ACA Plan Medical Forms

These forms are to be used if you have an ACA plan you bought directly through CareFirst or your state's Insurance Marketplace or Exchange.

  • If you are unsure of what plan you have, look on your Member ID card. You may contact Member Services by calling the telephone number on your card.
  • Other Member Services contact numbers are also available.

2022 Plans for Residents of Maryland

BlueChoice HMO Young Adult $8,700
BlueChoice HMO Bronze $8,250
BluePreferred PPO Bronze $8,250
BlueChoice HMO Value Bronze $6,100
BlueChoice HMO HSA Bronze $6,150
BluePreferred PPO HSA Silver $3,000
BlueChoice HMO Value Silver $2,250
BlueChoice HMO Gold $1,750
BluePreferred PPO Gold $1,750
BlueChoice HMO Value Gold $1,000

2022 Plans for Residents of Virginia

BlueChoice HMO Young Adult $8,700
BlueChoice HMO HSA Silver $3,000
BluePreferred PPO HSA Silver $3,000
BlueChoice HMO Gold $1,750
BluePreferred PPO Gold $1,750

2022 Plans for Residents of Washington, D.C.

BlueChoice HMO Young Adult $8,700
BlueChoice HMO Standard Bronze $7,500
BluePreferred PPO Standard Bronze $7,500
BlueChoice HMO HSA Standard Bronze $6,350
BluePreferred PPO Standard Bronze $6,350
BlueChoice HMO Standard Silver $4,000
BluePreferred PPO Standard Silver $4,000
BlueChoice HMO HSA Gold $1,500
BluePreferred PPO HSA Gold $1,500
BlueChoice HMO Standard Gold $500
BluePreferred PPO Standard Gold $500
BlueChoice HMO Standard Platinum $0
BluePreferred PPO Standard Platinum $0

2021 Plans for Residents of Maryland

BlueChoice HMO Young Adult $8,550
BlueChoice HMO Bronze $8,250
BluePreferred PPO Bronze $8,250
BlueChoice HMO Value Bronze $6,000
BlueChoice HMO HSA Bronze $6,150
BluePreferred PPO HSA Silver $3,000
BlueChoice HMO Value Silver $2,250
BlueChoice HMO Gold $1,750
BluePreferred PPO Gold $1,750
BlueChoice HMO Value Gold $1,000

2021 Plans for Residents of Virginia

BlueChoice HMO Young Adult $8,550
BlueChoice HMO HSA Silver $3,000
BluePreferred PPO HSA Silver $3,000
BlueChoice HMO Gold $1,750
BluePreferred PPO Gold $1,750

2021 Plans for Residents of Washington, D.C.

BlueChoice HMO Young Adult $8,550
BlueChoice HMO Standard Bronze $7,500
BluePreferred PPO Standard Bronze $7,500
BlueChoice HMO HSA Standard Bronze $6,350
BluePreferred PPO Standard Bronze $6,350
BlueChoice HMO Standard Silver $4,000
BluePreferred PPO Standard Silver $4,000
BlueChoice HMO HSA Gold $1,500
BluePreferred PPO HSA Gold $1,500
BlueChoice HMO Standard Gold $500
BluePreferred PPO Standard Gold $500
BlueChoice HMO Standard Platinum $0
BluePreferred PPO Standard Platinum $0

Plan Termination

View Form (applies to all plans)

Proof of Coverage

Social Security Number Submission Form

Reinstatement Request

View Form
For members who purchased their plan directly from CareFirst and not through a state Exchange.