BlueChoice HMO - Small Group On-SHOP Applications - Virginia

BlueChoice HMO (including HSA/HRA)

Group Size Group Subscriber Enrollment Form Group Contract Application
2-50 SUM6618 (for plans effective between 1/1/24 and 12/31/24)

SUM6922 (for plans effective 1/1/25 and after)
VA-GRPAPP-HCR (R. 1-24)-HIX (for plans effective between 1/1/24 and 12/31/24)

VA-GRPAPP-HCR (R. 1-25)-HIX (for plans effective 1/1/25 and after)