Edit, Download, and Sign the Maryland State COBRA Enrollment Form 2023
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How do I fill this out?
Begin by entering your personal and dependent information clearly. Select the applicable coverage options and provide the necessary details for each selection. Make sure to include all required documentation before submitting the form.
How to fill out the Maryland State COBRA Enrollment Form 2023?
1
Enter your personal information including name, address, and contact details.
2
Provide details for dependents and attach required documentation.
3
Select the appropriate coverage options such as medical, dental, and prescription drug plans.
4
Indicate the qualifying event and duration for continuation coverage if applicable.
5
Sign and submit the form along with any required supporting documents.
Who needs the Maryland State COBRA Enrollment Form 2023?
1
Employees or former employees losing group health coverage due to termination.
2
Spouses or dependents losing coverage due to divorce or legal separation.
3
Dependents aging out of eligibility for coverage under a parent's plan.
4
Employees transitioning to Medicare and needing continuation coverage for dependents.
5
State employees taking personal leave or facing suspension and needing health coverage continuation.
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2
Use the PDF editor to make necessary changes to your information.
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What are the instructions for submitting this form?
Completed and signed COBRA Enrollment Forms can be mailed to Employee Benefits Division, 301 W. Preston Street, Room 510, Baltimore, Maryland 21201. You can also call 410-767-4775 or 1-800-307-8283 for assistance. Fax submissions are accepted at 410-333-5191. You can email the form to ebd.mail@maryland.gov. Ensure all required dependent documentation is attached and the form is fully completed before submission. Our advice is to double-check all fields and documentation requirements to avoid any delays in processing.
What are the important dates for this form in 2024 and 2025?
For the years 2024 and 2025, important dates for this form include the open enrollment period beginning January 1st of each year. Ensure that qualifying event documentation is submitted within 60 days of the event. Failure to submit within this period may result in loss of coverage eligibility.
What is the purpose of this form?
The COBRA Enrollment Form for the State of Maryland is designed to help employees and their dependents continue health coverage during periods of transition. This includes scenarios such as job termination, divorce, or aging out of dependent coverage. By providing detailed personal and dependent information, along with necessary supporting documents, applicants can maintain their health benefits through COBRA.
Tell me about this form and its components and fields line-by-line.
- 1. Personal Information: Includes fields for name, address, phone numbers, and social security number.
- 2. Dependent Information: Fields for the names, birthdates, and social security numbers of dependents.
- 3. Coverage Options: Selection of medical, dental, and prescription drug plans.
- 4. Qualifying Event: Details of the event leading to COBRA coverage eligibility.
- 5. Signature: Area for the applicant's signature to validate the form.
What happens if I fail to submit this form?
Failing to submit this form can result in loss of health coverage eligibility under COBRA.
- Loss of Coverage: Without submitting the form, you and your dependents may not have health coverage.
- Late Submission: Submitting the form after the deadline may result in denial of COBRA benefits.
How do I know when to use this form?
- 1. Job Termination: Use this form to maintain coverage after losing your job.
- 2. Divorce: Submit the form to continue coverage after a divorce or legal separation.
- 3. Dependent Aging Out: Use the form to extend coverage when a dependent ages out of eligibility.
- 4. Medicare Transition: Ensure continued coverage for dependents when transitioning to Medicare.
- 5. Personal Leave: Submit the form to maintain coverage during personal leave or suspension.
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What information do I need to complete the COBRA Enrollment Form?
You need personal data, dependent details, and documentation specifying the qualifying event for COBRA coverage.
How do I choose the correct coverage options on the form?
Select from medical, dental, and prescription drug plans based on your needs and eligibility.
Is there a deadline to submit the COBRA Enrollment Form?
Yes, make sure to submit the form within 60 days of the qualifying event.
Where can I get help if I have questions about the form?
You can contact the Employee Benefits Division in Maryland for assistance with the form.
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