BlueChoice HMO - Small Group On-SHOP Applications - Virginia

BlueChoice HMO (including HSA/HRA)

Group Size	Group Subscriber Enrollment Form	Group Contract Application
2-50	SUM4738 (for plans effective between 1/1/20 and 12/31/20) SUM5061 (for plans effective 1/1/21 and after)	VA/GRPAPP/HCR (1/20) (HIX) (for plans effective between 1/1/20 and 12/31/20) VA/GRPAPP/HCR (1/21)(HIX) (for plans effective 1/1/21 and after)