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 SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint 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 SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint 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 SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint 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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