BlueChoice HMO and BlueChoice HMO Open Access Group and Member Applications - District of Columbia

DC Groups: If a group chooses BlueChoice medical coverage (BlueChoice, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI Non-Ridered Dental contract. In this case, the group is only required to sign one Group Contract Application for the BlueChoice medical product. In this situation, the participation rules for the dental will follow the medical participation rules stated in the BlueChoice Group Contract Application. In this situation, an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI).

BlueChoice HMO and BlueChoice HMO Open Access

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment Non-Parallel Dental Only
2-50 CUT5154 N/A N/A CUT5153
51+ CUT5154 DC/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) DC/GHMSI/CFBC/POE/
GCA/LG (R. 3/14)
CUT5153

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