Member Maintenance

Resources for group enrollment and changes to existing coverage.

Enrolling an employee in your group coverage or making changes to your existing coverage can be done electronically through our Employer Resource Center. Transactions will be processed within 24 hours - saving time and paper!

If you'd rather, you can submit request by completing the enrollment forms below and sending by email, fax, or mail.

Learn more about when you can enroll employees and what forms are needed for making updates below. 

Group Enrollment Changes

Below find the information and forms for making changes to your group's enrollment.

Employees may enroll in your group's plan during the following times.

  • Initial opportunity: the first opportunity in which employee is eligible to enroll following completion of company's waiting period if applicable.
  • Open enrollment period: usually the anniversary date of the group's original enrollment
  • Special enrollment period: triggered by a qualified event

Changes to existing coverage may be made during the open enrollment or special enrollment periods. Use the table below to help understand stand when enrollment or enrollment changes can be made.

Event Date of Submission Change Effective Date
New Hire/ Rehire* No later than 60 days from date of eligibility Group determines but not to exceed 90 days from date of hire.
Marriage/Civil Union* Within 31 days following marriage First of the month following marriage
32 - 60 days following marriage First of the month following receipt
After 60 days following marriage (small group) First of the month following receipt
After 60 days following marriage (large group) Void - must wait until next open enrollment
Birth*

Newborn is automatically added for first 60 days

Within 60 days following the date of birth, to continue coverage or to request other changes to your coverage

Date of birth for child and 61st day after the birth for the membership type change

After 60 days following birth (small group) First of month following receipt
After 60 days following birth (large group) Void - must wait until next open enrollment
Adoption*

Within 60 days following the date of birth, to continue coverage or to request other changes to your coverage

Date of birth for child and 61st day after the birth for the membership type change

After 60 days following birth (small group) First of month following receipt
After 60 days following birth (large group) Void - must wait until next open enrollment
Death Within 6 months of the date of death Date of death
Divorce Within 60 days of divorce First of the month following divorce
Qualifying Loss of Coverage* Within 31 days after notification of loss of coverage Retroactive to date of coverage loss
Voluntary Cancellation Must submit Group Enrollment Form with employee signature First of the month following receipt
Left Employment Submit Group Membership Update Form indicating key word as "LE" First of the month following receipt
COBRA Eligibility If subscriber accepts COBRA within 60 days, he or she can be retroactively reinstated Not Applicable
Medicare Supplemental Coverage Within 90 days of the date of Medicare coverage     Date of Medicare entitlement. 
If received prior to Medicare effective date, coverage will be effective to coincide with Medicare.
Addition of Employee who Refused Initial Enrollment

Prior to the Anniversary or Open Enrollment month

First of the Anniversary or Open Enrollment month

During the Anniversary or Open Enrollment month First of the month following receipt

* Requests not received as indicated above can be processed on your anniversary or open enrollment.

Before enrolling or making changes to your employee's membership, you must determine

  • Eligibility
  • The employee's dependent(s) eligibility
  • Type of membership the employee will need (employee only; two-person; adult and child(ren); or family)
  • If the plan requires a primary care provider (PCP) be selected, the PCP must be selected for the employee and all eligible dependents in order for the membership to become effective.

Prior to completing an enrollment form, you must ensure that your employees have the Summary of Benefits Coverage (SBC) that apply to the coverage for which they may enroll.

Employer Forms Purpose

2021 Small Group Employee Enrollment/Change Form 

2022 Small Group Employee Enrollment/Change Form

Used to submit a change or to enroll an employee in a small group qualified health plan

2021 Small Group: New Group Enrollment Packet

2022 Small Group: New Group Enrollment Packet

Small groups who are NEW to Blue Cross and Blue Shield of Vermont should complete this packet

Large Group Enrollment/Change Form

Large Group Enrollment Packet

Used for employee updates to enrollment

  • New Enrollment
  • Membership Change 
  • Cancellation
  • Declining Coverage

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.

Online Group Enrollment Form Used for new enrollment/hires only.

 

Employer Forms Purpose
Broker Authorization Form This form allows employer groups to designate a broker agency and/or individual brokers as authorized contacts to receive or change information on behalf of the group. It will be included in this year's renewal forms that CBSS and account managers review with both small and large groups.
Average Employee Count Calculation Medical Loss Ratio employee count

Continuity of Care

Members can complete this form electronically through the Member Resource Center (under "My Forms")

For new members receiving treatment for a chronic medical, mental health or substance abuse condition or pregnant and are in their 2nd or 3rd trimester. Completion of this form will ensure a seamless transition of health care and pharmacy needs.
Statement of Domestic Partnership Domestic Partner Coverage
Group Membership Update Form Membership Changes
Adult Dependent Coverage Request Request for coverage, and medical certification
MSP Step-by-Step Guide for Small Group Exception Step-by-step guidance on how to apply for a small employer exception from Medicare coordination of benefits contractor.
Waiver of Group Health Insurance Used by spouses or partners to opt-out of Blue Cross and Blue Shield of Vermont coverage.

Go to Member Forms

Forms Purpose
Credibility Analysis Important notice concerning prescription drug coverage
Creditable Coverage Simplified Determination Important notice concerning prescription drug coverage
Creditable Notice Template Important notice concerning prescription drug coverage
Non-Creditable Notice Template Important notice concerning prescription drug coverage
CMS Creditable Coverage Guidance Important notice concerning prescription drug coverage
Group Subscriber Medicare Supplement Application Form for a group subscriber's changes

Go to Member Forms

Enrollment Frequently Asked Questions (FAQs)

1. Where can I locate additional Blue Cross and Blue Shield of Vermont forms?

2. Where can I locate a directory for primary care physicians?

The PCP directory can be located by using our Find a Doctor application.

3. Is it required to submit a Group Membership Update form with the Group Enrollment Form?

No, most membership changes can be processed from the Group Enrollment Form.

4. When can I expect to receive my ID cards?

Generally, ID cards are mailed to the subscriber’s home address within 7-10 days of processing.

5. Can I submit membership changes using my invoice?

No, do not make membership changes on the invoice or send any membership changes to our payment address.

6. Can I pay a lower premium than billed based on a pending change?

It is highly recommended you pay the total amount due shown on the last page of your invoice. If you are expecting adjustments, because we bill a month in advance, these adjustments may appear on a future invoice.

7. How do I obtain information regarding COBRA/VIPER coverage?

COBRA is federally mandated. VIPER (VT Statute) is state mandated. Please contact your legal counsel for questions.

8. If COBRA/VIPER has been offered to a former employee, when should I submit the cancel request?

Blue Cross and Blue Shield of Vermont recommends you submit the cancel request once the individual has left employment. If continuation of coverage is elected, the coverage will be effective the day coverage was lost, as long as the paperwork is received on time.

9. When can I make benefit changes?

Benefit changes can only be made once a year, on the anniversary of your original enrollment or association renewal date, or due to special enrollment event.


All group enrollment & change forms must be signed and dated by the subscriber.
All membership update forms must be signed and dated by the appropriate group representative.