HealthyBlue PPO - Group and Member Applications - Maryland
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).
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 | SUM1984 | N/A | N/A |
51+ | SUM1984 | MD/GHMSI/GCA/LG (11/18) | MD/GHMSI/CFBC/POS-POE/GCA/LG (11/18) |
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 | SUM1983 | N/A | N/A |
51+ | SUM1983 | CFMI/GCA/LG (11/18) | CFMI/CFBC/POS-POE/GCA/LG (11/18) |