HealthyBlue PPO - 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 SUM4547 (for plans effective between 1/1/19 and 12/31/19) MD/CF/SE/PPO/GCA (R. 1/19) (for plans effective between 1/1/19 and 12/31/19) MD/SE/POE/GCA (R. 1/19) (for plans effective between 1/1/19 and 12/31/19)

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

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 SUM2332 (for plans effective before 1/1/15) or

SUM2332 (5/14) (for plans effective between 1/1/15 and 12/31/15) or

SUM3208 (9/15) (for plans effective 1/1/16 and after)
CFMI/SE/PPO/GCA (1/14) (for plans effective before 1/1/16) or

CFMI/SE/PPO/GCA (R. 1/16) (for plans effective 1/1/16 and after)
CFMI/SE/POE/GCA (1/14) (for plans effective before 1/1/16) or

CFMI/SE/POE/GCA (R. 1/16) (for plans effective 1/1/16 and after)

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