BlueFund CDH - BluePreferred - 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 GHMSI

For MD groups headquartered in Prince George's or Montgomery counties.

Group Size	Group Subscriber Enrollment Form	Group Contract Application
MSGR (2-50) BlueFund BluePreferred HSA	SUM1038	N/A
MSGR (2-50) BluePreferred HSA Compatible and HRA Compatible and BlueFund Plans	SUM1038	N/A
MSGR (2-50) BluePreferred High Deductible Health Plans	SUM1038	N/A

Maryland - MSGR CFMI

For MD groups headquartered in counties other than Prince George's and Montgomery.

Group Size	Group Subscriber Enrollment Form	Group Contract Application
MSGR (2-50) BlueFund BluePreferred HSA	SUM1037	N/A
MSGR (2-50) BluePreferred HSA Compatible and HRA Compatible and BlueFund Plans	SUM1037	N/A
MSGR (2-50) BluePreferred High Deductible Health Plans	SUM1037	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 BluePreferred HRA	CUT5141	N/A	N/A
2-50 NON-MSGR BlueFund BluePreferred HSA	CUT5141	N/A	N/A
2-50 NON-MSGR BluePreferred HSA or HRA Compatible Plans	CUT5141	N/A	N/A
2-50 NON-MSGR BluePreferred High Deductible Health Plans	CUT5141	N/A	N/A
51+ BlueFund BluePreferred HRA	CUT5141	MD/GHMSI/GCA/LG (11/18)	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (11/18)
51+ BlueFund BluePreferred HSA	CUT5141	MD/GHMSI/GCA/LG (11/18)	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (11/18)
51+ BluePreferred HSA or HRA Compatible Plans	CUT5141	MD/GHMSI/GCA/LG (11/18)	MD/GHMSI/ CFBC/POS-POE/ GCA/LG (11/18)
51+ BluePreferred High Deductible Health Plans	CUT5141	MD/GHMSI/GCA/LG (11/18)	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 BluePreferred HRA	CUT8514	N/A	N/A
2-50 NON-MSGR BlueFund BluePreferred HSA	CUT8514	N/A	N/A
2-50 NON-MSGR BlueFund BluePreferred HSA or HRA Compatible Plans	CUT8514	N/A	N/A
2-50 NON-MSGR BlueFund BluePreferred High Deductible Health Plans	CUT8514	N/A	N/A
51+ BlueFund BluePreferred HRA	CUT8514	CFMI/GCA/LG (11/18)	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)
51+ BlueFund BluePreferred HSA	CUT8514	CFMI/GCA/LG (11/18)	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)
51+ BlueFund BluePreferred HSA or HRA Compatible Plans	CUT8514	CFMI/GCA/LG (11/18)	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)
51+ BluePreferred High Deductible Health Plans	CUT8514	CFMI/GCA/LG (11/18)	CFMI/CFBC/ POS-POE/GCA/ LG (11/18)

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