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BlueChoice Plus / BlueChoice Plus Opt-Out - Small Group Off-SHOP Applications - Virginia
BlueChoice Plus (including HSA/HRA) / BlueChoice Plus Opt-Out
| Group Size | Group Subscriber Enrollment Form | Group Contract Application | Point of Enrollment |
|---|---|---|---|
| 2-50 | SUM6129 (for plans effective 1/1/23 and 12/31/23) SUM6620 (for plans effective 1/1/24 and after) |
VA/GRPAPP/HCR (1/23) (POS) | VA/GRPAPP/HCR (1/23) (POE) |
| 2-50 (BlueChoice Plus Opt-Out) |
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) |