BlueFund CDH - BlueChoice HMO Open Access - Maryland

Note: If the group is adding a BlueFund HRA at renewal or purchasing it as a new group, the group must complete the BenefitWallet HRA Set-Up Form as well as the Employer ACH Authorization.


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Group Size Group Subscriber Enrollment Form Group Contract Application
MSGR (2-50) BlueFund BlueChoice HSA SUM1039 N/A
MSGR (2-50) BlueChoice HSA Compatible Plan SUM1039 N/A
MSGR (2-50) BlueFund BlueChoice HRA SUM1039 N/A
MSGR (2-50) BlueChoice High Deductible Health Plans SUM1039 N/A

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

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50 NON-MSGR BlueFund BlueChoice HSA CUT5609 N/A N/A
2-50 NON-MSGR BlueChoice HSA or HRA Compatible Plans CUT5609 N/A N/A
2-50 NON-MSGR BlueFund BlueChoice HRA CUT5609 N/A N/A
2-50 NON-MSGR BlueChoice High Deductible Health Plans CUT5609 N/A N/A
51+ BlueFund BlueChoice HSA CUT5609 MD/CFBC/BC-BCOO-OA/GCA/LG (1/14) MD/GHMSI/CFBC/POE/GCA/LG (1/14)
51+ BlueChoice HSA or HRA Compatible Plans CUT5609 MD/CFBC/BC-BCOO-OA/GCA/LG (1/14) MD/GHMSI/CFBC/POE/GCA/LG (1/14)
51+ BlueFund BlueChoice HRA CUT5609 MD/CFBC/BC-BCOO-OA/GCA/LG (1/14) MD/GHMSI/CFBC/POE/GCA/LG (1/14)
51+ BlueChoice High Deductible Health Plans CUT5609 MD/CFBC/BC-BCOO-OA/GCA/LG (1/14) MD/GHMSI/CFBC/POE/GCA/LG (1/14)

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

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50 NON-MSGR BlueFund BlueChoice HSA CUT5609 N/A N/A
2-50 NON-MSGR BlueChoice HSA or HRA Compatible Plans CUT5609 N/A N/A
2-50 NON-MSGR BlueFund BlueChoice HRA CUT5609 N/A N/A
2-50 NON-MSGR BlueChoice High Deductible Health Plans CUT5609 N/A N/A
51+ BlueFund BlueChoice HSA CUT5609 MD/CFBC/BC-BCOO-OA/GCA/LG (1/14) CFMI/CFBC/POE/GCA/LG (1/14)
51+ BlueChoice HSA or HRA Compatible Plans CUT5609 MD/CFBC/BC-BCOO-OA/GCA/LG (1/14) CFMI/CFBC/POE/GCA/LG (1/14)
51+ BlueFund BlueChoice HRA CUT5609 MD/CFBC/BC-BCOO-OA/GCA/LG (1/14) CFMI/CFBC/POE/GCA/LG (1/14)
51+ BlueChoice High Deductible Health Plans CUT5609 MD/CFBC/BC-BCOO-OA/GCA/LG (1/14) CFMI/CFBC/POE/GCA/LG (1/14)

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