BlueFund CDH - BlueChoice Opt-Out Plus Open Access - Group and Member Forms and Applications - 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 Point of Enrollment
MSGR (2-50) BlueFund BlueChoice Opt-Out Plus HSA SUM1039 N/A N/A
MSGR (2-50) BlueFund BlueChoice Opt-Out Plus HSA Compatible Plan SUM1039 N/A N/A
MSGR (2-50) BlueChoice Opt-Out Plus High Deductible Health Plans SUM1039 N/A 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 Opt-Out Plus HRA CUT5139 N/A N/A
2-50 NON-MSGR BlueFund BlueChoice Opt-Out Plus HSA CUT5139 N/A N/A
2-50 NON-MSGR BlueChoice Opt-Out Plus HSA or HRA Compatible Plans CUT5139 N/A N/A
2-50 NON-MSGR BlueChoice Opt-Out Plus High Deductible Health Plans CUT5139 N/A N/A
51+ BlueFund BlueChoice Opt-Out Plus HSA CUT5139 MD/GHMSI/
CFBC/POS/
GCA/LG (1/14)
MD/GHMSI/
CFBC/POE/
GCA/LG (1/14)
51+ BlueFund BlueChoice Opt-Out Plus HRA CUT5139 MD/GHMSI/
CFBC/POS/
GCA/LG (1/14)
MD/GHMSI/
CFBC/POE/
GCA/LG (1/14)
51+ BlueChoice Opt-Out Plus HSA or HRA Compatible Plans CUT5139 MD/GHMSI/
CFBC/POS/
GCA/LG (1/14)
MD/GHMSI/
CFBC/POE/
GCA/LG (1/14)
51+ BlueChoice Opt-Out Plus High Deductible Health Plans CUT5139 MD/GHMSI/
CFBC/POS/
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 Opt-Out Plus HRA CUT8515 N/A N/A
2-50 NON-MSGR BlueFund BlueChoice Opt-Out Plus HSA CUT8515 N/A N/A
2-50 NON-MSGR BlueFund BlueChoice Opt-Out Plus HSA or HRA Compatible Plans CUT8515 N/A N/A
2-50 NON-MSGR BlueChoice Opt-Out Plus High Deductible Health Plans CUT8515 N/A N/A
51+ BlueFund BlueChoice Opt-Out Plus HRA CUT8515 CFMI/CFBC/
POS/GCA/
LG (1/14)
CFMI/CFBC/
POE/GCA/
LG (1/14)
51+ BlueFund BlueChoice Opt-Out Plus HSA CUT8515 CFMI/CFBC/
POS/GCA/
LG (1/14)
CFMI/CFBC/
POE/GCA/
LG (1/14)
51+ BlueFund BlueChoice Opt-Out Plus HSA or HRA Compatible Plans CUT8515 CFMI/CFBC/
POS/GCA/
LG (1/14)
CFMI/CFBC/
POE/GCA/
LG (1/14)
51+ BlueChoice Opt-Out Plus High Deductible Health Plans CUT8515 CFMI/CFBC/
POS/GCA/
LG (1/14)
CFMI/CFBC/
POE/GCA/
LG (1/14)

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