to go
paperless and receive email alerts when new documents are ready to view.
• Read your information anytime from your desktop or mobile device.
If your dentist
discontinues
participation in the
plan, is terminated
from the network
or closes his/her
practice to new
patients, you will
need to select
another primary
care dentist. You
will not be able to
change your plan or
withdraw from the
plan until the next
Open Enrollment
period.
28 2024 Health Benets Guide
Predetermination
of Benets
You or your dentist
should seek
predetermination
of benets before
a major dental
procedure so you
and your dentist will
know exactly what
will be covered and
what you will need to
pay out-of-pocket.
DHMO Fee Schedule
ADA Code ADA Description Member Pays $
0120 Periodic oral evaluation - established patient 0
0140 Limited oral evaluation - problem focused 0
0150 Comprehensive oral evaluation - new or established patient 0
0210 Intraoral - complete series of radiographic images 0
0220 Intraoral - periapical rst radiographic image 0
0230 Intraoral - periapical each additional radiographic image 0
0272 Bitewings - two radiographic images 0
0274 Bitewings - four radiographic images 0
0330 Panoramic radiographic image 0
1110 Prophylaxis - adult 0
1120 Prophylaxis - child 0
1206 Topical application of uoride varnish - through age 18 0
1208 Topical application of uoride (excluding varnish) 0
1351 Sealant - per tooth 0
2140 Amalgam - one surface, primary or permanent 0
2150 Amalgam - two surfaces, primary or permanent 0
2160 Amalgam - three surfaces, primary or permanent 0
2161 Amalgam - four or more surfaces, primary or permanent 0
2330 Resin-based composite - one surface, anterior 0
2331 Resin-based composite - two surfaces, anterior 0
2332 Resin-based composite - three surfaces, anterior 0
2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) 70
2391 Resin-based composite - one surface, posterior 40
2392 Resin-based composite - two surfaces, posterior 60
2750 Crown - porcelain fused to high noble metal 276
2752 Crown - porcelain fused to noble metal 270
2790 Crown - full cast high noble metal 228
2792 Crown - full cast noble metal 264
2920 Recement or rebond crown 15
2950 Core buildup, including any pins 100
2954 Prefabricated post and core in addition to crown 108
3310 Root canal - Endodontic therapy, anterior tooth (excluding nal restoration) 108
3320 Root canal - Endodontic therapy, bicuspid tooth (excluding nal restoration) 144
3330 Root canal - Endodontic therapy, molar (excluding nal restoration) 198
4341 Periodontal scaling and root planing - four or more teeth per quadrant 60
4910 Periodontal maintenance 30
7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) 20
7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and
including elevation of mucoperiosteal ap if indicated
27
7230 Removal of impacted tooth - partially bony 55
7240 Removal of impacted tooth - completely bony 65
9110 Palliative (emergency) treatment of dental pain - minor procedure 15
D9222 Deep sedation/general anesthesia – rst 15 minutes 103
D9223 Deep sedation/general anesthesia – each subsequent 15 minute increment 103
Please refer to the DBM website at www dbm maryland gov/benets.. . , select dental coverage and
then Delta Dental for a complete DHMO Copay Schedule.
292024 Health Benets Guide
Flexible Spending Accounts
A Flexible Spending Account (FSA) is an account that allows you to set aside pre-tax dollars from your pay
to be reimbursed for qualied healthcare or dependent daycare expenses. You choose how much money
you want to contribute to an FSA at the beginning of each plan year. You can be reimbursed from your
account throughout the plan year.
There are two types of FSAs: a healthcare FSA and a dependent daycare FSA. The FSAs are administered by
the P&A Group.
There are hundreds of eligible expenses for your FSA funds, including prescriptions, doctor visit copays,
health insurance deductibles and coinsurance for you, your spouse or eligible dependents, and daycare for
your eligible dependents while you work.
Tax Savings with an FSA
All FSA contributions are pre-tax, which means they come out of your pay before taxes. You save money
by not paying taxes on the amount you contribute to your account for eligible healthcare and dependent
daycare expenses.
Actual savings will vary based on your individual tax situation; please consult a tax professional for more
information.
Healthcare Flexible Spending Account
Through a Healthcare Flexible Spending Account, you can be reimbursed tax-free for eligible out-of-
pocket healthcare expenses not paid by insurance, including deductibles, copays or coinsurance for
eligible medical, prescription, dental and vision. Also, certain eligible over-the-counter (OTC) items are
eligible for reimbursement. For a complete list of what’s covered and what’s not, visit www.irs.gov/
publications/p502.
You can use the Healthcare Flexible Spending Account to pay eligible healthcare expenses for yourself,
your spouse, and your qualifying dependent children who have not reached age 27 by the end of
the taxable year. You and your dependent(s) do not have to be covered under a State medical plan to
participate in an FSA. To change the contributions you make to this account, the same qualifying status
change rules apply as for the medical plans.
For 2024, you may contribute between $120 and $3,050 on a pre-tax basis to your healthcare FSA.
Our plan does not allow Healthcare FSA funds to roll over from one year to the next, so be sure to plan
carefully when deciding how much to contribute. Any amount remaining in your account at year-
end for which you did not le a claim will be forfeited.
Healthcare FSA Minimum Maximum
Annually $120.00 $3,050.00
12 pay period deductions $10.00 $254.16
24 pay period deductions $5.00 $127.08
20 Pay Faculty Scheduled deduction $6.00 $152.50
This plan may
not discriminate
in favor of highly
compensated
employees with
respect to eligibility,
contribution
and benets
in accordance
with applicable
provisions of the
Internal Revenue
Code. The Plan
Administrator must
take such actions as
excluding certain
highly compensated
individuals from
participation in
the plan or limiting
the contributions
if, in the Plan
Administrator’s
judgment, such
actions serve to
assure that the
plan does not
violate applicable
nondiscrimination
rules.
Use It or Lose It!
Estimate carefully
so that you can be
sure you will use all
of your FSA funds by
the end of the year!
30 2024 Health Benets Guide
You may still have
to submit receipts
for some of your
purchases (per IRS
regulations), so don’t
throw your itemized
receipts away – you
may be asked to
show them even
after reimbursement
has been made.
Reimbursement
For the Healthcare FSA, the easiest way to pay for eligible expenses is by using the debit card. But, when
you cannot use your card for Healthcare FSA purchases, you may pay the amount due out of your pocket
and then submit a reimbursement request by following the steps below:
• Keep your itemized receipts as documentation for all your healthcare FSA purchases.
• Submit a claim online at MD.padmin.com from your computer or mobile device. (If you do not have
web or mobile access, you may contact Customer Service to request a paper claim form at the number
on the inside front cover of this guide.)
• For easy reimbursement, sign up to receive all reimbursements through direct deposit to your checking
or savings accounts.
How does the debit card work?
The debit card allows you to access your FSA funds quickly and easily. At many retailers, doctors’ oces,
vision centers, hospitals, pharmacies and grocery stores (for eligible over-the-counter items), your
charges may be veried automatically as an eligible expense, reducing the need for you to submit
receipts.
You may still be asked to provide verifying documentation. Failure to provide that documentation within
31 days of the request may result in reversal of the payment, card suspension and/or additional taxes
due. Documentation can be submitted directly online when logging into your P&A Group Account at
MD.padmin.com (under Member Tools choose Upload a Claim, then under Claim Type select Request for
Debit Card Documentation). You can also fax the verifying documentation to (844) 633-5399.
When will my debit card expire?
Be sure to keep your card (even after your funds have been used for the plan year) for future plan years.
Your card will remain active for three years from the date of issue; it is good through the last day of the
month shown on your card. When your card is nearing its expiration date, a new card will be mailed to the
address on le automatically, approximately one month before your current card expires as long as you
continue to enroll in a Healthcare FSA.
What items may I purchase using my debit card?
You can pay for most eligible expenses by using the debit card, including the cost of prescription drugs,
certain over- the-counter items at most retailers, and doctors’ charges at oces that accept debit
cards. Your card will not work at retail locations that do not oer healthcare items or medical services.
Dependent Daycare FSA funds cannot be paid by using the card.
Using the debit card for Over-The-Counter (OTC) Medicines
Under the CARES Act of 2020, OTC medications and feminine care products, like tampons and pads, are
reimbursable without a prescription. You can use your debit card at the point-of-service to purchase
these expenses, or pay out-of-pocket and submit a claim for. Please see
MD.padmin.com for details.
312024 Health Benets Guide
USING YOUR ONLINE Healthcare ACCOUNT
The Healthcare FSA comes with an online account feature. Use your online account to do the following:
• Get your account balance
• View debit card charges
• Enter a new claim
• View claim status
• Find answers to frequently asked questions
P&A Group Mobile Website
Visit P&A Group’s secure mobile website, MD.padmin.com, to access all of your healthcare account
information from your mobile device. You may also obtain your account balance using the automated
telephone service. Simply call P&A Group’s Customer Service Team at 844-638-1900.
You can also download P&A’s mobile app from the App Store or Google Play. Search “P&A Group” at the
store to download the app, where you can register for important account alerts!
FSA Distributions for Reservists
The Heroes Earning Assistance and Relief Tax Act of 2008 (HEART Act) allows plans to oer “qualied
reservist distributions” of unused amounts in healthcare exible spending accounts (FSAs) to reservists
ordered or called to active duty for at least 180 days or on an indenite basis. An Employee must request
a qualied reservist distribution on or after the date of the order or call to active duty, and before the last
day of the plan year (or grace period, if applicable) during which the order or call to active duty occurred.
The Employee Benets Division must receive a copy of the order or call to active duty (or extension
thereof) to conrm compliance with the 180-day/indenite requirement. To request a distribution of
unused amounts contributed to the healthcare FSA, submit your request in writing along with a copy of
your orders to the Employee Benets Division before December 31of the plan year.
Dependent Daycare Flexible Spending Account
The Dependent Daycare FSA covers dependent daycare expenses while you (or you and your spouse, if
married) work or look for work, or while you work and your spouse attends school full-time. The care may
be provided inside or outside of your home and may include things like before-and after-school care,
nursery school and summer day camp.
You can use the Dependent Daycare FSA to pay eligible expenses for the care of:
• Your dependent children under age 13;
• At a day camp, nursery school, or by a private sitter for a child that lives in your home at least eight
hours a day; or for before - and after - school care (must be kept separate from tuition expenses);
• Care of an incapacitated adult who lives with you at least eight hours a day; and
• Expenses for a housekeeper whose duties include caring for an eligible dependent.
For 2024, you may contribute between $120 and $5,000 on a pre-tax basis (or up to $2,500 a year pre-tax
if married and ling separately), to your Dependent Daycare FSA to pay for eligible dependent daycare
expenses. If your spouse is a full-time student or incapacitated, the maximum annual election is $3,000
for one child or $5,000 for two or more children. Our plan does not allow dependent daycare FSA funds
to roll over from one year to the next, so be sure to plan carefully when deciding how much to contribute.
Any amount remaining in your account at year-end for which you did not le a claim by the
deadline will be forfeited.
Dependent Daycare FSA Minimum Maximum
Annually $120.00 $5,000.00
12 pay period deductions $10.00 $416.66
24 pay period deductions $5.00 $208.33
20 Pay Faculty Scheduled deduction $6.00 $250.00
IMPORTANT NOTE:
If you retire
or terminate
employment during
the plan year, you
may only seek
reimbursement
for claims incurred
through your last
day of employment.
You have 90 days
from the date of
your termination
to submit claims
for reimbursement.
Remaining unused
funds will be
forfeited.
32 2024 Health Benets Guide
What’s Not Covered
Eligible dependent daycare services cannot be provided by a person you are claiming as your dependent.
You will need the Social Security or tax identication number of the person or facility that provides the
care. Sample ineligible expenses include the following:
• Education and tuition fees;
• Late payment fees;
• Overnight camps (in general);
• Sports lessons, eld trips, clothing; and
• Transportation to and from a dependent daycare provider.
Reimbursement
All Dependent Daycare Expenses must be submitted for reimbursement either online or using a paper
claim form. Requests for reimbursements for Dependent Daycare Expenses cannot be made until the
service is provided and an itemized statement from your dependent daycare provider is received by P&A
Group.
Timeline for Using Account Funds
You must use all of your FSA funds by the date below or the remaining funds will be forfeited, in
accordance with IRS regulations. Be sure to plan carefully so you contribute the right amount.
Availability of FSA funds
You may be reimbursed from your Healthcare FSA at any time throughout the plan year for expenses up to
the full amount you elected to contribute. This means you have your full contribution amount available to
you on the rst day of the plan year.
However, you can only be reimbursed from the Dependent Daycare FSA up to the amount contributed at
the time care is received. If you submit a reimbursement request for more than your current balance, it
will be held until additional contributions have been added to your account during subsequent payroll
deductions.
Deadline for Eligible Expenses
You have until March 15, 2025 to incur eligible expenses for your Healthcare FSA. You have until
December 31, 2024 to incur eligible expenses for your Dependent Daycare FSA.
Deadline for Submitting Reimbursement Requests
For both the Healthcare FSA and the Dependent Daycare FSA, you have until April 15, 2025 to submit
claims for eligible expenses. Remember, even though you have until April 15, 2025 to submit the claim,
the service dates must be on or before the dates listed above to be eligible for reimbursement.
P&A Group Contact Information
For more information or questions regarding your FSA, contact the P&A Group Monday – Friday, 8:00 AM
– 10:00 PM ET, or visit our website.
Website: MD.padmin.com
Phone: (844) 638-1900
Fax: (844) 638-1901
Mailing Address: 6400 Main Street, Suite 210, Williamsville, NY 14221
332024 Health Benets Guide
Term Life Insurance
Group Term Life insurance provides a base level of protection that will help protect your family against the
unexpected loss of your life during your working years. Term Life insurance builds no cash value; it simply
pays a benet at your death.
Life Insurance Choices for Active Employees
Coverage for Yourself
If you are an eligible employee, you may elect coverage in $10,000 increments up to $300,000. If you are
a public safety employee who scuba dives, or you y in or pilot a helicopter as part of your job, you may
elect coverage in $10,000 increments up to a maximum of $500,000. For employees who are eligible for
the $500,000 maximum, if you cease to be a scuba diver, y in or pilot a helicopter as part of your job, you
will no longer be eligible for the $500,000 maximum and your coverage will be reduced to $300,000.
You may choose up to $50,000 of guaranteed coverage without completing an Evidence of Insurability
(EOI) form. To receive guaranteed coverage, you must elect coverage within 60 days after your start
date. If you select coverage greater than $50,000 for yourself, or if you elect coverage after your initial
eligibility, you must complete and submit an EOI form to MetLife. Benet amounts over $50,000 will
not be in eect, nor will the increased premiums be deducted from your pay, until MetLife approves the
additional coverage.
Coverage for Your Dependents
You may elect coverage for your dependents in $5,000 increments up to a maximum of $150,000 or half
of your life insurance amount, whichever is less.
You may elect coverage up to the guaranteed coverage amount of $25,000 for your spouse or domestic
partner and each of your eligible child(ren). If total coverage for your spouse or domestic partner is
greater than $25,000, an EOI form is required. EOI forms are not required for eligible children.
Elected coverage above the guaranteed coverage amount is dependent upon the approval of the active
employee’s coverage as your dependents can never be more than half of your election as an active
employee.
PLEASE NOTE:
• Dependent eligibility requirements for term life insurance are the same as the requirements for all
other plans.
• Dependents with life insurance who become ineligible may contact the plan for information to convert
to an individual life insurance policy within 31 days after becoming ineligible. Please contact MetLife at
1-866-574-2863 for more information.
• Premium changes due to age start at the beginning of each plan year (January 1) based on your age on
January 1.
• The life insurance oered to you and your dependents is term life coverage. This type of life insurance
has no cash value.
How the Plan Works During Active Employment
New Enrollment
For new enrollment in the Group Term Life Insurance plan oered through the State to begin, you must
be employed by the State of Maryland and performing services for compensation on your regularly
scheduled working days. “Actively at work” means the individual is performing the material duties of his/
her own occupation at the employer’s usual place of business. You are considered Actively at Work if an
absence is due to a regularly scheduled day o, holiday or vacation day.
If you do not enroll when rst eligible, you will have to wait until a qualifying life change or the next Open
Enrollment period.
34 2024 Health Benets Guide
No Duplication
of Benets or
Enrollment
If you and your
spouse or domestic
partner are both
State employees
and/or retirees, and
you cover yourself
for life insurance, you
cannot be covered
as a dependent
of your spouse or
domestic partner.
Also, children of
State employees and
retirees cannot have
duplicate coverage
under both parents. If
a child has coverage
as a State employee,
he or she cannot
also be covered as a
dependent. MetLife
will only pay benets
under one policy.
You are always the
beneciary for your
dependent’s life
insurance coverage.
Changing Coverage and When Coverage is Eective
If you are currently enrolled in the plan, you may continue at your current coverage level each plan year
without medical review. If your election requires proof of good health, you must submit the Evidence of
Insurability (EOI) form directly to MetLife. Your increased coverage amount will become eective when
you pay increased premiums on:
• The rst of the month following the date MetLife approves your Evidence of Insurability.
If your request for increased coverage is denied, your coverage will remain at your previous amount.
Plan Features
Accelerated Benet
An Accelerated Benet is available in the event of a terminal illness. An insured employee, spouse,
domestic partner or child has the option to receive an accelerated benet of up to 100% of the life
insurance coverage amount, if the insured person is medically certied by MetLife to be terminally ill with
less than 12 months to live and has at least $10,000 in coverage.
Waiver of Premium During Total Disability
If you become totally disabled before you reach age 60 and are enrolled in the term life insurance plan as
an active State employee on your date of disability, you may be entitled to a waiver of premium after nine
months of total disability. Call MetLife at 1-866-574-2863 for information to apply.
Conversion and Portability of Coverage
If you are no longer eligible for coverage as an active employee and are not retiring, you may transfer
your Group Term Life insurance as well as your in-force dependent life insurance (portable coverage ends
at age 70) or you may convert your and your dependent’s life coverage to an individual life insurance
policy. Premiums may be higher than those paid by active employees. NOTE: You have 31 days after your
termination date to select one of the above options.
Additional Benets
If you are covered under the Term Life Insurance Plan, you and your dependents have access to travel
assistance services, will preparation, grief counseling, funeral discounts and planning services and Digital
Legacy; your beneciaries have access to beneciary claim assistance, grief counseling, funeral assistance,
and estate resolution services.
Beneciaries
MetLife requires a valid beneciary designation on le. If you do not name a beneciary, or if you are
not survived by your named beneciary, benets will be paid according to the plan provisions listed in
MetLife’s certicate of group coverage.
Beneciaries can be changed at any time throughout the year. Beneciary designation forms are available
from MetLife’s web site:
https://www.metlife.com/stateofmd.
352024 Health Benets Guide
Life Insurance Choices When You Retire
Coverage for Yourself
State retirees who retire directly from State service may:
• Continue life insurance at the same coverage level, subject to the age-related reduction schedule;
• Reduce life insurance coverage to a minimum of $10,000, also subject to the age-related reduction;
• Cancel life insurance coverage; or
• Convert to an individual policy.
You cannot increase your life insurance coverage or add new dependents to your life insurance coverage
when you retire or at any time after retirement. If you reduce or cancel life insurance coverage, you will
not be permitted to increase coverage or re-enroll in the State Life Insurance plan. There cannot be a
break in life insurance coverage between active employment and retirement.
Coverage for Your Dependents
As a retiree, you may choose to continue, reduce, or cancel your dependent life insurance coverage for any
dependents that were covered under the life insurance plan while you were an active employee.
Your dependent’s life insurance can never be more than half of your life insurance coverage amount.
Spouse, domestic partner or children who had life insurance as the dependent of a deceased retiree can
only continue life insurance coverage through a conversion policy.
Automatic Reduction of Benets for You and Your Dependents
As a retiree, life insurance benets for you and your spouse or domestic partner will reduce automatically
based on your age, according to the reduction schedule below. Premium changes due to an automatic
reduction of benets for you and your dependents will begin the rst of your birthday month.
At Age... Spouse Benets Reduce To...
65 65% of your and your dependent’s original amount
70 45% of your and your dependent’s original amount
75 30% of your and your dependent’s original amount
80 20% of your and your dependent’s original amount
For more information or questions about additional services, conversion policies, limitations, denitions,
restrictions, terminating events, or exclusions, please call MetLife at 1-866-574-2863 or visit their
dedicated website for the State of Maryland’s Group Term Life Insurance Plan:
https://www.metlife.com/stateofmd.
36 2024 Health Benets Guide
Accidental Death and Dismemberment
Accidental Death and Dismemberment (AD&D) is available to all active employees and their dependents
eligible for health benets with the State. AD&D is oered through MetLife. AD&D insurance provides
beneciaries with additional nancial protection if an insured’s death or dismemberment is due to a
covered accident, whether it occurs at work or elsewhere. Evidence of insurability is not required.
You can choose individual or family coverage in an amount equal to:
• $100,000,
• $200,000, or
• $300,000.
If you choose family coverage, the amount of a dependent’s AD&D insurance is based on the composition
of the employee’s family as follows:
Employee’s Family Consists of Amount of AD&D Insurance
Spouse , Domestic Partner and Eligible Children
Spouse/Domestic Partner:
Each Child:
55% of employee’s amount of insurance
15% of employee’s amount of insurance*
Spouse , Domestic Partner and No Eligible Children 65% of employee’s amount of insurance
No Spouse/Domestic Partner but Eligible Children 25% of employee’s amount of insurance*
*The maximum benet for child coverage is $50,000
How the Plan Works
Benets will be paid within 365 days after the date of an accident. The plan will pay a percentage of the
principal benet amount depending on whether there is a loss of life or dismemberment. If more than
one covered loss is sustained during one accident, the plan will pay all losses up to the principal sum.
As with Term Life Insurance, coverage under the AD&D Plan entitles you to additional benets through
MetLife. For more information or questions about additional services, conversion policies, limitations,
denitions, restrictions, terminating events, or exclusions, please call MetLife at 1-866-574-2863 or visit
their dedicated website for the State of Maryland’s Group Term Life Insurance Plan:
https://www.metlife.com/stateofmd.
372024 Health Benets Guide
Eligibility
The charts on the following pages explain if you are eligible for benets under the State of Maryland
Employee and Retiree Health and Welfare Benets Program. If you are eligible, you may also cover your
eligible dependents for certain benets.
For plans in which you are enrolled, your dependents must be in one of the categories listed in the table
beginning on page 40. Beneciaries of deceased State retirees can only cover dependents who would be
eligible dependents of the State retiree if they were still living.
Refer to the Required Documentation for Dependents section for a list of documentation you must submit
for all newly enrolled dependents.
NOTE: It is your responsibility to remove a covered dependent child, domestic partner or spouse
immediately when they no longer meet dependent eligibility criteria provided on page 51 under
“Removing Dependents Who Lose Eligibility.” Children (biological, adopted and stepchildren) reaching age
26 and/or other child relatives (grandchildren, legal wards, step-grandchildren or other child relatives)
reaching age 25 with no disability certication are removed from coverage automatically at the end of
the month in which they turn age 26 or 25 respectively. A notice will be sent to your address in the SPS
Benets system in advance of the termination of coverage.
When Coverage Begins
Generally speaking if enrolling during the annual Open Enrollment period, the coverage you elect will
begin January 1 and remain in eect through December 31 of the same calendar year unless you have a
qualifying status change that allows you to make a mid-year change in coverage, as described under the
Qualifying Status Changes section.
Refer to the chart below to see when your coverage begins when not enrolling during the annual Open
Enrollment period.
If you are... Coverage becomes eective...
A new employee enrolling for the
rst time
1st of the month after date of hire. If hired on the rst of the month, date of hire.
Coverage for Flexible Spending Accounts (FSAs) is eective the 1st of the month following the date
the enrollment event is approved.
An active employee making an
authorized mid-year change in
coverage
1st of the month following the qualifying status change.
Exceptions are births and adoptions which are eective on the date of the event. Term Life
Insurance & Accidental Death and Dismemberment coverage are eective the 1st of the month
following the date of birth. FSA coverage see “new active employee” above.
Newly retired or retiree beneciary 1st of the month of retirement.
A retiree making an authorized mid-
year change in coverage
1st of the month following the date of the qualifying status change. Exceptions are births and
adoptions which are eective on date of event.
Special Note for Employees
Any missed premium deductions (e.g., due to a short-term disability absence, a transfer between two
State agencies or because of a payroll errors, mid-month termination, etc.), must be paid by the due date
in the invoice. Three invoices will be mailed to the employee, failure to pay the invoice(s) will result in
the debt to be referred to the State Central Collections Unit (CCU) for collection. The payment due date
is strictly enforced. In some cases, your coverage may be canceled and you will not be permitted to re-
enroll until the next Open Enrollment period.
Active Employees who transferred or missed deductions due to a payroll error cannot have an interruption
of coverage for the plan year. Missing one to two pay periods is considered a short-term leave of absence.
Please review the policy section in the guide on Leave of Absence/COBRA Coverage.
Two State employees
and/or retirees may
not be covered as
both the
employee/retiree
and a dependent in
the same plan. It is
your responsibility
to make sure that
you and your
dependents do
not have duplicate
State coverage.
This includes your
children who
may also be State
employees. Duplicate
benets will not be
paid.
For our New Hires,
Newly Retired or
those experiencing
a qualied status
change - you have
60-days from the
initial date to enroll
or make changes.
Coverage will be
retroactive based
on this chart and
missed premium
deductions will be
billed to you for
payment.
38 2024 Health Benets Guide
Your Cost
The amount you pay for benets coverage depends on several factors, including:
• The benet plans you choose;
• Whom you choose to cover;
• Your age (for Life Insurance);
• Your Medicare eligibility;
• Your status (full-time permanent, part-time permanent, contractual/variable hour employee, retiree,
ORP retiree, etc.); and
• Your length of service with the State (retirees).
If you are eligible for the maximum State subsidy, you pay the amount shown on the Retiree Rate Sheet.
However, some individuals are eligible for only a percentage of the State subsidy or are not eligible to
receive the State subsidy. The Employee Benets Division will provide a conrmation statement reecting
actual monthly contributions.
Part-time regular (working less than a 50% work week), COBRA members, and employees on an
approved Armed Services leave 31 or more days do not receive any State subsidy for their coverage and
should refer to the Direct Pay Rate Sheet. Contractual/Variable hour employees who work less than
30 hours/week or 130 hours/month do not receive any State subsidy for their coverage. Contractual/
Variable hour employees working more than 30 hours/week or an average of 130 hours/month receive
an alternative State subsidy for medical and prescription coverage only. All Contractual/Variable hour
employees regardless of the number of hours worked should refer to the Contractual/Variable Hour Rate
Sheet. All rate sheets can be found at www.dbm.maryland.gov/benets.
It is your responsibility to verify your benet deductions on your check or retirement stub and
your Benets Summary Statement to ensure they match the coverage you elected. If there is
an error, contact the following immediately:
• Your Agency Benets Coordinator, if you are an Active, Satellite or Direct Pay employee; or
• The Employee Benets Division, if you are a retiree or a COBRA enrollee.
• You may not retroactively elect to participate in a Flexible Spending Account.
392024 Health Benets Guide
Enrolling Eligible Dependents
You must submit documentation for each dependent you wish to enroll for coverage verifying they meet
the eligibility requirements of the Program. If you do not provide all required documentation at the time
of enrollment the dependent(s) will not have coverage. The following chart lists eligible dependents and
the documents you must submit to cover an eligible dependent. Photocopies are acceptable provided any
seal or ocial certication can be seen clearly.
Employees/retirees adding dependents during Open Enrollment or following a qualifying status change
(including new hires) must attach the dependent documentation to the SPS Benets System Benet
Event.
Satellite employees and COBRA enrollees must attach the dependent documentation to the enrollment
form.
Dependent
Relationship
Eligibility Criteria Required Documentation
Spouse • Lawfully married to an
employee or retired
employee as recognized
by the laws of the State
of Maryland or in a
jurisdiction where such
marriage is legal
• Ocial State marriage certicate (must be a certied copy recorded, signed
by the appropriate State or County ocial, such as the Clerk of Court):
- From the court in the County or City in which the marriage took place; or
- From the Maryland Division of Vital Records for marriages that occurred
at least six months prior to enrollment; or
- From the Department of Health and Mental Hygiene (DHMH) website:
www.dhmh.maryland.gov (click Online Services) – also
www.vitalchek.com
Children
• Biological Child
• Adopted Child
• Step-child
• Under age 26
• Except for grandchildren
and legal wards, no
requirement to reside in
your home
• May be eligible for
coverage under own
employer
• May be married or
unmarried, or;
• Over age 26 and incapable
of self-support due
to mental or physical
incapacity occurring prior
to age 26 with proof of
continuous employer
sponsored coverage
Biological Child
• Copy of child’s ocial state birth certicate showing lineage
• NEWBORNS:
Ocial birth certicate is required within 60 days of birth.
https://www.vitalchek.com (recommended)
OR
https://health.maryland.gov
Adopted Child
• Pending Adoption: Notice of placement for adoption on adoption agency
letterhead or copy of court order placing child pending nal adoption
• Final Adoption: Copy of nal adoption decree signed by a judge or a State-
issued birth certicate showing employee/retiree as the parent
Step-child
• Copy of child’s ocial state birth certicate with name of spouse of
employee/retiree as child’s parent
• Copy of employee/retiree’s ocial state marriage certicate
Other Child Relatives
• Grandchild
• Legal ward
• Step-grandchild or
other dependent child
relatives
• Under age 25
• Must reside in your home
• Must be unmarried
• May not be eligible for
coverage under own
employer
• For whom you provide
sole support
Other Child Relatives (for all types)
• Copy of child’s ocial state birth certicate showing lineage
• Proof of permanent residence with enrolled employee/retiree (one of the
following):
- Valid driver’s license,
- State-issued identication card,
- School records certifying child’s address,
- Daycare records certifying child’s address, or
- Tax documents with child’s name listed certifying address.
Must also submit following specic documentation for specied dependent:
Legal Wards (temporary guardianship not covered):
• Copy of Legal Ward/Testamentary court document, signed by a judge.
Grandchild, Step-grandchild, or other child relative:
• Proof of relation by blood or marriage
Medical Child Support
Order
• Copy of court order requiring Employee/Retiree to provide support and
health coverage, signed by the child support ocer or judge
Information on how
to upload documents
into the SPS Benets
System is included
on the DBM Health
Benets website:
https://dbm.
maryland.gov/sps/
pages/benefits_
helpcenter.aspx.
If you add a
qualifying dependent
during open
enrollment, you must
provide all required
documentation
when completing the
“Open Enrollment
Benet Event” in the
SPS Benets System.
If documentation is
not appropriately
provided by the end
of open enrollment,
your dependent(s)
will be removed from
the plan
If you are enrolling
using a paper
enrollment form,
you must attach all
required supporting
dependent
documentation, or
your dependent(s)
will not be covered.
40 2024 Health Benets Guide
Dependent
Relationship
Eligibility Criteria Required Documentation
Domestic Partner • Lived together for at least
twelve months.
• Not married to anyone else
nor have another Domestic
Partner.
• At least 18 years of age
and mentally competent to
consent to contract.
• Reside together in the same
residence and intend to do
so indenitely.
• Have an exclusive mutual
commitment similar to that
of marriage.
• Are jointly responsible
for each other’s common
welfare and share nancial
obligations.
• Adavit of Domestic Partnership
• Two of the following:
- Joint lease or mortgage
- Designation of Domestic Partner as beneciary for life insurance AND
retirement contract
- Designation of Domestic Partner as primary beneciary in employee’s
or insured’s will
- Durable property AND health care powers of attorney
- Joint ownership of a motor vehicle, joint checking account or joint
credit account
Domestic Partner
Children
• Biological Child
• Adopted Child
• Under age 26
• Except for grandchildren and
legal wards, no requirement
to reside in your home
• May be eligible for coverage
under own employer
• May be married or
unmarried, or;
• Over age 26 and incapable
of self-support due to
mental or physical incapacity
occurring prior to age 26
with proof of continuous
employer sponsored
coverage
Biological Child
• Copy of child’s ocial state birth certicate showing lineage
• NEWBORNS:
Ocial birth certicate is required within 60 days of birth.
https://www.vitalchek.com (recommended)
OR
https://health.maryland.gov
Adopted Child
• Pending Adoption: Notice of placement for adoption on adoption agency
letterhead or copy of court order placing child pending nal adoption
• Final Adoption: Copy of nal adoption decree signed by a judge or a
State-issued birth certicate showing employee/retiree as the parent
If domestic partner is NOT a covered dependent, documentation of
domestic partnership (see Required Documentation for Domestic
Partners)
Domestic Partner
Other Child Relatives
• Grandchild
• Legal ward
• Other dependent child
relatives
• Under age 25
• Must reside in your home
• Must be unmarried
• May not be eligible for
coverage under own
employer
For whom you provide sole
support
Other Child Relatives (for all types)
• Copy of child’s ocial state birth certicate showing lineage
• Proof of permanent residence with enrolled employee/retiree (one
of the following):
- Valid driver’s license,
- State-issued identication card,
- School records certifying child’s address,
- Daycare records certifying child’s address, or
- Tax documents with child’s name listed certifying address.
Must also submit following specic documentation for specied
dependent:
Legal Wards (temporary guardianship not covered):
Copy of Legal Ward/Testamentary court document, signed by a judge.
Grandchild or other child relative:
Proof of relation by blood or marriage
If domestic partner is NOT a covered dependent, documentation of
domestic partnership (see Required Documentation for Domestic
Partners)
412024 Health Benets Guide
Important Information About Covering Your Domestic Partner and Your Domestic Partner’s
Child(ren)
• How your taxes may be aected- Internal Revenue Service (IRS) regulations treat insurance costs associated with health
benets related to domestic partners and their children dierently. In most cases, domestic partners and their eligible children
are considered non-qualied dependents. Thus, health benets will be taxed as outlined below:
• Payroll Deduction- For each health insurance plan where there is an Employee contribution and a State subsidy in which you
enroll your domestic partner and your partner’s eligible dependents, you will pay:
• Post-tax deduction for the coverage attributable to the domestic partner (and/or domestic partner’s child(ren); and
• Pre-tax deduction applicable to the Employee only coverage.
• Retiree deductions are always post-tax
• Imputed Income- Each health benet plan that includes a State subsidy for your domestic partner and your domestic partner’s
children is subject to tax withholding. In other words, the State’s contribution toward health benets is considered earnings and
will be included in your taxable gross income. This is known as imputed income.
• Retirees-domestic partners and domestic partner’s dependents do not receive State subsidy towards the cost of their enrolled
health benets. Therefore, retirees are not subject to imputed income.
Important information About Covering Grandchildren, Legal Wards and Other Child Relatives
• How your taxes may be aected- Internal Revenue Service (IRS) regulations treat insurance costs associated with Health
benets related to grandchildren, legal wards and other child relatives dierently. In many cases, grandchildren, legal wards and
other child relatives are considered non-qualied dependents. Thus, health benets will be taxed as outlined below:
• Payroll Deduction- For each health insurance plan where there is an Employee contribution and a State subsidy in which you
enroll your grandchild, legal ward or other child relative, you will pay:
• Post-tax deduction for the coverage level attributable to the grandchild, legal ward or other child relative; and
• Pre-tax deduction applicable to the Employee only coverage.
• Retiree deductions are always post-tax.
• Imputed Income- Each health benet plan that includes a State subsidy for grandchildren, legal wards and/or other child
relatives is subject to tax withholding. In other words, the State’s contribution toward health benets is considered earnings and
will be included in your taxable gross income. This is known as imputed income.
• Retirees-grandchildren, legal wards and other child relatives do not receive State subsidy towards the cost of their enrolled
health benets. Therefore, retirees will pay the full premium associated with each of the listed other child relatives.
For information on Domestic Partner’s or Grandchild, Legal Ward or Other Child Relative
Federal Tax Dependent Status visit dbm.maryland.gov/benets
Dependent Child to Age 26
• Dependent child is dened as a biological, adopted or stepchild.
• You can cover your eligible dependent child through the end of the month in which they turn age 26. Disability certication is
required to cover children beyond age 26.
• Disabled Eligible Dependent Child: You are not required to provide disability certication until a disabled, eligible dependent
child reaches age 26. You will then be required to provide certication of their permanent disability status to keep them on your
coverage. The application must be received in the Employee Benets Division no later than 60-days following the date coverage
is terminated. Note: The onset of disability must have occurred before the child reached age 26. Contact the Employee Benets
Division for details and requirements.
Other Dependent Child Relative to Age 25
• Other Dependent Child Relative is dened as grandchild, legal ward, great grandchild or other child relative.
• You can cover your eligible other dependent child relative through the end of the month in which they turn age 25. Disability
certication is required to cover other dependent child relative beyond age 25.
• Disabled Eligible Other Dependent Child: You are not required to provide disability certication until a disabled, eligible other
dependent child reaches age 25. You will then be required to provide certication of their permanent disability status to keep
them on your coverage. The application must be received in the Employee Benets Division no later than 60-days following the
date coverage is terminated. Note: The onset of disability must have occurred before the child reached age 25.
Translation of Non-English Documentation
If you submit dependent documentation that is written in a language other than English, it must be translated by an ocial
translator—someone other than you or your dependent(s). Generally, an ocial translator can be found at any college or university.
The translation of each document must be signed by the translator and notarized.
Important Note About Documentation
• Marriage certicates must be recorded, signed, dated, and certied by the clerk of the court or other appropriate state or county
ocial. Certicates signed by a clergy member (e.g., a minister or rabbi) are not acceptable.
• Birth certicates must show direct lineage to you, your spouse or your domestic partner.
For information on
Domestic Partners OR
grandchildren, legal
wards or other child
relatives Federal Tax
Dependent Status
visit dbm.maryland.
gov/benefits
42 2024 Health Benets Guide
Eligibility by Employee/Retiree Type
Eligibility Subsidy Amount How You Will Pay for Benets
STATE REGULAR EMPLOYEES
You are eligible for benets if you are:
• A permanent full-time or part-time permanent
(working 50% or more of the workweek) State
employee who is regularly paid salary or wages
through an ocial State payroll center, including but
not limited to:
– Central Payroll Bureau;
– Maryland Transit Administration; and
– University of Maryland, including graduate
assistants and the University’s Far East and
European Divisions;
• An elected State ocial;
• Register of Wills or an employee of the Register of
Wills;
• Clerk of the Court or an employee of the oces of
Clerks of the Court; or
• A State Board or Commission member who is
regularly paid salary or wages and works at least
50% of the work week.
Maximum State
Subsidy
Through payroll deductions, using pre-tax deductions,
where pre-tax deductions are permitted.
If for any reason you do not have a deduction for a
pay period, or if your wages are not enough to cover
your deductions, you will be required to pay the State
directly for that unpaid amount. An invoice will be
mailed to the home address on le for any missed
payroll premium deductions. Unpaid invoices will be
referred to the State’s Central Collections Unit (CCU)
where an additional 17% administrative fee will be
added to the debt.
STATE REGULAR EMPLOYEES WORKING LESS THAN 50%
You are eligible to enroll in the same benets as
full-time State employees, with the exception of the
Flexible Spending Accounts. Part-time employees
must follow the same participation rules as full-time
employees.
No State Subsidy – you
pay the full amount
Premiums are paid on a post-tax basis. Monthly
payment coupons will be mailed to the address
provided in the SPS Benets System for the rst
month of coverage through the end of the plan year
or the end of your current contract period, whichever
comes rst.
Payments must begin with the rst coupon received
and are due the rst of every month, with a 30-day
grace period.
Unpaid invoices will be referred to the State’s Central
Collections Unit (CCU) where an additional 17%
administrative fee will be added to the debt.
SATELLITE EMPLOYEES
• You are eligible for benets if you are:
– An employee of a political subdivision which
participates in the State’s health benets program
with the approval of the governing body; or
– An employee of an agency, commission, or
organization permitted to participate in the State’s
health benets program by law.
• Satellite Employees may not participate in the
Program’s FSA plans.
As determined by the
Satellite Employer
As determined by the Satellite Employer
432024 Health Benets Guide
Eligibility by Employee/Retiree Type
Eligibility Subsidy Amount How You Will Pay for Benets
CONTRACTUAL/VARIABLE HOUR EMPLOYEES
WORKING LESS THAN 30 HOURS/WK OR 130 HOURS/MO
Premiums are paid on a post-tax basis. Monthly
payment coupons will be mailed to the address
provided in the SPS Benets System for the rst
month of coverage through the end of the plan year
or the end of your current contract period, whichever
comes rst.
Payments must begin with the rst coupon received
and are due the rst of every month, with a 30-day
grace period.
Unpaid invoices will be referred to the State’s Central
Collections Unit (CCU) where an additional 17%
administrative fee will be added to the debt.
If you do not receive payment coupons within one
month of submitting your “Benet Event” through
the SPS Benets System, please contact your Agency
Benets Coordinator.
You are eligible to enroll in the same benets as
full-time State employees, with the exception of the
Flexible Spending Accounts. Contractual employees
must follow the same participation rules as
full-time employees:
• Changes to coverage normally cannot be made at the
time of an employment contract renewal.
• Contractual employees must have a current active
contract to enroll.
No State Subsidy – you
pay the full amount
CONTRACTUAL/VARIABLE HOUR EMPLOYEES
WORKING MORE THAN 30 HOURS/WK OR 130 HOURS/MO
You are eligible to enroll in the same benets as
full-time State employees, with the exception of the
Flexible Spending Accounts. Contractual employees
must follow the same participation rules as
full-time employees:
• Changes to coverage cannot be made at the time of
an employment contract renewal.
• Contractual employees must have a current active
contract to enroll.
75% State Subsidy
for Medical and
Prescription; no State
Subsidy for other
benet options.
44 2024 Health Benets Guide
Eligibility by Employee/Retiree Type
Eligibility Subsidy Amount How You Will Pay for Benets
MARYLAND STATE RETIREMENT SYSTEM RETIREES HIRED PRIOR TO 7/1/11
You are eligible for benets if you are a State retiree
who is currently receiving a monthly State retirement
allowance and meet one of the following criteria:
• You left State service with at least 16 years of service;
• You retired directly from State service with at least
ve years of service;
• You left State service (deferring your retirement
allowance) with at least 10 years of service and
within ve years of normal retirement age;
• You retired from State service with a disability
retirement; or
• Your State employment ended before July 1, 1984.
Note: Retirees of a County that participates with the
State Retirement System are generally not eligible for
health benets coverage through the State Employee
and Retiree Health and Welfare Benets Program.
Certain other retirees, including but not limited to
retirees of the Maryland Environmental Service or the
University of Maryland Medical System that receive a
State retirement allowance, may be eligible. Contact
your Agency Benets Coordinator or the Employee
Benets Division if you think you may be eligible.
Maximum State
Subsidy if:
• You retire with 16 or
more years of service;
• You receive a
disability
retirement; or
• You retired from State
service before July 1,
1984.
Partial State Subsidy if
you have at least ve
years of State service,
but less than 16. For
example, if you have 10
years of State service,
you would receive
10/16 of the maximum
State subsidy.
Premiums will be deducted from your monthly
retirement check once the State Retirement Agency
(SRA) has created a pension record.
When deductions begin to be taken from your
pension check, our oce will then send a mandatory
retroactive adjustment bill for missed pension
deductions from the date of retirement to the date of
the rst successful pension deduction. You must pay
this mandatory bill by the due date or risk having the
debt referred to the State’s Central Collections Unit
(CCU) where an additional 17% administrative fee may
be added.
Deductions taken from your retirement check are
always taken after any taxes have been deducted. If
your retirement check is not enough to cover all of
your monthly plan premiums, you will be billed for the
plan premiums that could not be deducted. You will
receive invoices mailed to the home address on le.
Premium payments are due on the rst of every
month, with a 30-day grace period (Exception:
January premiums are due upon receipt of the
coupons, with a 30-day grace period).
Unpaid invoices will be referred to the State’s Central
Collections Unit (CCU) where an additional 17%
administrative fee will be added to the debt.
MARYLAND STATE RETIREMENT SYSTEM RETIREES HIRED ON OR AFTER 7/1/11
You are eligible for benets if you are a State retiree
who is currently receiving a monthly State retirement
allowance and meet one of the following criteria:
• You left State service with at least 25 years of
creditable service;
• You retired directly from State service with at least
10 years of creditable service;
• You left State service (deferring your retirement
allowance) with at least 10 years of creditable service
and within ve years of normal retirement age; or
• You retired from State service with a disability
retirement.
Note: Retirees of a County that participates with the
State Retirement System are generally not eligible for
health benets coverage through the State Employee
and Retiree Health and Welfare Benets Program.
Certain other retirees, including but not limited to
retires of the Maryland Environmental Services or the
University of Maryland Medical System that receive a
State retirement allowance, may be eligible. Contact
your Agency Benets Coordinator or the Employee
Benets Division if you think you may be eligible.
Maximum State
Subsidy if:
• You retire with 25
or more years of
creditable service; or
• You receive a
disability retirement.
Partial State Subsidy if
you have least 10 years
of State creditable
service, but less than
25. For example, if you
have 15 years of State
creditable service, you
would receive 15/25
of the maximum State
subsidy.
Premiums will be deducted from your monthly
retirement check once the State Retirement Agency
(SRA) has created a pension record.
When deductions begin to be taken from your
pension check our oce will then send a mandatory
retroactive adjustment bill for missed pension
deductions from the date of retirement to the date of
the rst successful pension deduction. You must pay
this mandatory bill by the due date or risk having the
debt referred to the State’s Central Collections Unit
(CCU) where an additional 17% administrative fee may
be added.
Deductions taken from your retirement check are
always taken after any taxes have been deducted. If
your retirement check is not enough to cover all of
your monthly plan premiums, you will be billed for
the plan portion that could not be deducted. You will
receive invoices mailed to the home address on le.
Premium payments are due on the rst of every
month, with a 30-day grace period. (Exception:
January premiums are due upon receipt of the
coupons, with a 30-day grace period).
Unpaid invoices will be referrred to the State’s Central
Collections Unit (CCU) where an additional 17%
administrative fee will be added to the debt.
452024 Health Benets Guide
Eligibility by Employee/Retiree Type
Eligibility Subsidy Amount How You Will Pay for Benets
BENEFICIARIES OF DECEASED MARYLAND STATE RETIREMENT SYSTEM RETIREES
You are eligible for benets if you are a surviving
spouse, domestic partner or child of a deceased State
retiree and:
• Are receiving a monthly State retirement allowance
as the surviving beneciary of a deceased retiree;
and
• Meet the dependent eligibility criteria for health
benets.
If the surviving spouse or domestic partner is the
beneciary, the spouse or domestic partner may
cover themselves and any eligible dependent
children of the deceased retiree. However, they
may only cover dependents that would be eligible
dependents of the deceased retiree if they were still
living.
If the beneciary is a child, the child will only be
eligible for subsidized health benets as long as
they meet the dependent eligibility requirements
for children. When the child no longer meets the
dependent eligibility criteria for children, the
subsidized health benets end. Non-subsidized
benets under COBRA may then be available for up
to 36 months.
If you were enrolled in dependent Term Life
Insurance at the time of the retiree’s death, that
policy must be converted to an individual policy
directly through MetLife within 30 days in order to
continue Term Life Insurance coverage. Plan phone
numbers are located on the inside front cover of this
guide.
If you are eligible for
coverage as a beneciary,
you will receive the same
State subsidy that the
retiree was entitled to
receive at the time of his or
her death.
If you are the deceased
retiree’s domestic partner
beneciary, you will not
receive a State subsidy
towards benets premiums.
Premiums will be deducted from your monthly
retirement check once the State Retirement Agency
(SRA) has created a pension record.
When deductions begin to be taken from your
pension check our oce will then send a mandatory
retroactive adjustment bill for missed pension
deductions from the date of retirement beneciary
status to the date of the rst successful pension
deduction. You must pay this mandatory bill by
the due date or risk having the debt referred to
the State’s Central Collections Unit (CCU) where an
additional 17% administrative fee may be added.
Deductions taken from your retirement check are
always taken after any taxes have been deducted.
If your retirement check is not enough to cover all
of your monthly plan premiums, you will be billed
for the plan premiums that could not be deducted.
You will receive invoices mailed to the home address
on le.
Premium payments are due on the rst of every
month, with a 30-day grace period (Exception:
January premiums are due upon receipt of the
coupons, with a 30-day grace period).
Unpaid invoices will be referrred to the State’s Central
Collections Unit (CCU) where an additional 17%
administrative fee will be added to the debt.
A deceased retiree’s domestic partner beneciary will
have premiums direct billed:
Premiums are paid on a post-tax basis. Monthly
payment coupons will be mailed to the address
provided on your enrollment form for the rst month
of coverage through the end of the plan year.
Payments must begin with the rst coupon received
and are due the rst of every month, with a 30-day
grace period.
Unpaid invoices will be referrred to the State’s Central
Collections Unit (CCU) where an additional 17%
administrative fee will be added to the debt.
Payment deadlines are strictly enforced. If you do
not receive payment coupons within one month of
submitting your enrollment form, please contact the
Employee Benets Division.
46 2024 Health Benets Guide
Eligibility by Employee/Retiree Type
Eligibility Subsidy Amount How You Will Pay for Benets
OPTIONAL RETIREMENT PROGRAM ORP RETIREES HIRED PRIOR TO 7/1/11
There are special rules governing your eligibility and
costs for health benets if you are a retiree of an
Optional Retirement Program (ORP). Current and
former ORP vendors include: Teachers Insurance and
Annuity Association College Retirement Equities
Fund (TIAA-Cref), AIG-Valic, Fidelity, American
Century, and ING. You are eligible for benets with
the rst of the month of retirement, which must
coincide with the initial periodic distribution from
a Maryland ORP account if you meet one of the
following criteria:
• You retire directly from and have at least 5 years of
service with a Maryland State institution of higher
education with a periodic distribution of benets;
• You ended service with a Maryland State institution
of higher education when you were at least 57 and
had at least 10 years of service; or
• You ended service with a Maryland State institution
of higher education with at least 16 years of
service.
Maximum Individual/No
Dependent State subsidy
if you:
• retire directly from a
Maryland State institution
of higher education and
have at least 16 years of
service but less than 25
years of service.
Partial Individual/No
Dependent State subsidy
if you:
• retire directly from a
Maryland State institution
of higher education and
have at least 5 years of
service but less than 16
years of service.
No Individual or
Dependent State subsidy
if you:
• do not retire directly upon
ending ORP service with a
Maryland State institution
of higher education, with
the exception noted below.
Premiums are paid on a post-tax basis. Monthly
payment coupons will be mailed to the address
provided on your enrollment form for the rst
month of coverage through the end of the plan
year.
Payments must begin with the rst coupon
received and are due the rst of every month, with
a 30-day grace period.
Unpaid invoices will be referrred to the State’s
Central Collections Unit (CCU) where an additional
17% administrative fee will be added to the debt.
Payment deadlines are strictly enforced.
If you do not receive payment coupons within one
month of submitting your enrollment form, please
contact the Employee Benets Division.
472024 Health Benets Guide
Eligibility by Employee/Retiree Type
Eligibility Subsidy Amount How You Will Pay for Benets
OPTIONAL RETIREMENT PROGRAM ORP RETIREES HIRED ON OR AFTER 7/1/11
You are eligible for benets with maximum, partial
or no State subsidy beginning the rst of the month
of retirement, which must coincide with the initial
periodic distribution from a Maryland ORP account if
you meet one of the following criteria:
•You retire directly from a Maryland State institution of
higher education with 10 years of service;
•You ended service with a Maryland State institution
of higher education when you were at least age 57
and had at least 10 years of service; or
•You ended service with a Maryland State institution
of higher education with at least 25 years of service.
Maximum Individual/
Dependent State Subsidy
if you:
• retire directly from a
Maryland State institution
of higher education and
have at least 25 years of
service.
Partial Individual/No
Dependent State subsidy
if you:
• retire directly from a
Maryland State institution
of higher education and
have at least 10 years
but less than 25 years of
service.
No Individual or
Dependent State Subsidy
if you:
• do not retire directly upon
ending ORP service with a
Maryland State Institution
of higher education, with
the exception noted below.
Premiums are paid on a post-tax basis. Monthly
payment coupons will be mailed to the address
provided on your enrollment form for the rst
month of coverage through the end of the plan
year.
Payments must begin with the rst coupon
received and are due the rst of every month,
with a 30-day grace period.
Unpaid invoices will be referrred to the State’s
Central Collections Unit (CCU) where an
additional 17% administrative fee will be added
to the debt.
Payment deadlines are strictly enforced.
If you do not receive payment coupons within
one month of submitting your enrollment form,
please contact the Employee Benets Division.
OPTIONAL RETIREMENT PROGRAM ORP RETIREES REGARDLESS OF DATE OF HIRE
If you are an ORP retiree with service equal to 25 or more full years of regular employment with the State, in any branch of government,
you may be eligible for the maximum State subsidy of the coverage for you and your dependent(s), even if you did not retire directly from
a Maryland State institution of higher education.
One year of employment at 50% of standard work hours, with contributions to a Maryland ORP, provides six months of applicable ORP
service. If you stop receiving a periodic distribution from your Maryland ORP account, you will no longer be eligible for health benets.
Lump sum payments, supplemental retirement accounts, or non-Maryland State institution service do not count for enrollment in, or
State subsidy for, retiree health benets.
If coverage in the Program is terminated for an ORP Retiree or Beneciary for any reason, either voluntarily or involuntarily,
documentation conrming the current continuing receipt of a periodic distribution from the Maryland ORP must be provided to qualify for
re-enrollment.
Required Documentation: Completion of a Retiree Health Enrollment and Change form and a State of Maryland Optional Retirement
Program (ORP) Packet. The form and packet are available from your Agency Benets Coordinator, by mail from the Employee Benets
Division, or from our website at www.dbm.maryland.gov/benets.
48 2024 Health Benets Guide
Eligibility by Employee/Retiree Type
Eligibility Subsidy Amount How You Will Pay for Benets
BENEFICIARIES OF DECEASED ORP RETIREES
You are eligible for health benets coverage if you are
the surviving spouse, domestic partner or child of a
deceased ORP retiree and:
• You are receiving a periodic distribution of benets
from the retiree’s Maryland ORP; and
• You meet the spouse, domestic partner or child
dependent eligibility criteria for health benets.
If the surviving spouse or domestic partner is the
beneciary, the spouse or domestic partner may cover
themself and any eligible dependent of the deceased
ORP retiree. However, only dependents that would be
eligible dependents of the deceased ORP retiree if they
were still living may be covered.
If a child is the beneciary, only the child will be
eligible for health benets as long as they meet
dependent eligibility requirements for children (see
page 39).
Required Documentation: Completion of a Retiree
Health Benets Enrollment and Change form and
a State of Maryland Optional Retirement Program
(ORP) packet. The form and packet are available from
an Agency Benets Coordinator, at a Maryland State
institution of higher education, from our website,
www.dbm.maryland.gov/benets, or by calling
the Employee Benets Division.
If you were enrolled in dependent Term Life Insurance
at the time of the retiree’s death, that policy must
be converted to an individual policy directly through
MetLife within 30 days in order to continue Term Life
Insurance coverage. Plan phone numbers are located
on the inside front cover of this guide.
• Maximum State subsidy
if the retiree had service
equal to 25 or more
full years of regular
employment with the
State in any branch of
government; you may be
eligible for the maximum
State subsidy even if
the retiree did not retire
directly from a Maryland
State institution of higher
education.
• No State Subsidy if the
retiree had less than 25
years of Maryland State
service.
• No State Subsidy If
you are the deceased
retiree’s domestic
partner beneciary
regardless of the
number of years of
service.
Same as ORP retirees
If coverage in the Program is terminated for an ORP Retiree or Beneciary for any reason, either voluntarily or involuntarily,
documentation conrming the current continuing receipt of a periodic distribution from the Maryland ORP must be provided to qualify for
re-enrollment.
492024 Health Benets Guide
Qualifying Status Changes
IRS regulations strictly govern when and how benets election changes can be made. The same rules
apply to all program participants including employees and retirees.
Generally, you can only change your health coverage during the Open Enrollment period each year. The
coverage you elect during Open Enrollment will be eective January 1 through December 31. However,
you may make certain changes to your coverage outside of the annual Open Enrollment period if you have
a qualifying change in status. Examples include the following:
• Birth or adoption/placement for adoption of a child;
• Death of a dependent;
• Marriage or divorce;
• Dissolution of a domestic partnership;
• You or your dependent child’s loss of State Children’s Health Insurance Program (SCHIP)/Medicaid/
Medical Assistance coverage;
• You or your dependent gain access to a SCHIP/Medicaid subsidy based on your residence in another
state;
• Loss of other coverage, such as if coverage under your spouse’s or domestic partner’s employment ends;
• Gaining Medicare eligibility allows a reduction in coverage.
• Losing Medicare eligibility allows an increase in coverage.
• Changes in your other coverage (such as through a spouse’s employer), which has a dierent plan year.
You have 60 days from the date of the qualifying change in status to submit the Benet Event through
the SPS Benets System, upload the supporting documentation to change your coverage, and make
your elections. Any changes submitted later than 60 days after the qualifying change in status will not
be accepted, and you will have to wait until the next Open Enrollment period to make a change,with the
exception of a divorce and death of a dependent. Divorce or Death events may be older than 60 days only
when removing ineligible dependents.
NOTE: Documentation supporting a qualifying status change must be submitted with your Benet Event
through the SPS Benets System. For example, if you are ending your State coverage because you have
coverage under another employer’s health plan, you must provide a letter from the other employer (on
company letterhead) or the insurance provider with the eective date of coverage.
If you decline enrollment under a State plan for yourself or a dependent during Open Enrollment because
you have other coverage, you may be able to enroll outside of the Open Enrollment period if you or your
dependent(s) lose that other coverage.
Aging Out Dependent Child
If you are covering a child (biological, adopted or stepchild) reaching age 26 and/or an other child relative
(grandchild, legal ward, step-grandchild, or other child relative) reaching age 25 with no disability
certication, he/she will be removed as a dependent from health coverage automatically. A COBRA notice
will be sent directly to the dependent child at your home address.
You can initiate your
life event changes
online using the SPS
Benets System. See
the job aids provided
on https://dbm.
maryland.gov/sps/
Pages/Benets_
HelpCenter.aspx
for instructions.
IRS regulations
strictly govern when
and how benet
election changes can
be made.
50 2024 Health Benets Guide
Removing Dependents Who Lose Eligibility
You must provide supporting documentation with the Benet Event through the SPS Benets System
to remove any dependent as soon as they lose eligibility for coverage under a State benet plan. If you
do not remove the ineligible dependent within 60 days following the date of ineligibility, you will be
billed the full insurance premium (including the State subsidy) from the date they became ineligible
until the date removed. You may also face disciplinary action, termination of employment, and/
or criminal prosecution for continuing to cover dependents who no longer meet the denition of an
eligible dependent (see page 39). In most cases, dependents that lose eligibility are entitled to COBRA/
Continuation Coverage for a limited time. This coverage is not subsidized by the State. Please see the
COBRA/Continuation of Coverage section for more information.
Coverage for Your Former Spouse
If you are obligated to continue coverage for a former spouse according to the terms of your divorce
agreement your former spouse cannot remain covered as a dependent under your State health benets.
The former spouse may elect COBRA which will be his/her own account and he/she will be responsible for
paying premiums directly. COBRA coverage is not subsidized by the State.
Instructions on how to make mid-year changes
IF YOU... THEN...
Are rehired or transferred
to another state agency
within 30 days following
termination from previous
agency
You will automatically be enrolled into the same elections you had previously upon rehire or transfer. This is
not applicable to contractual employees.
Are an active State
employee (New Hire)
enrolling for the rst time
A “New Hire Benet Event” will be sent to the employee’s SPS Benets System inbox. You have 60 days
from the date of hire to submit the “New Hire Benet Event” including benets elections, dependent
documentation, etc. If you need assistance with dependent documentation accuracy, please contact your
Agency Benets Coordinator before submitting the “New Hire Benet Event” to the Employee Benets
Division. The Benet Event will not be accepted after 60 days. Your coverage will begin the rst of the
month following your date of hire or on the date of hire if you are hired on the rst of the month. You will
be required to pay a post-tax retroactive adjustment for missed premiums back to your enrollment eective
date.
Are enrolling as a new
retiree
You must submit an enrollment form within 60 days of your retirement date. Submit the enrollment form
and any required documentation to the Employee Benets Division. You will receive a retroactive adjustment
letter from the Employee Benets Division regarding how to pay any missed premiums between your
retirement date and the period covered by your rst retiree premium deduction.
Active Employees mid-year
qualifying status change
A qualifying status change will be eective the rst of the month following the event date or the date of
the event, if the event date is the rst of the month. The only exception is for birth/adoption which will be
eective on the event date. You have 60 days from the event date to initiate your qualifying event in the SPS
Benets System and provide applicable documentation verifying the qualifying event. Mandatory post-tax
retroactive adjustments will be required as necessary. Flexible Spending Accounts cannot be made eective
retroactively.
Retiree mid-year
qualifying status change
A qualifying status change will be eective the rst of the month following the event date or the date of
the event, if the event date is the rst of the month. The only exception is for birth/adoption which will be
eective on the event date. You have 60 days from the event date to initiate or submit an enrollment form
and provide applicable documentation verifying the qualifying event to the Employee Benets Division.
Mandatory post-tax retroactive adjustments will be required as necessary.
Have a newborn child that
you want to add to your
health benets
You must add your child within 60 days from the date of birth. You must initiate “Birth/Adoption Event”
and upload an ocial state birth certicate. Provide the child’s social security number upon receipt by
uploading the document into SPS Benets System Worker Documents. A retroactive adjustment invoice will
be mailed to the employee’s address listed on le and payment must be submitted by the due date listed
in the invoice, unless you already have family coverage. Active employees with questions should contact
their Agency Benets Coordinator. All other enrollees should contact the Employee Benets Division for
assistance. If a newborn is not added within 60 days of birth, you must wait until the next Open Enrollment
period to enroll the child.
Need to remove an
ineligible dependent
(e.g., divorced spouse, etc.)
You must initiate the related Benet Event in the SPS Benets System and upload the applicable supporting
documentation verifying the ineligible dependent within 60 days of becoming an ineligible dependent.
Retirees can initiate the related Benet Event or notify the Employee Benets Division directly. If you do not
remove an ineligible dependent within 60 days of the loss of eligibility, you will be responsible for the lesser
of the premium or the claims incurred while the ineligible dependent was covered. In addition, keeping an
ineligible dependent on your coverage may result in disciplinary action, termination of employment, and/or
criminal prosecution.
512024 Health Benets Guide
Leave of Absence
While on Leave of Absence
If you take a Leave of Absence Without Pay (LWOP), you may continue the same health benets coverage
you had as an active employee by electing to enroll as a Direct Pay participant and submitting premiums
payments directly to DBM via payment coupons.
Short-Term LWOP
If you are on short-term LWOP (two pay periods or less or up to 30 days), you will be billed for all missed
payroll deductions. You will receive a“Zero Pay” invoice from the Employee Benets Division for your
missed premiums. Payroll deductions may resume if you return to work before the due date on the“Zero
Pay” invoice. However, payment for the missed premiums is mandatory; you cannot have a break in your
benets coverage. The payment due date is strictly enforced failure to pay the “Zero Pay” invoices will
result in the debt to be referred to the State Central Collections Unit (CCU). In some cases, your coverage
may be canceled and you will not be permitted to re-enroll until the next Open Enrollment period.
Long-Term LWOP
If you are on a leave of absence without pay for more than two bi-weekly pay periods (more than 30
days), your leave is considered a long-term LWOP. If you are on an approved long-term LWOP, you may
elect to continue or discontinue health insurance for the duration of the LWOP.
If you wish to continue or discontinue your coverage, you must complete the “Benet Event” in the SPS
Benets System inbox as soon as you receive the event in your SPS Benets System inbox. You may
continue any or all of your current health benet plans, or you may reduce your coverage level when
enrolling for LWOP benets. However, you may not change plans until the next Open Enrollment period or
within 60 days of a qualifying status change—the same as an active employee.
Returning from Long Term LWOP
When you return from Long Term LWOP, please check your SPS Benets System inbox for the “Return from
Leave Benet Event”. This request for re-enrollment in employee pre-tax benets must be completed
within 60 days after your return to work along with any required supporting documentation such as
military discharge orders.
Eligibility Subsidy Amount How You Will Pay for Benets
LONG TERM LEAVE WITHOUT PAY
Personal
If on approved leave without pay for personal reasons,
your current health benet plans will continue for 30
calendar days. If leave exceeds 30 calendar days, you
may continue coverage under COBRA.
Maximum State
Subsidy for the rst 30
days of the approved
leave.
No State Subsidy – you
pay the full amount
under COBRA
Premiums are paid on a post-tax basis. Monthly
payment coupons will be mailed to the address
provided in the SPS Benets System for the rst
month of coverage through the end of the plan year or
the end of your approved leave, whichever comes rst.
Payments must begin with the rst coupon received
and are due the rst of every month, with a 30-day
grace period.
Missed payments or payments not postmarked within
the 30-day grace period will result in the termination
of your coverage. You will not be permitted to re-enroll
until the next Open Enrollment period.
Payment may be made in advance to cover any or
all coupons received, payment deadlines are strictly
enforced.
If you do not receive payment coupons within one
month of submitting your Benet Event, please
contact your Agency Benets Coordinator.
Temporary Total Disability
If on approved leave without pay due to an on-the-job
injury, you will receive a Benet Change Leave event
to continue current coverage or waive coverage, while
on leave for up to two (2) years.
Maximum State
Subsidy
52 2024 Health Benets Guide
Eligibility by Employee/Retiree Type
Eligibility Subsidy Amount How You Will Pay for Benets
LEAVE OF ABSENCE MILITARY ADMINISTRATIVE ACTIVE DUTY
If on approved leave of absence for active military duty,
you may continue any or all of your current health benet
plans, or you may reduce your coverage level while on
leave for up to ve (5) years.
Your agency HRC must enter the leave type in the SPS
Benets System along with uploading the employee’s
Active Military Orders under Worker’s Documents.
• Employee and State
Subsidy paid by
State for medical,
prescription and dental
• Employee responsible
for payment of
premiums if he/she
elects to continue
AD&D and Life
insurance.
Premiums are paid on a post-tax basis. Monthly payment coupons will be mailed to the
address provided in the SPS Benets System for the rst month of coverage through the
end of the plan year or the end of your approved leave, whichever comes rst.
Payments must begin with the rst coupon received and are due the rst of every month,
with a 30-day grace period.
If paying via check or money order, the payment coupon must be included with your
payment and mailed to the address indicated on the payment coupon cover letter. You
also have the option to pay online by going to www.dbm.maryland.gov/benets; click on
“Pay Your Direct Pay Coupons Now.”
Missed payments or payments not postmarked within the 30-day grace period will result
in the termination of your coverage. You will not be permitted to re-enroll until the next
Open Enrollment period.
Payment may be made in advance to cover any or all coupons received. Payment deadlines
are strictly enforced.
If you do not receive payment coupons within one month of submitting your Benet
Event, please contact your Agency Benets Coordinator.
LEAVE OF ABSENCEARMED SERVICES 30 DAYS OR LESS MILITARY
TRAINING
If on an approved leave of absence for military training,
you may continue any or all of your current health benet
plans (except the healthcare or dependent day care exible
spending accounts), or you may reduce your coverage
while on leave for the rst 30 days of approved unpaid
military training duty.
Your agency HRC must enter the leave type in the SPS
Benets System along with uploading the employees
Training Military Orders under Worker’s Document.
Maximum State Subsidy
ARMED SERVICES MORE THAN 30 DAYS
If on approved unpaid leave of absence for military
training for more than 30 days, you may continue any or
all of your current health benet plans, or you may reduce
your coverage level while on leave.
Your agency HRC must enter the leave type in the SPS
Benets System along with uploading the employee’s
Training Military Orders under Worker Documents.
No State Subsidy
FAMILY MEDICAL LEAVE ACT FMLA
If you are on approved FMLA, we will maintain your health
coverage under our group health plan on the same terms
as when you were actively working.
If you are on paid leave while on FMLA and receiving a
paycheck, we will continue deducting your premiums
through pre-tax payroll deductions.
If you are on FMLA and do not have paid leave available,
you will be responsible for the payment of your share
of the premiums payments for your health insurance
coverage for the period of time you are on approved FMLA
leave. You may choose to submit payment due while on
leave or within 30 days upon returning to work.
Maximum State Subsidy If FMLA leave is unpaid, premiums are paid on a post-tax basis. Biweekly coupons will
be mailed to the address on le. You may pay each coupon as it is received, or you may
pay all coupons within 30 days upon returning to work.
Payments must begin with the rst coupon received and are due by the due date
indicated on the payment coupon. If payment is not made by the due date indicated,
this debt may be forwarded to the State of Maryland’s Central Collections Unit. If
referred to the Central Collections Unit, a collection fee of 17% will be added to the
amount owed.
In addition, the Central Collections Unit is authorized to report this debt to consumer
reporting agencies. Debts referred to these agencies may aect your credit rating.
MEDICAL LEAVE WITHOUT PAY
If on approved medical leave without pay, you will receive
a Benet Change Leave event to continue current coverage
or waive coverage, while on leave for up to six (6) months.
Maximum State Subsidy Premiums are paid on a post-tax basis. Monthly payment coupons will be mailed to the
address provided in the SPS Benets System for the rst month of coverage through the
end of the plan year or the end of your approved leave, whichever comes rst.
Payments must begin with the rst coupon received and are due the rst of every
month, with a 30-day grace period.
Missed payments or payments not postmarked within the 30-day grace period will
result in the termination of your coverage. You will not be permitted to re-enroll until
the next Open Enrollment period.
Payment may be made in advance to cover any or all coupons received. Payment
deadlines are strictly enforced.
If you do not receive payment coupons within one month of submitting your Benet
Event, please contact your Agency Benets Coordinator
532024 Health Benets Guide
When Coverage Ends
If you are... Coverage ends...
Leaving State employment Last day of the month in which you worked.
On an unpaid leave of absence See page 53-54 for details
Age 25/26 Last day of the month in which age 25/26 is reached
Divorce Last day of the month in which divorce event with decree is approved
Gaining coverage elsewhere If new coverage is eective the 1st day of a month, coverage will terminate on the last day of the
preceding month.
If new coverage is eective the 2nd through last day of a month, coverage will terminate on the
last day of the month in which coverage was gained.
When Coverage Ends
You may choose to cancel your coverage during the annual Open Enrollment period or if you have a
qualifying status change that allows you to end your coverage mid-year.
• If you cancel your coverage during the Open Enrollment period, your coverage will end on December 31
of the current plan year.
• If you end your coverage because of a qualifying status change, the date your coverage ends will be the
end of the month in which the qualifying event occurred unless it is for a divorce.
• For a divorce, coverage ends on the last day of the month in which the divorce qualifying event is
approved in the SPS Benets System.
• FSA claims cannot be incurred past the last day of employment. You have 90 days from your last day of
employment to submit claims for reimbursement.
FOR MORE INFORMATION about enrollment and changes outside of the Open Enrollment period, please
contact the following:
• Your Agency Benets Coordinator, if you are an Active or Satellite employee; or
• The Employee Benets Division, if you are a retiree or COBRA participant.
For additional information about qualifying status changes, visit
www.irs.gov.
Coverage is through
the end of the
month. Missed
payroll deductions
for premium will
be billed to you for
payment.
54 2024 Health Benets Guide
COBRA Continuation of Coverage
You and/or your dependents may elect to continue your health, prescription drug, dental, and/or
healthcare exible spending account participation by paying for coverage with after-tax dollars, for a
timeframe determined based on Federal regulations.
If you or one of your dependents experiences a COBRA Coverage qualifying status change, you or your
dependent may be eligible to continue the same health benets that you or your dependent(s) had at the
time of the qualifying status change.
NOTE: Loss of coverage through an Open Enrollment transaction is not a qualifying status change. You
must have one of the qualifying status changes listed below to enroll in continuation coverage.
Summary of COBRA Coverage Conditions
QUALIFYING EVENT PERSON AFFECTED LENGTH OF COBRA COVERAGE
Termination of employment (other than
for gross misconduct), including layo or
resignation of employee or reduction in hours
resulting in loss of coverage
• Employee
• Spouse
• Dependent Child(ren)
18 months or until eligible for coverage elsewhere,
including Medicare*, whichever occurs rst
Dependent child(ren) of an employee or retiree
no longer meets the dependent eligibility
requirements
• Dependent Child(ren) 36 months or until eligible for coverage elsewhere,
including Medicare*, whichever occurs rst
Death of employee or retiree • Spouse
• Dependent Child(ren)
36 months or until eligible for coverage elsewhere,
including Medicare*, whichever occurs rst
Divorce, limited divorce/legal separation
NOTE: A separated spouse who is still
legally married to the employee remains
eligible for coverage.
• Former Spouse
• Dependent Child(ren)
Indenitely until remarriage or until eligible for
coverage elsewhere, including Medicare, whichever
occurs rst
COBRA coverage includes the ability to enroll with
dependents that meet the eligibility criteria.
• Step-child(ren) of
employee or
retiree
If enrolled separately, 36 months or until eligible for
coverage elsewhere, including Medicare*, whichever
occurs rst
Qualifying Events After the Start of COBRA (Second Qualifying Events)
QUALIFYING EVENT PERSON AFFECTED LENGTH OF COBRA COVERAGE
Divorce or legal separation from COBRA
participant
• Spouse
• Step-child(ren) of
participant
36 months from the original qualifying event or until
eligible for coverage elsewhere, including Medicare*,
whichever occurs rst
Dependent child(ren) of a COBRA participant
who no longer meets the dependent eligibility
requirements
• Child(ren) 36 months from the original qualifying event or until
eligible for coverage elsewhere, including Medicare*,
whichever occurs rst
Total and Permanent Disability of the employee
or retiree (as dened by the Social Security Act)
within the rst 60 days of COBRA coverage
• Employee
• Spouse
• Dependent Child(ren)
The 18 months can be extended to 29 months at
increased premiums equal to 150% of usual premiums
for the additional 11 months.
* If you are enrolled in Medicare Parts A & B before leaving State service, you are entitled to elect continued coverage at the full COBRA
premium. If you become entitled to Medicare while on COBRA, you will not be able to continue your medical coverage after you become
eligible for Medicare. You may, however, continue your prescription drug and dental coverage. If you have dependents on your COBRA
coverage when you become entitled to Medicare, your dependents may elect to continue their coverage under COBRA.
552024 Health Benets Guide
Other Health Coverage Options
There may be other coverage options for you and your family on a Health Insurance Marketplace
(exchange) provided by the state in which you live or the federal government. If you choose coverage
from a Marketplace, you may receive a federal tax credit that lowers your monthly premiums. Being
eligible for COBRA does not limit your eligibility for a tax credit through a Marketplace. For information
about health insurance options available through a Health Insurance Marketplace, visit
www.healthcare.gov outside of Maryland or www.marylandhbe.com in Maryland.
Additionally, you may qualify for a special enrollment opportunity for another group health plan for
which you are eligible (such as your spouse’s plan), even if that plan generally does not accept late
enrollees, if you request enrollment within 30 days of losing your State coverage.
Coupons and Payments
If you receive COBRA Coverage, premium payment coupons will be mailed to your address on le. If you
pay with a personal check or money order, the payment coupon must be included with your payment and
mailed to the address indicated on the payment coupon cover letter.
You may pay for coverage online by going to
www.dbm.maryland.gov/benets; click on “Pay Your
Direct Pay Coupons Here.” Your benets will be eective as of the date noted on your payment coupon
cover letter. Payments are due the rst of every month; there is a 30-day grace period each month.
Payment may be made in advance to cover any or all coupon(s) received, but must be made in full
monthly increments. If payment is not post-marked by the end of the 30-day grace period, your COBRA
coverage will be canceled and you will not be permitted to re-enroll.
Payment deadlines are strictly enforced. If you do not receive these coupons within one month of signing
your enrollment form, or you change your mailing address, please contact the Employee Benets Division
immediately.
The section entitled General Notice of COBRA and Continuation of Coverage Rights reviews your rights
and responsibilities beginning on page 65. It is important for you to review it carefully with all covered
dependents. If you have questions about a qualifying status change or continuation of coverage, please
contact the Employee Benets Division.
Domestic
partners, domestic
partner’s children,
grandchildren, legal
wards, and other
child relatives do
not have individual
COBRA election
rights, unless they
are considered
a qualied tax
dependent.
Domestic
partners, domestic
partner’s children,
grandchildren, legal
wards, and other
child relatives may be
enrolled under the
former employee/
retiree’s COBRA
elections.
56 2024 Health Benets Guide
Domestic partners
and domestic
partner’s dependents
covered under an
active employee’s
policy should contact
1-800-Medicare or
CMS.gov to discuss
Medicare enrollment
in Parts A, B, & D
upon becoming
Medicare eligible due
to age or disability.
Medicare and Your State Benets
Medicare Parts A, B and D
Medicare Parts A and B (Hospital and Physician Expenses)
Active employees and or their dependents enrolled in the State Health Benets Program do not have to
sign up for Medicare Parts A and B when you or the enrolled dependents become eligible because of age
or disability. The State benets coverage will continue as primary insurance as long as you are an active
employee.
Retirees and/or their dependents enrolled in the State Health Benets Program must enroll in Medicare
Parts A and B to have full medical claims coverage as soon as you and/or your enrolled dependents
become eligible for Medicare because of reaching age 65 or due to disability, regardless of your Social
Security full retirement age (which may be greater than 65, depending on your birth date). Even if you do
not wish to start receiving your Social Security retirement benet, you must still enroll in Medicare Parts
A and B to have full medical claims coverage. Medicare Part A and B becomes your primary insurance and
the State health plan automatically becomes secondary-meaning the State medical plans will pay eligible
hospital and physician expenses after Medicare pays its portion. Medicare Part A helps pay for hospital
care, some skilled nursing facility care, and hospice; Medicare Part B helps pay for physician charges and
other medical services. If you and/or your covered dependents are eligible for, but not enrolled
in, Medicare Parts A and B, you will be responsible for the claims that Medicare would have
paid. For information on Medicare enrollment, call the Social Security Administration at 1-800-772-1213.
Employees, retirees, or enrolled dependents eligible for Medicare because of End Stage Renal Disease
(ESRD), see the ESRD rules on the next page.
Medicare Part D – Medicare Drug Benet
How Does This Apply to You?
If you are a retiree and have prescription drug coverage through the State Employee and Retiree Health
and Welfare Benets Program, and are eligible for Medicare due to age or disability you are automatically
enrolled in Medicare Part D through the Program’s CVS Caremark plan (SilverScript). For the 2024 plan
year, the State of Maryland Prescription Drug Plan remains as good as, or better than, the standard
Medicare Part D plan. See the Notice of Creditable Coverage in this guide.
Initial, Special, and General Enrollment Periods for Medicare Parts A, B and D
As a retiree enrolled in the State Employee and Retiree Health and Welfare Benets Program, you must
enroll in Medicare Parts A&B when rst eligible in order to have full claims coverage. In addition, you
may pay a late enrollment penalty for Part B coverage (which will be applied to your monthly premium
for as long as you have Part B coverage). A similar penalty may apply under Medicare Part D (prescription
coverage) if you do not enroll in either the State’s retiree prescription drug coverage or an individual
Medicare Part D plan when rst eligible.
If your health benets coverage is under an active employee’s policy when you reach age 64, you do
not have to enroll in Medicare until you retire, unless your employment or coverage under an active
employee’s policy will end during your initial enrollment period. See the Special Enrollment Period
information table.
572024 Health Benets Guide
Your Initial Enrollment Period for Medicare
You are eligible for Medicare coverage when you reach age 65. Your Initial Enrollment Period is a 7 month period
which begins three months before the month you are eligible for Medicare and ends three months after the month
you are eligible for Medicare. The timing of when your Medicare eligibility begins depends on the day of the month
you become age 65, as follows:
• If you reach age 65 on the 1st day of the month – Medicare eligibility begins the 1st day of the previous month;
Example: If your birthday is January 1, you are eligible for Medicare on December 1 of the previous year.
• If you reach age 65 on the 2nd day through the last day of the month – Medicare eligibility begins the 1st day of
the month you turn 65; Example: If your birthday is January 2 – 31, you are eligible for Medicare on January 1.
The chart on page 64 shows the schedule for an Initial enrollment Period and a sample schedule for a birth date of
April 2nd – 30th.
Medicare Special Enrollment Period
The Medicare Special Enrollment Period is an eight-month period beginning the month your group coverage ends
or the month your employment ends, whichever comes rst. If you were eligible for Medicare, but didn’t enroll
because you had health benets under an active employee’s policy, you can enroll during your Special Enrollment
Period without paying a monthly penalty for Part B coverage. Special enrollment period rules don’t apply if
employment or active employee group coverage ends during your initial enrollment period.
Medicare General Enrollment Period
The Medicare General Enrollment Period is a three-month enrollment period for Medicare each year from January
1 through March 31 for Part B coverage to start the rst of the month following the month of Medicare Part B
enrollment or sign-up. If you were eligible for but did not enroll in Medicare and you did not have health benets
coverage under an active employee’s policy, your Part B premium will be penalized 10% for every 12 months you
were entitled to Part B coverage but you were not enrolled.
If your Initial Enrollment Period or Special Enrollment Period enrollment falls between January 1 and March 31, you
must tell the Social Security Administration representative that you have an initial or special enrollment period.
Otherwise, you may be enrolled as a general enrollee, which means your Part B coverage will not start until the rst
of the month following the month of Medicare Part B enrollment and you may pay a Part B premium penalty.
The Open Enrollment Period for Medicare Part D is October 15th through December 7th.
Disability
If you are certied as being disabled by the Social Security Administration, you will become eligible for Medicare
two years (24 months) after your disability determination date. If you are a retiree, you and your covered
dependents enrolled in the State’s benets program and eligible for Medicare MUST enroll in Medicare Parts A & B
if you are eligible due to disability in order to receive the maximum coverage available. This is the case regardless of
your age. It is your responsibility to notify the Employee Benets Division of Medicare entitlement due
to disability.
If the Social Security Administration denies your Medicare coverage, you must provide a copy of the Social Security
Administration’s denial to the Employee Benets Division. If your Medicare entitlement is due to disability and the
Social Security Administration determines that your disability status ends, you must provide the Employee Benets
Division documentation from the Social Security Administration stating when Medicare entitlement ended.
Medicare Due to Disability
If you are entitled to Medicare due to a disability, the same enrollment period rules apply as described above. If you
have health benets coverage under an active employee’s policy, you do not have to enroll in Medicare. However,
when your employment or active employee coverage ends, you must apply for Medicare Parts A &
B to have the full level of benets coverage you would otherwise have. Otherwise, you must pay
the portion of covered expenses that Medicare would have paid if you were enrolled for Medicare
coverage.
Domestic partners
and domestic
partner’s dependents
covered under an
active employee’s
policy should contact
1-800-Medicare or
CMS.gov to discuss
Medicare enrollment
in Parts A, B, & D
upon becoming
Medicare eligible due
to age or disability.
58 2024 Health Benets Guide
Initial Enrollment Period Schedule
Sample Initial Enrollment Period for Individuals
with birth dates between April 2nd and 30th
MONTH
ENROLLED
PART B COVERAGE STARTS
MONTH
ENROLLED
PART B COVERAGE STARTS
1st month
1st day of the month you reach age 65*
January April 1st
2nd month
1st day of the month you reach age 65*
February April 1st
3rd month
1st day of the month you reach age 65*
March April 1st
4th month
First day of the month following enrollment
April May 1st
5th month
First day of the month following enrollment
May June 1st
6th month
First day of the month following enrollment
June July 1st
7th month
First day of the month following enrollment
July August 1st
To nd your Initial Enrollment Period, circle the month you turn 65 and the three months before and after.
*If you were born on the rst day of the month, move your schedule back one month.
January February March April May June July August September October November December
If your employment or your health benets coverage under an active employee’s policy ends during
your initial enrollment period, special enrollment period rules do not apply.
Special Enrollment Period Schedule
Sample Initial Enrollment Period for
someone retiring on April 1st
MONTH
ENROLLED
PART B COVERAGE STARTS
MONTH
ENROLLED
PART B COVERAGE STARTS
1st month
You choose: 1st day of month enrolled or
1st day of following three months
March
March 1st, April 1st,
May 1st or June 1st
2nd month
You choose: 1st day of month enrolled or
1st day of following three months
April
April 1st, May 1st,
June 1st or July 1st
3rd month 1st day of the month after enrollment May June 1st
4th month 1st day of the month after enrollment June July 1st
5th month 1st day of the month after enrollment July August 1st
6th month 1st day of the month after enrollment August September 1st
7th month 1st day of the month after enrollment September October 1st
8th month 1st day of the month after enrollment October November 1st
General Enrollment Period Schedule
ENROLLMENT DATE PART B COVERAGE STARTS
January 1st – March 31st The rst of the month following Medicare enrollment.
592024 Health Benets Guide
About End Stage Renal Disease (ESRD) and Medicare Coverage
If you have ESRD, you may be eligible for coverage under Medicare Parts A and B. If you have ESRD, it
is strongly recommended that you read the Centers for Medicare and Medicaid Services publication
“Medicare Coverage for Kidney Dialysis and Kidney Transplant Services” before making a decision about
whether to enroll in Medicare Part A and/or Part B. This publication is available at your local Social
Security oce, by calling the Social Security Administration at 1-800-772-1213, or going to www.
medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf. The information below about the
Coordination of Benets (COB) for Medicare due to End Stage Renal Disease (ESRD) applies to individuals
enrolled in an active employee group only.
During the 30-Month Coordination of Benets (COB) Period
If you become eligible for Medicare because of ESRD, there is a 30-month COB period (determined by
Social Security) during which your active State health coverage is primary (which means it pays benets
rst, before Medicare), regardless of whether or not you are enrolled in Medicare Part A and/or Part B.
Do not change your coverage level in the State health plan to a Medicare coverage level during your
30-month COB period.
After the 30-Month Coordination of Benets (COB) Period
NOTE: If you are enrolled in a medical plan under the State’s Program and you are covered as a participant
in an active employee group, you are not required to enroll in Medicare. However, if you choose to enroll
in Medicare Part A only, or in Parts A and Part B because you are eligible for Medicare coverage due to
ESRD (determined by Social Security), your claims will be processed according to the Coordination of
Benets (COB) regulations described below.
Medicare Coverage After a Successful Kidney Transplant
If you were eligible for Medicare because of ESRD and have a successful kidney transplant, Medicare will
no longer be your primary insurer starting three years after the transplant. If Medicare eligibility ends,
you should contact the Social Security Administration to conrm that Medicare Part A and Part B have
been canceled. If you are enrolled in a State medical plan with a Medicare coverage level and you receive
a Medicare cancellation letter from the Social Security Administration, please contact the Employees
Benets Division (EBD) immediately or EBD will automatically change you to a non-Medicare coverage
level based on the information provided by the medical plans, whichever comes rst.
The following link is for the Social Security publication “Medicare Coverage of Kidney Dialysis and Kidney
Transplant Services”: www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf.
According to the
Centers for Medicare
and Medicaid
Services, the
information in this
section only applies
to you if you are
eligible for Medicare
because of ESRD, not
based on your age or
disability.
60 2024 Health Benets Guide
Important Notice From the State of Maryland About
Prescription Drug Coverage and Medicare
PART D NOTICE OF CREDITABLE COVERAGE
Please read this notice carefully and keep it where you can nd it. This notice applies to all
State of Maryland employees, retirees, and dependents that are entitled to Medicare and
are enrolled in the current prescription drug plan through the State Employee and Retiree
Health Benets Program (“The Program”) and has information about our Program’s prescrip-
tion drug coverage. It also explains the options you have under Medicare Part D prescription
drug coverage and can help you decide whether or not you want to enroll. At the end of this
notice is information about where you can get help to make decisions about your prescription
drug coverage.
IMPORTANT POINTS TO REMEMBER
Medicare prescription drug coverage (“Medicare Part D”) is available to everyone with Medicare if you
join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that
oers prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of
coverage set by Medicare. Some plans may also oer more coverage for a higher monthly premium.
• The prescription drug plan is not available to retirees and/or dependents who reside or have an address
listed outside of the United States.
• The State of Maryland has determined that the prescription drug coverage oered through our
Program is creditable coverage. Creditable coverage means that, on average for all plan participants,
our Program is expected to pay out as much or more than the standard Medicare Part D prescription
drug coverage will pay. It also means that if you keep our Program’s coverage and do not enroll in a
Medicare prescription drug plan now, you will not pay extra if you later decide to enroll in a Medicare
prescription drug plan, so long as you do not have a break in coverage of 63 or more continuous days.
• If you go 63 or more continuous days without prescription drug coverage that is at least as good as
Medicare’s prescription drug coverage, your monthly premium will go up at least 1% per month for
every month that you did not have that coverage. For example, if you go nineteen months without
coverage, your premium will always be at least 19% higher than what many other people pay. You will
have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition,
you may have to wait until the following November to enroll.
• Individuals can enroll in a Medicare prescription drug plan when they rst become eligible for Medicare
and each year from October 15th through December 7th. In addition, if you cancel or lose coverage
with our Program, you may be eligible for a Special Enrollment Period to sign up for a Medicare
prescription drug plan.
You should compare your current coverage, including which drugs are covered, with the coverage and
cost of the Medicare prescription drug plans in your area. Remember, our Program will only cover eligible
dependents in a plan in which you are enrolled as well.
• If you decide to enroll in a Medicare prescription drug plan and drop your prescription drug coverage
through our Program, you may not be able to get our Program coverage back until our next Open
Enrollment period or when you cancel or lose your Medicare prescription drug coverage. If you lose or
cancel Medicare Part D prescription drug coverage, you may be able to re-enroll in our Program before
the next annual Open Enrollment period if you request re-enrollment with the Employee Benets
Division within 60 days and you have had a change in circumstances that permits a mid-year change
in enrollment. See the annual Benets Guide section entitled “Qualifying Status Changes” on page 50
612024 Health Benets Guide
for more information. If you drop our Program coverage for prescription drug benets, your
dependent(s) will also lose coverage under our Program’s prescription drug plan.
If you cancel your coverage under our Program’s prescription drug plan, you are still eligible for enrollment
in our Program’s other types of coverage, such as health and dental plans. Prescription coverage is elected
separately from these other coverages.
• Keep this notice with your important papers. If you enroll in one of the Part D plans approved by
Medicare that oer prescription drug coverage, you may need to give a copy of this notice when you
join to show that you are not required to pay a higher premium amount.
For more information about this notice or your current prescription drug coverage, contact the Employee
Benets Division at 410-767-4775 or 1-800-307-8283. More information can also be found by visiting
www.dbm.maryland.gov/benets. NOTE: A copy of this Notice will appear in our Program’s annual
Open Enrollment guide each year. You also may request a paper copy at any time.
For more information about your options under Medicare prescription drug coverage:
More detailed information about Medicare plans that oer prescription drug coverage is in the “Medicare
& You” handbook. If you are enrolled in Medicare, you will get a copy of the handbook in the mail every
year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more
information about Medicare prescription drug plans:
• Visit www.medicare.gov;
• Call your State Health Insurance Assistance Program (see your copy of the “Medicare & You” handbook
or visit www.mdoa.state.md.us for the telephone number of the local oce in your area); or
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
For people with limited income and resources, extra help paying for a Medicare prescription drug plan is
available. Information about this extra help is available from the Social Security Administration (SSA). For
more information about this extra help, visit the SSA online at
www.socialsecurity.gov, or call them at
1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this notice. If you enroll in one of the prescription drug plans approved by Medicare,
you may be required to provide a copy of this notice when you join, to determine whether or not you are
required to pay a higher premium amount.
If you are eligible
for Medicare
prescription drug
coverage, you have
the right to:
• Keep our Program’s
coverage and not
enroll in a Medicare
prescription drug
plan; or
• Enroll in a Medicare
prescription drug
plan and drop
our Program’s
coverage.
62 2024 Health Benets Guide
Important Notices & Information
This guide contains several very important Notices for you and your dependents covered through the
State Employee and Retiree Health and Welfare Benets Program (the Program). These Notices inform you
of your rights under State and Federal Laws on such important topics as healthcare reform, continuation
of coverage (COBRA), the Program’s privacy practices, and creditable prescription drug coverage. Please
read all the Notices carefully.
Employee Fraud and Abuse
Fraud, abuse and unethical conduct in connection with the benets provided through the State Employee
and Retiree Health and Welfare Benets Program is a serious issue. Fraud and abuse can take many forms,
including the following:
• Adding a dependent to your coverage who you know is not eligible for coverage;
• Submitting false or altered adavits or documentation as part of adding or removing a dependent;
• Letting someone else who is not covered under your enrollment use your insurance card to get health
benets or services;
• Lying to get coverage or access to health benets (such as prescription drugs or treatments) that are
not medically necessary;
• Giving or selling your prescriptions to another person; or
• Submitting reimbursement requests for health benets or services that were not provided.
The Department of Budget and Management Employee Benets Division must investigate allegations of
fraud and abuse; each plan and benet option has programs to look for and eliminate fraud and abuse. If
fraud or abuse is determined to have taken place, there can be serious consequences, including:
• Lock-down of your prescription benets to only one doctor or pharmacy;
• Termination of coverage; and/or
• Seeking repayment or reimbursement of any claims or premiums for benets that were inappropriately
paid.
There may also be serious criminal or civil consequences.
Notice About Disclosure and Use of Your Social Security Number
A federal mandatory reporting law (Section 111 of Public Law 110-173) requires group health plans to
report, as directed by the Secretary of the Department of Health and Human Services, information that
the Secretary requires for purposes of coordination of benets. Two key elements that will be required to
be reported are Social Security numbers (SSNs) of covered individuals or Health Insurance Claim Number
(HICNs) and the plan sponsor’s employer identication number (EIN). For Medicare to coordinate
Medicare payments properly with other insurance and/or workers’ compensation benets, Medicare
relies on the collection of both the SSN or HICN and the EIN, as applicable. As an employee/retiree (or
family member of an employee/retiree) covered by a group health plan arrangement, your SSN and/
or HICN will likely be requested to meet the requirements of this law. For more information about the
mandatory reporting requirements under this law, visit the CMS website at
https://www.cms.gov/
Medicare/Medicare.html. In addition, because of the tax benets of employer-sponsored health
benets coverage, we need your SSN to make sure your income tax and other employment related taxes
are calculated and withheld from your paycheck properly.
How We Calculate Hours
Under the Aordable Care Act (ACA), the Program is required to oer aordable health insurance
coverage meeting minimum value to all full-time employees and dependents to avoid being penalized
by the Internal Revenue Service (IRS). Each employer is required to establish a measurement period
used to identify full-time employees for purposes of oering health insurance coverage. The Program’s
measurement period is from October 15 to October 14 of each year. The Program uses the “look-back”
measurement method to determine employee’s hours of service during the measurement period to
determine his or her full-time status for a future period (the stability period). The stability period begins
with the start of the next plan year which is January 1 of each year. The Program will oer a special
limited enrollment period during the annual open enrollment, which is known as the administrative
period. This allows each employee who is newly qualied as a full-time employee during the
measurement period to elect or decline health insurance coverage for the stability period.
632024 Health Benets Guide
General Notice of Continuation of Coverage (COBRA) Rights
The Employee Benets Division may process an enrollment for you as the employee/retiree, spouse,
or covered dependent in the State Employee and Retiree Health and Welfare Benets Program (the
Program). If so, this notice on possible future group health insurance continuation coverage rights applies
individually to you, your spouse and all covered dependent children enrolled under the Program. It is
important that you and all enrolled individuals take the time to read this notice carefully and become
familiar with its contents. If you are the employee, and if there is a covered dependent whose legal
residence is not yours, please provide written notication of that covered dependent’s address to the
Employee Benets Division so a notice can be sent to that covered dependent as well.
The Department of Budget and Management Employee Benets Division administers the Program. The
Program sponsored by the State of Maryland is a governmental group health plan covered by the Public
Health Service Act, which includes the COBRA continuation of coverage provisions described in this
Notice. This Notice explains continuation coverage rights only for these health benets oered through
the Program: the medical PPO, the medical IHM, the medical EPO, the prescription drug plan, the dental
PPO, the dental HMO and the Healthcare Flexible Spending Account. You may be enrolled in one or more
of these benets. This Notice does not apply to any other benets oered by the State of Maryland or
through the Program, such as the Dependent Daycare Flexible Spending Account, life insurance benet, or
accidental death and dismemberment insurance benet. For SLEOLA participants your medical plans are
separate and are limited to PPO, POS and EPO.
Under federal law, group health plans like the Program must oer covered employees and covered
family members the opportunity for a temporary extension of health coverage (called COBRA) at group
premiums when coverage under the health plan would otherwise end due to certain qualifying status
changes. In this Notice, the term “covered employee” also means “covered retiree.” This Notice is intended
to inform all plan participants of potential future options and obligations related to COBRA. Should an
actual qualifying status change occur in the future, the State of Maryland would send you additional
information and the appropriate election notice at that time. Please take special note, however, of your
notication obligations, highlighted in this Notice.
Other Coverage Options
There may be other coverage options for you and your family through the Marketplace. By enrolling in
coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower
your out-of-pocket costs. Additionally, you may qualify for a special enrollment opportunity for another
group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not
accept late enrollees, if you request enrollment within 30 days. For information about health insurance
options available through a Health Insurance Marketplace, visit www.healthcare.gov. For information on
the Marketplace for Maryland residents visit www.marylandhbe.com.
64 2024 Health Benets Guide
Who is Entitled to Elect COBRA Continuation Coverage?
Qualifying Status Changes For Covered Employee
If you are the covered employee, you may have the right to elect COBRA coverage if you lose group health
coverage because of the following qualifying status changes:
• Termination of your employment (for reasons other than gross misconduct);
• Resignation;
• Layo; or
• A reduction in your hours of employment.
Qualifying Status changes For Covered Spouse
If you are the covered spouse of an employee, you may have the right to elect COBRA coverage for yourself
if you lose group health coverage under the Program because of any of the following qualifying status
changes:
• A termination of your spouse’s employment, including resignation and layo, (for reasons other than
gross misconduct);
• A reduction in your spouse’s hours of employment;
• The death of your spouse; and
• Divorce from your spouse.
If your spouse (the employee or retiree) reduces or eliminates your group health coverage in anticipation
of your divorce and your divorce happens soon after that, then the divorce may be considered a qualifying
status change for you even though you lost coverage earlier than the date of the divorce. The rules of
the Program do not require you to lose coverage if you and your spouse are legally separated but are still
legally married to the employee or retiree.
Qualifying Status Changes for Covered Dependent Children
If you are the covered dependent child of an employee, you may have the right to elect COBRA coverage
for yourself if you lose group health coverage under the Program because of any of the following
qualifying status changes:
• A termination of the employee’s employment (for reasons other than gross misconduct);
• A reduction in the employee’s hours of employment;
• The death of the employee;
• Parent’s divorce or, if applicable, legal separation;
• You cease to be a “dependent child” under the terms of the Program.
Please contact the Employee Benets Division regarding the special rule for newly born or adopted
children.
When is COBRA or Continuation of Coverage available?
Coverage starts from the day you lose coverage due to a qualifying status change – usually the end of
the month in which the qualifying status change occurred. When the qualifying status change is the
end of employment, reduction of employment hours or death of the employee, the Program will oer
this coverage to qualied beneciaries. Qualied beneciaries are the employee, the spouse and the
dependent children who lost group health coverage as a result of the qualifying status change. You will
not need to notify the Employee Benets Division of any of these three qualifying status changes because
your employing agency should notify the Employee Benets Division of these events. You will need to
notify the Employee Benets Division of any other qualifying status change.
652024 Health Benets Guide
Important: Notications Required By the Employee, Spouse and Dependent
For the other qualifying status changes (divorce, and a covered dependent ceasing to meet the denition
of a “dependent” under the Program’s rules), you must notify the Employee Benets Division within 60
days after the later of: (1) the date of the event or (2) the date on which health plan coverage would be
lost under the terms of the Program because of the qualifying status change. If you do not notify the
Employee Benets Division of the qualifying status change within 60 days after the change, you will lose
the right to elect COBRA or Continuation of Coverage. Under federal law, this is the responsibility of all
employees, spouses and covered dependent children (or the parent of covered dependent children).
To provide the required notication, you must contact the Employee Benets Division and request that a
Direct Pay Enrollment form be mailed to you. Complete the form, attach documentation of the qualifying
status change (e.g., copy of divorce decree), and mail the form and documentation to Employee Benets
Division, 301 West Preston Street, Room 510, Baltimore, Maryland 21201.
If this notication is not completed according to these procedures and within the required 63-day
notication period, rights to continuation coverage will be forfeited. Read the dependent eligibility
rules contained in this benet guide carefully so you and all covered enrollees are familiar with when a
dependent is no longer a dependent under the terms of the plan. The Direct Pay Enrollment form is also
available at www.dbm.maryland.gov/benets.
How much does COBRA coverage cost?
You or a qualied beneciary covered under COBRA must pay the entire applicable premium plus a
2% administration charge for continuation coverage. The State of Maryland does not subsidize COBRA
coverage. These premiums will be adjusted during the continuation period if the applicable premium
amount changes. In addition, if continuation coverage is extended from 18 months to 29 months due to
Social Security disability, the State of Maryland can charge up to 150% of the applicable premium during
the extended coverage period for the disabled beneciary. Qualied beneciaries are required to pay on a
monthly basis. Premiums are due on the rst day of every month. There will be a maximum grace period
of thirty days for regularly scheduled monthly premiums.
How Do I Elect COBRA or Continuation of Coverage?
Each qualied beneciary will have an independent right to elect COBRA or Continuation of Coverage;
parents may elect COBRA coverage on behalf of minor children who were covered dependents.
The Employee Benets Division will send you an Election Notice outlining your rights to COBRA or
Continuation of Coverage after it receives notication of a qualifying status change from you or your
agency. Each qualied beneciary has the right to elect COBRA or Continuation of Coverage in the group
health benets the qualied beneciary had on the last day of coverage in the Program, but must do so
within 63 days of receiving the notice.
How long does COBRA or Continuation of Coverage last?
COBRA coverage is a temporary continuation of coverage. Depending on the nature of the qualifying
status change that caused the loss of coverage, COBRA coverage may last a maximum of 18 months or
36 months, except in the case of COBRA continuation coverage in a healthcare exible spending account.
If you are participating in a healthcare exible spending account at the time of the qualifying status
change, you will only be allowed to continue the healthcare exible spending account on a post-tax
basis until the end of the current plan year in which the qualifying status change occurs. See below for
a description of how COBRA continuation coverage may end earlier than these maximum periods if your
account has a positive balance at the time of termination.
66 2024 Health Benets Guide
Length of Continuation Coverage – 18 Months
If the event causing the loss of coverage is a termination of employment (other than for reasons of gross
misconduct), resignation, layo or a reduction in work hours, each qualied beneciary will have the
opportunity to continue coverage for 18 months from the date of the qualifying status change. This
18-month coverage period may be extended only in limited situations: (1) when the qualied beneciary
receives a Social Security disability determination, (2) when a second qualifying status change occurs
during COBRA continuation coverage, and (3) when the employee became eligible for Medicare within
18 months before the termination of employment or reduction in hours (see below for explanation). You
must notify the Employee Benets Division in writing within 60 days after these events to be eligible
for an extension of the maximum coverage period. If you do not do so, you cannot extend your coverage
period.
Social Security Disability
The 18 months of continuation coverage can be extended an additional 11 months, to a maximum of
29 months, for all qualied beneciaries if the Social Security Administration determines a qualied
beneciary was disabled according to Title II or XVI of the Social Security Act on the date of the qualifying
status change or at any time during the rst 60 days of coverage. The disability must last during the entire
18 months of continuation coverage. It is the qualied beneciary’s responsibility to obtain this disability
determination from the Social Security Administration and provide a copy of the determination to the
Employee Benets Division within 60 days of the later of: (1) the date of the determination, (2) the date
of the termination of employment or reduction in hours, or (3) the date the original 18-month coverage
period expires. This notice must be provided no later than the date the original 18-month coverage period
expires. If you do not notify the Employee Benets Division in writing within this timeframe, you may lose
the ability to extend this coverage.
This extension applies separately to each qualied beneciary. If the disabled qualied beneciary
chooses not to continue coverage, all other qualied beneciaries are still eligible for the extension. If
coverage is extended, and the disabled qualied beneciary has elected the extension, the applicable
premium is 150% of the premium. If only the non-disabled qualied beneciaries extend coverage, the
premium will remain at 102%. It is also the qualied beneciary’s responsibility to notify the Employee
Benets Division within 30 days if a nal determination has been made that they are no longer disabled.
Secondary Qualifying Status Changes
Extension of the 18- or 29-month continuation period could occur, if during the 18 or 29 months of
continuation coverage, a second event takes place (divorce, legal separation, death, or a dependent child
ceasing to be a dependent) that would have caused the qualifying beneciary to lose coverage under
the Program if the rst qualifying status change (termination of employment or reduction of hours)
had not occurred. If a second event occurs, the original 18 or 29 months of continuation coverage can be
extended to 36 months from the date of the original qualifying status change date for eligible dependent
qualied beneciaries. If a second event occurs, it is the qualied beneciary’s responsibility to notify the
Employee Benets Division in writing within 60 days after the second event and within the original 18- or
29-month continuation period. In no event, however, will continuation coverage last beyond 36 months
from the date of the rst qualifying status change that originally made the qualied beneciary eligible
for continuation coverage. A reduction in hours followed by a termination of employment is not a second
qualifying status change.
672024 Health Benets Guide
Length of Continuation Coverage - 36 Months
If the original event causing the loss of coverage was the death of the employee (or a dependent child
ceasing to be a dependent child), each qualied beneciary of the employee will have the opportunity
to continue coverage for 36 months from the date of the qualifying status change. When the employee
had become entitled to Medicare benets less than 18 months before the termination of employment
or reduction in work hours, the covered spouse and covered dependent qualifying beneciaries may be
entitled to continued coverage for up to 36 months. This extension does not apply to the employee, who
will only have a maximum of 18 months of COBRA coverage unless a secondary qualifying status change
occurs. The 36-month coverage period cannot be extended.
Length of Continuation Coverage – Indenitely
If the original event causing the loss of group health coverage was your divorce, the qualied beneciary
will have the opportunity to continue coverage indenitely under Maryland law. This indenite period of
coverage will end when any of the following non-exhaustive list of events happens: (1) Program coverage
for the employee terminates, (2) the qualied beneciary obtains coverage elsewhere (including
Medicare), or (3) the qualied beneciary spouse remarries.
This indenite period of continuation coverage is a result of a Maryland state law that is similar to COBRA
and does not apply to healthcare exible spending arrangements. However, the dependent child qualied
beneciary will also lose coverage when the child does not meet Program eligibility requirements under
standard COBRA rules.
Former stepchildren of the covered employee do not gain access to indenite continuation coverage
under these provisions of Maryland law.
Notication of Address Change
To ensure you and your eligible dependents receive information properly and on time, you must notify the
State of Maryland Employee Benets Division of any address change as soon as possible. The Employee
Benets Division must have your current address at all times. A Personal Information Change form is
available at www.dbm.maryland.gov/benets; click on Forms. Instructions for completing and ling
the form are at the bottom of the form. If you don’t follow the instructions on the form, your notications
may be delayed and you may lose your opportunity for benet coverage continuation.
If You Have Questions
This Notice is simply to inform you of your responsibility to notify the Employee Benets Division if you
have a qualifying status change that allows you to continue your coverage beyond the date it would
otherwise end. If you have a qualifying status change and you are eligible for coverage continuation,
you will be notied of your rights at that time as part of the COBRA Election Notice. If you or any covered
individual does not understand any part of this summary notice or has questions about this information
or your obligations, please contact the State of Maryland Employee Benets Division at 410-767-4775.
More information about COBRA continuation coverage is available at www.dbm.maryland.gov/
benets. The Program name and address is:
The State of Maryland Employee and Retiree Health and Welfare Benets Program
c/o Employee Benets Division
301 West Preston Street, Room 510
Baltimore, Maryland 21201.
68 2024 Health Benets Guide
Health Insurance Portability and Accountability Act (HIPAA)
Certicates of Coverage and the Health Insurance Portability and Accountability Act of 1996
(HIPAA)
If you or your dependents obtain new employment, you may request a certicate of coverage from the
State, which describes the length and types of benets coverage (e.g., medical, dental, etc.) you and your
dependents had under the State Program. You may request a HIPAA Certicate of Coverage by writing to
the Department of Budget and Management (DBM), Employee Benets Division, at the address on the
inside front cover of this guide.
Notice of Privacy Practices and HIPAA Authorization Form
The State conforms to Federal HIPAA and State regulations regarding the privacy of your health
information. The Notice of Privacy Practices describes the privacy practices of the State Employee and
Retiree Health and Welfare Benets Program.
HIPAA and State regulations require your written authorization to disclose certain health information
to other people. If your written authorization is needed, you may use the HIPAA authorization form
to provide the needed authorization. This form is located on our website, www.dbm.maryland.gov/
benets; click on Forms. Assigned HIPAA authorizations remain in eect unless you change or revoke the
authorization.
Notice of Privacy Practices – The State Employee and Retiree Health And Welfare
Benets Program
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. PLEASE ALSO CAREFULLY
REVIEW ANY SEPARATE NOTICE OF PRIVACY PRACTICES MAINTAINED BY DEPARTMENT OF BUDGET &
MANAGEMENT.
Under Federal and State law, DBM administers the State Employee and Retiree Health and Welfare
Benets Program (the Program) and protects the privacy of your protected health information. DBM takes
steps to ensure that your protected health information is kept secure and condential and is used only
when necessary to administer the Program. DBM is required to give you this notice to tell you how DBM
and your Healthcare Flexible Spending Account (HCFSA) Administrator may use and give out (“disclose”)
your protected health information held by DBM and your HCFSA. This information generally comes to
DBM when you enroll in the Program, from your plan administrator as part of administration of the health
plan, and to your HCFSA when you submit requests for reimbursement. DBM and the HCFSA abide by the
terms of this Notice. Your health plan in the Program (for example, the CareFirst BlueCross BlueShield
PPO) will also protect, use, and disclose your personal health information. For questions about your
health information held by your health plan, please contact your health plan directly. The plans in the
Program all follow the same general rules that DBM and the HCFSA follow to protect, use, and disclose
your protected health information. Each plan will use and disclose your protected health information for
payment purposes, for treatment purposes, and for administration purposes. DBM has the right to use
and disclose your protected health information to administer the Program. For example, DBM will use and
disclose your protected health information:
• To communicate with your Program health plan when you or someone you have authorized to act
on your behalf asks for our assistance regarding a benet or customer service issue. DBM may need
written authorization from you for your health plan to discuss your case.
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• To determine your eligibility for benets and to administer your enrollment in your chosen health plan.
• For payment related purposes, such as to pay claims for services provided to you by doctors, hospitals,
pharmacies, and others for services delivered to you that are covered by your health plan, to coordinate
your benets with other benet plans (including Workers’ Compensation plans or Medicare) to
reimburse you from your HCFSA, or to make premium payments.
• To collect payment from you when necessary, such as copayments, premiums or other contributions.
• For treatment related purposes, such as to review, make a decision about, or litigate any disputed or
denied claims.
• For healthcare operations, such as to conduct audits of your health plan’s quality and claims payments,
to procure health benets oered through this Program, to set premiums, and to investigate
potential fraudulent claims. However, note that federal law prohibits the use and disclosure of genetic
information about an individual, including for underwriting purposes. The group health plan benets
options and the HCFSA oered through the Program do not use genetic information for underwriting
(or for any other) purposes.
DBM and/or your HCFSA will also use and disclose your protected health information:
• To you or someone who has the legal right to act for you (your personal representative). To authorize
someone other than you to discuss your protected health information, please contact DBM to complete
an authorization form.
• To law enforcement ocials when investigating and/or processing alleged or ongoing civil or criminal
actions.
• Where required by law, such as to the Secretary of the U.S. Department of Health and Human Services,
to the Oce of Legislative Audits, or in response to a subpoena.
• For healthcare oversight activities (such as mandatory reporting, and fraud and abuse investigations).
• To avoid a serious and imminent threat to health or safety.
DBM must have written permission (an “authorization”) from you, or your dependents over the age of 18
years, to use or give out your protected health information to other persons or organizations. You may
revoke an authorization at any time by written notice.
DBM and your HCFSA do not use your protected health information for fundraising or marketing purposes.
DBM and your HCFSA are prohibited from selling your protected health information. However, we can
request payment for treatment or coverage provided to you, for services provided in connection with the
health plan (such as processing claims), and for copying costs when you ask for copies of records we have
containing your information.
By law, you have rights related to protected health information about you. These include your rights to:
• Make a written request and see or get a copy of your protected health information held by DBM, the
HCFSA, or a plan in the Program. If DBM or your HCFSA use Electronic Health Records (“EHR”), you can
ask for a copy of that EHR. We do not use EHRs currently.
• Amend any of your protected health information created by DBM or the HCFSA if you believe it is wrong
or if information is missing, and DBM agrees. If DBM or the HCFSA disagrees, you may have a statement
of your disagreement added to your protected health information.
• Ask in writing for a listing of those receiving your protected health information from DBM or your
HCFSA for up to six years prior to your request. The listing will not cover your protected health
information that was used or disclosed for treatment, healthcare operations or payment purposes,
given to you or your personal representative, disclosed pursuant to an authorization. If DBM or your
70 2024 Health Benets Guide
HCFSA begins to use EHRs, you could ask for a copy of EHR disclosures over the most recent three years
for healthcare operations, treatment, and payment purposes as well.
• Ask DBM or your HCFSA in writing to communicate with you in a dierent manner or at a dierent place
(for example, by sending materials to a P.O. Box instead of your home address) if using your address on
le creates a danger to you.
• Ask DBM or your HCFSA in writing to limit how your protected health information is used or given
out. However, DBM or your HCFSA may not be able to agree to your request if the information is used
for treatment, payment, or to conduct operations in the manner described above, or if a disclosure is
required by law. If you wish to exercise these rights in connection with the Program or a health plan,
you may contact DBM at the address below.
• Get a separate paper copy of this notice. If you wish to exercise any of these rights in connection with
your HCFSA, you can contact the FSA Administrator at the address listed on the inside front cover or you
can contact DBM for assistance. You may also contact your dental plan, prescription plan, medical PPO,
medical POS, or medical EPO directly.
DBM cannot disclose protected health information to an employer for employment-related actions or
personnel transactions without authorization.
For more information on exercising your rights in this notice, visit the DBM website:
www.dbm.maryland.gov/benets. You may also call 410-767-4775 or 1-800-30-STATE (1-800-307-
8283) and ask for DBM’s HIPAA Privacy Ocial. If you believe DBM has violated your privacy rights, you
may submit a written complaint with DBM at the following address:
Department of Budget and Management
Employee Benets Division
301 West Preston Street
Room 510
Baltimore, MD 21201
ATTN: HIPAA Privacy Ocer
Filing a complaint will not aect your benets under the HIPAA. You also may submit a complaint with
the Secretary of the U.S. Department of Health and Human Services at:
Department of Health and Human Services
Oce of Civil Rights
150 South Independence Mall West, Suite 372
Public Ledger Building
Philadelphia, PA 19106-9111
712024 Health Benets Guide
Newborns’ and Mothers’ Health Protection Act Of 1996
Under federal law, group health plans and health insurance issuers oering group health insurance
coverage generally may not restrict benets for any hospital benets for any hospital length of stay in
connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal
delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer
may pay for a shorter stay if the attending provider (e.g., your physician, nurse, midwife, or physician
assistant), after consultation with the mother, discharges the mother or newborn earlier.
Also, under federal law, plans and issuers may not set the level of benets or out-of-pocket costs so that
any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or
newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician or other healthcare
provider obtain authorization for prescribing a length of stay up to 48 hours (or 96 hours). However, to
use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain
precertication. For information, contact your plan administrator.
Notice of Women’s Health & Cancer Rights Act Of 1998
As required by the Women’s Health and Cancer Rights Act (WHCRA) of 1998, the group health plan
benets options oered here provide coverage for:
• All stages of reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and physical complications of mastectomy, including lymphedemas, in a manner
determined in consultation with the attending physician and the patient.
Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed
appropriate and are consistent with those established for other benets under the plan or coverage.
Written notice of the availability of such coverage shall be delivered to the participant upon enrollment
and annually thereafter. Contact your plan administrator, the State of Maryland Employee Benets
Division, for more information.
Genetic Information Nondiscrimination Act Of 2008
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual except as specically allowed by this law. To comply with this law, we are asking
that you not provide any genetic information when responding to any request for medical information.
“Genetic information,” as dened by GINA, includes an individual’s family medical history, the results
of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family
member sought or received genetic services, and genetic information of a fetus carried by an individual
or an individual’s family member or an embryo lawfully held by an individual or family member receiving
assistive reproductive services.
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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program
that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these
premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.
healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium
assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs,
contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a
program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to
enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being
determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.
dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31,
2023. Contact your State for more information on eligibility –
ALABAMA – Medicaid ALASKA – Medicaid
Website: http://myalhipp.com/
Phone: 1-855-692-5447
The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspx
ARKANSAS – Medicaid CALIFORNIA – Medicaid
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
Health Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hipp
Phone: 916-445-8322
Fax: 916-440-5676
Email: [email protected]
COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health
Plan Plus (CHP+)
FLORIDA – Medicaid
Health First Colorado Website: https://www.healthrstcolorado.com/
Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711
CHP+: https://hcpf.colorado.gov/child-health-plan-plus
CHP+ Customer Service: 1-800-359-1991/State Relay 711
Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/
HIBI Customer Service: 1-855-692-6442
Website: https://www.medicaidtplrecovery.com/medicaidtplrecovery.com/hipp/index.html
Phone: 1-877-357-3268
GEORGIA – Medicaid INDIANA – Medicaid
GA HIPP Website: https://medicaid.georgia.gov/health-insurance-premium-payment-pro-
gram-hipp
Phone: 678-564-1162, Press 1 GA CHIPRA Website:
https://medicaid.georgia.gov/programs/third-party- liability/childrens-health
-insurance-program-reauthorization- act-2009-chipra
Phone: 678-564-1162, Press 2
Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/
Phone: 1-877-438-4479
All other Medicaid
Website: https://www.in.gov/medicaid/
Phone: 1-800-457-4584
IOWA – Medicaid and CHIP (Hawki) KANSAS – Medicaid
Medicaid Website: https://dhs.iowa.gov/ime/members
Medicaid Phone: 1-800-338-8366
Hawki Website: http://dhs.iowa.gov/Hawki
Hawki Phone: 1-800-257-8563
HIPP Website: https://dhs.iowa.gov/ime/members/medicaid- a-to-z/hipp
HIPP Phone: 1-888-346-9562
Website: https://www.kancare.ks.gov/
Phone: 1-800-792-4884
HIPP Phone: 1-800-967-4660
KENTUCKY – Medicaid LOUISIANA – Medicaid
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website:
https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx
Phone: 1-855-459-6328
Email: KIHIPP.PROGRAM@ky.gov
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx
Phone: 1-877-524-4718
Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dms
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp
Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIP
Enrollment Website:
https://www.mymaineconnection.gov/benets/s/?language=en_US
Phone: 1-800-442-6003
TTY: Maine relay 711
Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/o/
applications-forms Phone: 1-800-977-6740
TTY: Maine relay 711
Website: https://www.mass.gov/masshealth/pa
Phone: 1-800-862-4840
TTY: 711
Email: masspremassistance@accenture.com
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MINNESOTA – Medicaid MISSOURI – Medicaid
Website:
https://mn.gov/dhs/people-we-serve/children-and- families/health-care/health-
care-programs/programs-and- services/other-insurance.jsp
Phone: 1-800-657-3739
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
MONTANA – Medicaid NEBRASKA – Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084
Email: HHSHIPPProgram@mt.gov
Website: http://www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
Lincoln: 402-473-7000
Omaha: 402-595-1178
NEVADA – Medicaid NEW HAMPSHIRE – Medicaid
Medicaid Website: http://dhcfp.nv.gov
Medicaid Phone: 1-800-992-0900
Website: https://www.dhhs.nh.gov/programs- services/medicaid/health-insurance-
premium-program
Phone: 603-271-5218
Toll free number for the HIPP program: 1-800-852-3345, ext. 5218
NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid
Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
Website: https://www.health.ny.gov/health_care/medicaid/
Phone: 1-800-541-2831
NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid
Website: https://medicaid.ncdhhs.gov/
Phone: 919-855-4100
Website: https://www.hhs.nd.gov/healthcare
Phone: 1-844-854-4825
OKLAHOMA – Medicaid and CHIP OREGON – Medicaid
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
Website: http://healthcare.oregon.gov/Pages/index.aspx
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid and CHIP RHODE ISLAND – Medicaid and CHIP
Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP- Program.aspx
Phone: 1-800-692-7462
CHIP Website: Children’s Health Insurance Program (CHIP) (pa.gov)
CHIP Phone: 1-800-986-KIDS (5437)
Website: http://www.eohhs.ri.gov/
Phone: 1-855-697-4347, or
401-462-0311 (Direct RIte Share Line)
SOUTH CAROLINA – Medicaid SOUTH DAKOTA - Medicaid
Website: https://www.scdhhs.gov
Phone: 1-888-549-0820
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS – Medicaid UTAH – Medicaid and CHIP
Website: Health Insurance Premium Payment (HIPP) Program | Texas Health and Human
Services
Phone: 1-800-440-0493
Medicaid Website: https://medicaid.utah.gov/
CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT– Medicaid VIRGINIA – Medicaid and CHIP
Website: Health Insurance Premium Payment (HIPP) Program | Department of Vermont
Health Access
Phone: 1-800-250-8427
Website: https://coverva.dmas.virginia.gov/learn/premium- assistance/famis-select
https://coverva.dmas.virginia.gov/learn/premium- assistance/health-insurance-
premium-payment-hipp-programs
Medicaid/CHIP Phone: 1-800-432-5924
WASHINGTON – Medicaid WEST VIRGINIA – Medicaid and CHIP
Website: https://www.hca.wa.gov/
Phone: 1-800-562-3022
Website: https://dhhr.wv.gov/bms/
http://mywvhipp.com/
Medicaid Phone: 304-558-1700
CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
WISCONSIN – Medicaid and CHIP WYOMING – Medicaid
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: 1-800-362-3002
Website: https://health.wyo.gov/healthcaren/medicaid/programs-and-eligibility/
Phone: 1-800-251-1269
To see if any other states have added a premium assistance program since July 31, 2023, or for more information on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benets Security Administration
www.dol.gov/agencies/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a
valid Oce of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is
approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays
a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a
collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of
Labor, Employee Benets Security Administration, Oce of Policy and Research, Attention: PRA Clearance Ocer, 200 Constitution Avenue, N.W., Room N-5718, Washington,
DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2026)
74 2024 Health Benets Guide
Benets Appeal Process
Important Information about Your Health Benets Claims Review and Appeal Rights
Internal Appeals: If a healthcare claim you will be incurring or have incurred is denied, you may contact
your insurance carrier using the contact information on your Explanation of Benets (EOB) form or on the
back of your insurance identication card for information on ling an internal appeal. This must be done
within 180 days (six months) from the date the claim was denied. If your insurance carrier upholds the
denial, you have the right to request an external review (external appeal) of the denial by the Maryland
Insurance Administration.
External Appeals: For a claim denied because the service was considered not medically necessary,
medically inappropriate or is considered cosmetic, experimental or investigational, you may be entitled
to request an independent, external review within 120 days (four months) from the date the claim was
denied. If you request an external review of the type of claim denial noted above, the Maryland Insurance
Administration (MIA) will review and provide a nal, written determination. If MIA decides to overturn
the insurance carrier’s decision, we will instruct the insurance carrier to provide coverage or payment for
your healthcare item or service. For questions on your rights to external review, contact the Maryland
Insurance Administration (MIA):
Maryland Insurance Administration
Attn: Appeals and Grievance Unit
200 St. Paul Place, Suite 2700
Baltimore, Maryland 21202
Telephone: (410) 468-2000
Toll-free: 1-800-492-6116
Facsimile: (410) 468-2270
TTY: 1-800-735-2258
If a claim is denied because the service was not a covered service and is not eligible for an independent,
external review, but you still disagree with the denial, you may contact the Employee Benets Division for
additional review:
Employee Benets Division
Attn: Adverse Determinations
301 West Preston Street, Room 510
Baltimore, MD 21201
Telephone: (410) 767-4775
Toll-free: 1-800-307-8283
Facsimile: (410) 333-7104
Urgent Care Request: If your situation meets the denition of urgent care under the law, a review of
your claim will be conducted as expeditiously as possible. An urgent care situation is one in which your
health may be in serious jeopardy or, in the opinion of your physician, you may experience pain that
cannot be adequately controlled while you wait for a decision on the external review of your claim. If
you believe your situation is urgent, you may request an expedited review process by contacting your
insurance carrier at the phone number listed on the back of your insurance identication card.
Assistance resources: For questions about your rights or for assistance in ling an appeal, you can
contact the Oce of Health Insurance Consumer Assistance:
Maryland Oce of Attorney General Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202
Telephone: (877) 261-8807
http://www.oag.state.md.us/Consumer/HEAU.htm
[email protected]te.md.us
OR
Employee Benets Security Administration 1-866-444-3272
752024 Health Benets Guide
Nondiscrimination and Accessibility Requirements Notice
The State Employee and Retiree Health and Welfare Benets Program (the Program) complies with
applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin,
age, disability or sex in its activities or the health plans that are oered.
1
The Program does not exclude or
treat people dierently because of race, color, national origin, age, disability or sex.
The Program provides free aids and services to people with disabilities to enable them to communicate
eectively with us, such as qualied sign language interpreters and written information in other format
and provides free language services to people whose primary language is not English, such as qualied
interpreters and information written in other languages. If you need these services, contact the Employee
Benet Division’s Compliance Ocer (see below).
If you believe that the Program has failed to provide these services or discriminated in another way on
the basis of race, color, national origin, age, disability or sex in its activities or the health plans that are
oered, you can le a complaint with the Compliance Ocer . You can le a complaint in person or by
mail, fax, or email. If you need help ling a complaint, the Compliance Ocer is available to help you.
You can also le a civil rights complaint with the U.S. Department of Health and Human Services, Oce
for Civil Rights, electronically through the Oce for Civil Rights Complaint Portal, at https://ocrportal.
hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services,
200 Independence Avenue, SW, room 509F, HHH Building, Washington, D.C. 20201. 1-800-368-1019, 800-
537-7697 (TDD). Complaint forms are available at
https://www.hhs.gov/civil-rights/ling-a-complaint/complaint-process/index.html.
Compliance Ocer: Compliance Ocer
Employee Benets Division
301 West Preston Street – Room 510
Baltimore, MD 21201
Phone: 410.767.4775
Fax: 410.333.7104
compliance.ebd@maryland.gov
Interpreter Services Are Available for Free
Help is available in your language: 1-800-307-8283 (TTY: 711). These services are available for free.
Español/Spanish
Hay ayuda disponible en su idioma: 1-800-307-8283 (TTY: 711). Estos servicios están disponibles gratis.
0/Amharic
ôÈΎ[ΎLL½ΎùpΎÚxņ: 1-800-307-8283 (TTY: 711)łΎÇΎôùqxΎØ¤ijØΎÕôΎ
ĢΎs¼
/Arabic
(1-800-307-8283
) 1-800-307-8283
୰ᩥ/Chinese
䓟 寔 ḡ䓟 1-800-307-8283 (TTY: 711
/Farsi
(1-800-307-8283
) 1-800-307-8283
76 2024 Health Benets Guide
Français/French
Vous pouvez disposer d’une assistance dans votre langue : 1-800-307-8283 (TTY : 711). Ces services sont
disponibles pour gratuitement.
FK^hSj/Gujarati
S\h^j[hch\h5\UU;X_ZuVJp: 1-800-307-8283 (NjNjah]: 1-800-307-8283). dpahB
\YS;X_ZuVJp.
kreyòl ayisyen/Haitian Creole
Gen èd ki disponib nan lang ou: 1-800-307-8283 (TTY: 711). Sèvis sa yo disponib gratis.
Igbo
Enyemaka di na asusu gi: 1-800-307-8283 (TTY: 711). Ọrụ ndị a dị na enweghi ugwo i ga akwu maka ya.
ଛ˯ߪ/Korean
یࡈଜݤЕ߯߭ԻएࡕଥҖվТЬ: 1-800-307-8283 (TTY: 711).
הՎԻࢿ˓ѼТЬ.
Português/Portuguese
A ajuda está disponível em seu idioma: 1-800-307-8283 (TTY: 711). Estes serviços são oferecidos de graça.
Русский/Russian
: 1-800-307-8283 (TTY: 711).
.
Tagalog
Makakakuha kayo ng tulong sa iyong wika: 1-800-307-8283 (TTY: 711). Ang mga serbisyong ito ay libre.
ϭΩέ/Urdu
(1-800-307-8283
) 1-800-307-8283
Tiếng Việt/Vietnamese
Hỗ trợ là có sẵn trong ngôn ngữ của quí vị 1-800-307-8283 (TTY: 711). Những dịch vụ này có sẵn miễn phí.
yorùbá/Yoruba
Ìrànlọwọ wà ní àrọwọtó ní èdè rẹ: 1-800-307-8283 (TTY: 711). Awon ise yi wa fun o free.
1
In addition to the federal notication requirements, we also want you to know that Maryland State law also prohibits discrimination on the basis of ancestry,
creed, gender identity and expression, genetic information, marital status, sexual orientation and religious aliation, belief or opinion, pursuant to Executive
Order 01.01.2007.16 and other State laws and regulations.
772024 Health Benets Guide
Denitions
Allowed Benet: The maximum fee a health plan will pay for a covered service or treatment. The
allowed benet is determined by each health plan.
Balance Billing: When an out-of-network provider bills you for the dierence between the provider’s
charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount
is $70, the provider may bill you for the remaining $30. This amount is not counted toward your out-of-
pocket maximum. An in-network provider is not permitted to balance bill you for covered services.
Cafeteria Plans: Plans under Section 125 of the Internal Revenue Code that allow employees to choose
from a menu of one or more qualied benets and to pay for those qualied benets on a pre-tax basis.
CHIP: Children’s Health Insurance Program. Your state may have a premium assistance program to help
pay for coverage, if you are eligible for assistance.
CMS: Centers for Medicare and Medicaid Services. The agency of the U.S. Department of Health and
Human Services that is responsible for administering the Medicare and Medicaid programs.
COB (Coordination of Benets): If an employee, retiree, or eligible dependents are covered under more
than one insurance plan, the insurance plan of the person with the earlier birthday in the calendar year is
primary and the other plan is secondary. The employee’s or retiree’s primary coverage will pay its benets
rst, without regard to other coverage.
COBRA (The Consolidated Omnibus Budget Reconciliation Act of 1985): This law amended by
ERISA, the PHSA, and the tax code requires employers to oer the option of purchasing continuation
coverage to qualied beneciaries who would otherwise lose group health insurance coverage as the
result of a qualifying status change. The federal statute that applies to the State of Maryland Health plans
is the Public Health Service Act (PHSA).
Coinsurance: The percentage of the cost you and the plan pay for a covered expense. Coinsurance is
dierent for services received from in-network providers and out-of-network providers.
Copayment: The xed dollar amount an employee, retiree, or covered dependent pays at the time
service is rendered. This money goes directly to the healthcare provider. Copayments dier for each type
of service.
Creditable Service: Service credit used for calculating the amount of a benet, and credit used to
determine when a member qualies to receive a benet. Consists of earned, purchased, or claimed credit.
Deductible: The amount an employee or retiree is required to pay before your medical plan pays benets
for out-of-network care.
Deferred Retirement: Retirement option when employee elects to receive benet after the last day on
payroll 60 day window.
DHMO (Dental Health Maintenance Organization): A dental plan that operates in a way similar to
a medical HMO but provides dental services. Participants can use only those designated dental providers
approved by and registered with the DHMO.
Direct Retirement: Retirement option when within 60 days of the last day on payroll an employee/
retiree claims/receives retirement benets.
78 2024 Health Benets Guide
DPPO (Dental Preferred Provider Organization): A dental plan that operates in a way similar to a
medical PPO. You have the option to go in or out-of the network. You do not need to designate a primary
dentist or get referrals to see a specialist. Your costs are lower if you remain in-network.
Emergency Services or Medical Emergency: Healthcare services that are provided in a hospital
emergency facility after the sudden onset of a medical condition that manifests itself by symptoms
of sucient severity, including severe pain, that the absence of immediate medical attention could
reasonably be expected by a prudent layperson, who possesses an average knowledge of health and
medicine, to result in the following:
• placing the patient’s health in jeopardy;
• serious impairment of bodily functions; or
• serious dysfunction of any bodily organ or part.
EPO (Exclusive Provider Organization): An EPO is a type of managed care medical plan. The EPO
contracts with providers from a specic network from which members must choose. Benets for EPO
members are provided only if a member sees a network EPO provider (except for emergency care).
ESRD (End Stage Renal Disease): A medical condition of the kidneys and renal system when the
kidneys do not work well enough to function without dialysis or a transplant. This kind of kidney failure is
permanent; it cannot be xed.
Flexible Spending Account (FSA): A benet option that allows employees to contribute tax-free
money from their pay to an account that can be used for reimbursement of eligible healthcare and/or
dependent daycare expenses. These arrangements are regulated by federal tax law.
FMLA (Family and Medical Leave Act of 1993): A type of Leave of Absence governed by Federal and
State statutes under which an employee may take a leave of absence due to his/her medical condition, a
family member’s medical condition, or his/her active military duty.
HIPAA (Health Insurance Portability and Accountability Act of 1996): A federal law that calls
for among other aspects certain condentiality standards and requires employers to provide certicates
of coverage for former employees and their eligible dependents to minimize preexisting condition
exclusions by the former employee’s next employer.
IHM: An Integrated Health Management plan is one in which all of your care is managed by your primary
care physician generally in a regional network of providers.
In-Network Service: Service provided by a participating provider, Primary Care Physician or other
provider approved by the plan.
LWOP (Leave of Absence Without Pay): An employer-approved period of leave during which the
employee is not paid but continues to be a State employee. Any approved leave of absence of two pay
periods or less is considered a short-term LAW. Any approved leave of absence more than two pay periods
is considered a long-term LAW.
Medicare: A federal health insurance program administered by the Social Security Administration for
disabled individuals and those age 65 or older. Eligible Medicare participants must enroll in Parts A & B;
the State healthcare plan is often the secondary payer and will not cover healthcare expenses covered by
Medicare. The optional Medicare Part D program covers prescription drugs.
Network: A group of providers that contract with an insurance carrier to provide healthcare services and
treatment to individuals at reduced, xed fees.
Open Enrollment Period: An annual period during which employees and retirees may enroll for
benets coverage or change their benets coverage.
ORP (Optional Retirement Program): The ORP is a dened contribution plan open only to eligible
faculty and administrators of Maryland public institutions of higher education.
Out-of-Network Service: Service received from providers outside of the plan’s network. Such services
are subject to deductibles and coinsurance.
Out-of-Pocket Maximum: The most a covered individual or family will pay out of his or her pocket in
deductible and coinsurance charges in a plan year. Copayments have a separate out-of-pocket maximum.
Preauthorization: A decision by your health insurer or plan that a healthcare service, treatment
plan, prescription drug or durable medical equipment is medically necessary. Sometimes called
prior authorization, prior approval or precertication. Your health insurance or plan may require
preauthorization for certain services before you receive them, except in an emergency. Preauthorization
isn’t a promise your health insurance or plan will cover the cost.
PPO (Preferred Provider Organization): A health plan that oers the exibility to choose a doctor or
hospital with no referrals in or out-of-network. Members will pay a lower cost by remaining in-network.
Premium: The amount of money an employee or retiree pays for insurance coverage. Premium does not
include additional copayments or deductibles incurred for treatment.
Primary Care Provider (PCP): A General Practitioner, Nurse Practitioner, Family Practice, Internal
Medicine, Pediatrician, OB-GYN, or Physician Assistant, as allowed under state law, who provides,
coordinates or helps a patient access a range of healthcare services.
Provider: Any approved healthcare professional who provides treatment or services.
Qualied Medical Child Support Order (QMCSO): A court order that requires a parent to provide
healthcare coverage for dependent children.
Qualifying Status Change: An event such as marriage, divorce, or the birth of a child, that allows a
change in healthcare coverage outside of the Open Enrollment period. Refer to page 50 for a complete list.
Retroactive Adjustment: The process of paying back premiums owed back to the eective date of the
qualifying status change. (Applicable to active employees and retirees only).
State Subsidy: The portion of the insurance premium(s) paid by the State for eligible employees and
retirees enrolled in Health Benets.
Urgent Care: Care for an illness, injury or condition serious enough that a reasonable person would seek
care right away, but not so severe as to require emergency room care.
