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Change Healthcare notifying individuals of data breach. Learn more here.

BlueFund CDH - BlueChoice Opt-Out Plus Open Access - Group and Member Forms and Applications - Maryland

Note: If the group is adding a BlueFund HRA at renewal or purchasing it as a new group, the group must complete the HRA Plan Design Guide as well as the Employer ACH Authorization.

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Maryland – MSGR

Group Size	Group Subscriber Enrollment Form	Group Contract Application	Point of Enrollment
MSGR (2-50) BlueFund BlueChoice Opt-Out Plus HSA	SUM1039	N/A	N/A
MSGR (2-50) BlueFund BlueChoice Opt-Out Plus HSA Compatible Plan	SUM1039	N/A	N/A
MSGR (2-50) BlueChoice Opt-Out Plus High Deductible Health Plans	SUM1039	N/A	N/A

Maryland - GHMSI

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 NON-MSGR BlueFund BlueChoice Opt-Out Plus HRA	CUT5139	N/A	N/A
2-50 NON-MSGR BlueFund BlueChoice Opt-Out Plus HSA	CUT5139	N/A	N/A
2-50 NON-MSGR BlueChoice Opt-Out Plus HSA or HRA Compatible Plans	CUT5139	N/A	N/A
2-50 NON-MSGR BlueChoice Opt-Out Plus High Deductible Health Plans	CUT5139	N/A	N/A
51+ BlueFund BlueChoice Opt-Out Plus HSA	CUT5139	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (1/18)	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (11/18)
51+ BlueFund BlueChoice Opt-Out Plus HRA	CUT5139	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (1/18)	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (11/18)
51+ BlueChoice Opt-Out Plus HSA or HRA Compatible Plans	CUT5139	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (1/18)	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (11/18)
51+ BlueChoice Opt-Out Plus High Deductible Health Plans	CUT5139	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (1/18)	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (11/18)

Maryland – CFMI

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 NON-MSGR BlueFund BlueChoice Opt-Out Plus HRA	CUT8515	N/A	N/A
2-50 NON-MSGR BlueFund BlueChoice Opt-Out Plus HSA	CUT8515	N/A	N/A
2-50 NON-MSGR BlueFund BlueChoice Opt-Out Plus HSA or HRA Compatible Plans	CUT8515	N/A	N/A
2-50 NON-MSGR BlueChoice Opt-Out Plus High Deductible Health Plans	CUT8515	N/A	N/A
51+ BlueFund BlueChoice Opt-Out Plus HRA	CUT8515	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)
51+ BlueFund BlueChoice Opt-Out Plus HSA	CUT8515	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)
51+ BlueFund BlueChoice Opt-Out Plus HSA or HRA Compatible Plans	CUT8515	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)
51+ BlueChoice Opt-Out Plus High Deductible Health Plans	CUT8515	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)

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