BlueChoice HMO Referral - Small Group Off-SHOP Applications -Virginia
BlueChoice HMO Referral (including HSA/HRA)
| Group Size | Group Subscriber Enrollment Form | Group Contract Application | Point of Enrollment |
|---|---|---|---|
| 2-50 | SUM6128 (for plans effective 1/1/23 and 12/31/23) SUM6619 (for plans effective 1/1/24 and after) |
VA/GRPAPP/HCR (1/23) (HMO) | VA/GRPAPP/HCR (1/23) (POE) |