CDH - BlueChoice Opt-Out Plus 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 Opt-Out Plus Open Access
Group Size | Group Subscriber Enrollment Form | Group Contract Application | Point of Enrollment |
---|---|---|---|
2-50 BlueFund BlueChoice Opt-Out Plus HRA | CUT5148 | N/A | N/A |
2-50 BlueFund BlueChoice Opt-Out Plus HSA | CUT5148 | N/A | N/A |
2-50 BlueChoice Opt-Out Plus HSA or HRA Compatible Plans | CUT5148 | N/A | N/A |
2-50 BlueChoice Opt-Out Plus High Deductible Health Plans | CUT5148 | N/A | N/A |
51+ BlueFund BlueChoice Opt-Out Plus HRA | CUT5148 | DC/GHMSI/CFBC/POS/ GCA/LG (R. 3/14) |
DC/GHMSI/CFBC/POE/ GCA/LG (R. 3/14) |
51+ BlueFund BlueChoice Opt-Out Plus HSA | CUT5148 | DC/GHMSI/CFBC/POS/ GCA/LG (R. 3/14) |
DC/GHMSI/CFBC/POE/ GCA/LG (R. 3/14) |
51+ BlueFund BlueChoice Opt-Out Plus HSA or HRA Compatible Plans | CUT5148 | DC/GHMSI/CFBC/POS/ GCA/LG (R. 3/14) |
DC/GHMSI/CFBC/POE/ GCA/LG (R. 3/14) |
51+ BlueChoice Opt-Out Plus High Deductible Health Plans | CUT5148 | DC/GHMSI/CFBC/POS/ GCA/LG (R. 3/14) |
DC/GHMSI/CFBC/POE/ GCA/LG (R. 3/14) |