HealthyBlue HMO, 2.0 and Triple Option Group and Member Applications - Maryland
Notes below are applicable to group contracts effective 4/1/04 and after:
Non-MSGR MD Groups: If a group chooses BlueChoice medical coverage (HealthyBlue, BlueChoice, BlueChoice Open Access, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus Open Access ) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI or CFMI Non-Ridered Dental contract. In this case, the group is required to sign two Group Contract Applications (BlueChoice & GHMSI or CFMI), unless the group selects a Point-of-Enrollment package, which only requires the signed Point-of-Enrollment Group Contract Application. In this situation, an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI or CFMI).
MSGR MD Groups: If a group chooses BlueChoice medical coverage (HealthyBlue, BlueChoice, BlueChoice Open Access, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus Open Access ) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI Non-Ridered Dental contract. In this case, the group is required to sign two Group Contract Applications (BlueChoice & GHMSI) and an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI).
For HealthyBlue 2.0 and Triple Option only.
Group Size | Group Subscriber Enrollment Form | Group Contract Application | Point of Enrollment |
---|---|---|---|
MSGR 2-50 | CUT8690 | N/A | N/A |
For MD groups headquartered in Prince George's or Montgomery counties.
Group Size | Group Subscriber Enrollment Form | Group Contract Application | Point of Enrollment | Non-Parallel Dental Only |
---|---|---|---|---|
2-50 NON-MSGR | SUM1982 | N/A | N/A | N/A |
51+ | SUM1982 | MD/GHMSI/CFBC/ POS-POE/GCA/LG (11/18) |
MD/GHMSI/ CFBC/POS-POE/ GCA/LG (11/18) |
MD/GHMSI GRP APP (R. 1/13) (GHMSI BP & Med with NonRdr D-V 1/13) and CUT5141 |
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 | Non-Parallel Dental Only |
---|---|---|---|---|
2-50 NON-MSGR | SUM1982 | N/A | N/A | N/A |
51+ | SUM1982 | CFMI/CFBC/ POS-POE/GCA/LG (11/18) |
CFMI/CFBC/ POS-POE/GCA/ LG (11/18) |
CFMI/GCA (R. 1/13) (CFMI BP & Med with NonRdr D-V 1/13) |