BlueChoice Plus / BlueChoice Plus Opt-Out - Small Group Off-SHOP Applications - Maryland

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BlueChoice Plus (including HSA/HRA) / BlueChoice Plus Opt-Out GHMSI

For MD groups headquartered in Prince George's or Montgomery counties.

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 SUM5378 (for plans effective between 1/1/21 and 12/31/21)

SUM5851 (for plans effective 1/1/22 and after		 MD/SE/POS/GCA (R. 1/19) (for plans effective 1/1/19 and after) MD/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after)
2-50
(BlueChoice Plus Opt-Out)		 SUM5376 (for plans effective between 1/1/21 and 12/31/21)

SUM5849 (for plans effective 1/1/22 and after)		 MD/CFBC/SE/HMO-BCOO/GCA (R. 1/19) (for plans effective 1/1/19 and after) MD/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after)

BlueChoice Plus (including HSA/HRA) / BlueChoice Plus Opt-Out CFMI

For MD groups headquartered in counties other than Prince George's and Montgomery.

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 SUM5381 (for plans effective between 1/1/21 and 12/31/21)

SUM5854 (for plans effective 1/1/22 and after)		 CFMI/SE/POS/GCA (R. 1/19) (for plans effective 1/1/19 and after) CFMI/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after)
2-50 (BlueChoice Plus Opt-Out) SUM5376 (for plans effective between 1/1/21 and 12/31/21)

SUM5849 (for plans effective 1/1/22 and after)		 MD/CFBC/SE/HMO/BCOO/GCA (R. 1/19) (for plans effective 1/1/19 and after) CFMI/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after)

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