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BlueChoice Plus / BlueChoice Plus Opt-Out - Small Group Off-SHOP Applications - Maryland
For MD groups headquartered in Prince George's or Montgomery counties.
| Group Size | Group Subscriber Enrollment Form | Group Contract Application | Point of Enrollment |
|---|---|---|---|
| 2-50 | SUM6513 (for plans effective 1/1/23 and 12/31/23) SUM6864 (for plans effective 1/1/24 and after) |
MD/SE/POS/GCA (R. 1/19) (for plans effective 1/1/19 and after) | MD/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after) |
| 2-50 (BlueChoice Plus Opt-Out) |
SUM6511 (for plans effective 1/1/23 and 12/31/23) SUM6863 (for plans effective 1/1/24 and after) |
MD/CFBC/SE/HMO-BCOO/GCA (R. 1/19) (for plans effective 1/1/19 and after) | MD/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after) |
For MD groups headquartered in counties other than Prince George's and Montgomery.
| Group Size | Group Subscriber Enrollment Form | Group Contract Application | Point of Enrollment |
|---|---|---|---|
| 2-50 | SUM6516 (for plans effective 1/1/23 and 12/31/23) SUM6866 (for plans effective 1/1/24 and after) |
CFMI/SE/POS/GCA (R. 1/19) (for plans effective 1/1/19 and after) | CFMI/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after) |
| 2-50 (BlueChoice Plus Opt-Out) | SUM6511 (for plans effective 1/1/23 and 12/31/23) SUM6863 (for plans effective 1/1/24 and after) |
MD/CFBC/SE/HMO/BCOO/GCA (R. 1/19) (for plans effective 1/1/19 and after) | CFMI/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after) |