Employer Forms
Group Benefits Manager's Manual Comprehensive guidance for handling Group-level changes.
Updated: 12-06-2012
| Form | Purpose |
|---|---|
| Average Employee Count Calculation | Medical Loss Ratio employee count. |
| Group Enrollment |
Used for EMPLOYEE updates to enrollment NOTE: Application forms must be accompanied by a copy of the Summary of Benefits and Coverage (SBC) when provided to an employee enrolling in an employer group plan that has renewed on or after October 1, 2012. |
BlueCare Access Enrollment/Change Form
 |
BlueCare Access Enrollment form for subscribers. NOTE: Use this form ONLY if you have BlueCare Access coverage. |
| Continuity of Care
|
To be used for transitioning members who are being treated for a life threatening/disabling or degenerative condition, are in their 2nd or 3rd trimester of pregnancy, have an upcoming surgery OR are on a medication that the previous insurer has given prior approval for. |
| Online Group Enrollment Form | Used for NEW ENROLLMENT/HIRES only. |
| Incapacitated Dependent
|
Request for coverage, and medical certification |
| Domestic Partner Coverage | |
| Group Membership Update
|
Membership Changes |
| MSP Step-by-Step Guide for Small Group Employer Exception
|
Step-by-step guidance on how to apply for a small employer exception from Medicare coordination of benefits contractor. |
| Small Group Certification
|
Small Employer Qualification |
| Small Group Certification: New Group
|
Small Employer Qualification for NEW GROUPS |
| Small Group Certification: Requalification
|
Small Employer Qualification for REQUALIFICATIONS |
| Small Group Certification: Transfer
|
Small Employer Qualification for TRANSFERS |
| Waiver of Group Health Insurance |
Used by spouses or partners to opt out of BCBSVT coverage |
VT Blue 65 (CMS, Credible/Non-Credible Coverage)
| Form | Purpose | |
|---|---|---|
| Credibility Analysis |
Important notice concerning prescription drug coverage | |
| Creditable Coverage Simplified Determination |
Important notice concerning prescription drug coverage | |
| Creditable Notice (Word Doc) | Important notice concerning prescription drug coverage | |
| Non-Creditable Notice (Word Doc) | Important notice concerning prescription drug coverage | |
| CMS Creditable Coverage Guidance |
Important notice concerning prescription drug coverage | |
| Group Subscriber Medicare Supplement Application and Change Form |
Form for a group subscriber's changes | |
New Enrollment Instructions Membership Change Instructions
Note: The group enrollment form is used to notify us of membership changes.