HealthyBlue Advantage - Small Group Off-SHOP Applications - Maryland

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

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 SUM4545 (for plans effective between 1/1/19 and 12/31/19)

SUM4741 (for plans effective 1/1/20 and after)
MD/SE/POS/GCA (R. 1/19) (for plans effective 1/1/19 and after) MD/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after)

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

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 SUM4549 (for plans effective between 1/1/19 and 12/31/19)

SUM4744 (for plans effective 1/1/20 and after)
CFMI/SE/POS/GCA (R. 1/19) (for plans effective 1/1/19 and after) CFMI/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after)

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