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BlueChoice HMO - Small Group On-SHOP Applications - Virginia

BlueChoice HMO (including HSA/HRA)

Group SizeGroup Subscriber Enrollment FormGroup 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)