CDH - BlueChoice HMO Open Access Group and Member Forms and Applications - District of Columbia

Note: If the group is adding a BlueFund HRA at renewal or purchasing it as a new group, the group must complete the HRA Set-Up Form as well as the Employer ACH Authorization.

CDH - BlueChoice HMO Open Access

Group Size	Group Subscriber Enrollment Form	Group Contract Application	Point of Enrollment
2-50 BlueFund BlueChoice HSA	CUT5154	N/A	N/A
2-50 BlueChoice HSA or HRA Compatible Plans	CUT5154	N/A	N/A
2-50 BlueFund BlueChoice HRA	CUT5154	N/A	N/A
2-50 BlueChoice High Deductible Health Plans	CUT5154	N/A	N/A
51+ BlueChoice HSA or HRA Compatible Plans	CUT5154	DC/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2)	DC/GHMSI/CFBC/POE/ GCA/LG (R. 3/14)
51+ BlueFund BlueChoice HSA	CUT5154	DC/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2)	DC/GHMSI/CFBC/POE/ GCA/LG (R. 3/14)
51+ BlueFund BlueChoice HRA	CUT5154	DC/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2)	DC/GHMSI/CFBC/POE/ GCA/LG (R. 3/14)
51+ BlueChoice High Deductible Health Plans	CUT5154	DC/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2)	DC/GHMSI/CFBC/POE/ GCA/LG (R. 3/14)