HealthyBlue HMO, 2.0 and Triple Option Group and Member Applications - Maryland

Notes below are applicable to group contracts effective 4/1/04 and after:

Non-MSGR MD Groups: If a group chooses BlueChoice medical coverage (HealthyBlue, BlueChoice, BlueChoice Open Access, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus Open Access ) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI or CFMI Non-Ridered Dental contract. In this case, the group is required to sign two Group Contract Applications (BlueChoice & GHMSI or CFMI), unless the group selects a Point-of-Enrollment package, which only requires the signed Point-of-Enrollment Group Contract Application. In this situation, an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI or CFMI).

MSGR MD Groups: If a group chooses BlueChoice medical coverage (HealthyBlue, BlueChoice, BlueChoice Open Access, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus Open Access ) 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 required to sign two Group Contract Applications (BlueChoice & GHMSI) and an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI).


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For HealthyBlue 2.0 and Triple Option only.

Group Size Group Subscriber Enrollment FormGroup Contract Application Point of Enrollment
MSGR 2-50 CUT8690  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 Non-Parallel Dental Only
2-50 NON-MSGR SUM1982 N/A N/A N/A
51+ SUM1982  MD/CFBC/
BC-BCOO-OA/GCA/
LG (1/14)
MD/GHMSI/
CFBC/POE/
GCA/LG (1/14)
MD/GHMSI GRP APP (R. 1/13) (GHMSI BP & Med with NonRdr D-V 1/13) and CUT5141

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 Non-Parallel Dental Only
2-50 NON-MSGR SUM1982 N/A N/A N/A
51+ SUM1982 MD/CFBC/
BC-BCOO-OA/
GCA/LG (1/14)
CFMI/CFBC/
POE/GCA/
LG (1/14)
CFMI/GCA (R. 1/13) (CFMI BP & Med with NonRdr D-V 1/13)

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