CDH - BlueChoice Opt-Out Plus Open Access - Group and Member Forms and Applications - Virginia
Note: If the group is adding a BlueFund HRA at renewal or purchasing it as a new group, the group must complete the HRA Plan Design Guide as well as the Employer ACH Authorization.
CDH - BlueChoice Opt-Out Plus Open Access
Group Size | Group Subscriber Enrollment Form | Group Contract Application | Point of Enrollment |
---|---|---|---|
2-50 BlueFund BlueChoice Opt-Out Plus HRA (product other than VA & ES) | CUT6188 | N/A | N/A |
2-50 BlueFund BlueChoice Opt-Out Plus HSA (product other than VA & ES) | CUT6188 | N/A | N/A |
2-50 BlueChoice Opt-Out Plus HSA or HRA Compatible Plans (product other than VA & ES) | CUT6188 | N/A | N/A |
2-50 BlueChoice Opt-Out Plus High Deductible Health Plans (product other than VA & ES) | CUT6188 | N/A | N/A |
51+ BlueFund BlueChoice Opt-Out Plus HRA (product other than VA & ES) | CUT6188 | VA/GHMSI/ CFBC/POS/ GCA/LG (R. 3/14) |
VA/GHMSI/ CFBC/POE/ GCA/LG (R. 3/14) |
51+ BlueFund BlueChoice Opt-Out Plus HSA (product other than VA & ES) (electronic version only) | CUT6188 | VA/GHMSI/ CFBC/POS/ GCA/LG (R. 3/14) |
VA/GHMSI/ CFBC/POE/ GCA/LG (R. 3/14) |
51+ BlueChoice Opt-Out Plus HSA or HRA Compatible Plans (product other than VA & ES) | CUT6188 | VA/GHMSI/ CFBC/POS/ GCA/LG (R. 3/14) |
VA/GHMSI/ CFBC/POE/ GCA/LG (R. 3/14) |
51+ BlueChoice Opt-Out Plus High Deductible Health Plans (product other than VA & ES) | CUT6188 | VA/GHMSI/ CFBC/POS/ GCA/LG (R. 3/14) |
VA/GHMSI/ CFBC/POE/ GCA/LG (R. 3/14) |