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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) |