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: outside Open Enrollment, employees have the right to sign up for a health plan if they experience a qualifying life change, such as marriage, divorce, or involuntarily lose of other coverage. A qualifying event will allow a 60-day Special Enrollment Period from the date of the event to elect new coverage.

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.

EventDate of SubmissionChange Effective Date
New Hire/ Rehire*No later than 60 days from the date of hireEffective date based on Group's probationary period – not to exceed 90 days from date of hire
Marriage/Civil Union* (Small Group)Within 60 days following marriageFirst of the month following receipt
After 60 days following marriageVoid - must wait until next Open Enrollment
Marriage/Civil Union* (Large Group)Within 31 days following marriageFirst of the month following receipt
32 - 60 days following marriageFirst of the month following receipt
After 60 days following marriageVoid - 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 birthVoid - 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 coverageDate of birth for child and 61st day after the birth for the membership type change
After 60 days following birthVoid - must wait until next Open Enrollment
DeathWithin 6 months of the date of deathDate of death
DivorceWithin 60 days of divorceFirst of the month following divorce
Qualifying Loss of Coverage*Within 31 days after notification of loss of coverageRetroactive to date of coverage loss or first month following receipt
Voluntary Cancellation

Submit Group Employee Enrollment and Change Form with employee signature

Outside of Open Enrollment, proof of other coverage must be provided

First of the month following receipt or mid-month date if other coverage begins mid-month
Left EmploymentSubmit Group Membership Update Form indicating key word as "LE"Term date of employment termination or first of the month following date of receipt
COBRA EligibilityIf subscriber accepts COBRA within 60 days, he or she can be retroactively reinstatedNot Applicable
Medicare Supplement CoverageWithin 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 EnrollmentPrior to or After Open EnrollmentVoid - must wait until next Open Enrollment
During Open EnrollmentEffective the first of the new calendar year (January 1) after Open Enrollment ends

*Requests not received as indicated above can be processed during Open Enrollment to begin the first of the new calendar year (January 1).

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 FormsPurpose

2024 Small Group Employee Enrollment/Change Form

2025 Small Group Employee Enrollment/Change Form

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

2024 Small Group: New Group Enrollment Packet

2025 Small Group: New Group Enrollment Packet

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

2024 Small Group Plan Selection Form

2025 Small Group Plan Selection Form

To show your employees what plan(s) you are offering and what contribution amounts are and allow employees to provide you their plan selection. 

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.

 

Employer FormsPurpose
Group Contact Update FormThis form allows employer groups to add or change designated contacts to receive or change information at Blue Cross VT for your organization.
Broker Authorization FormThis 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 CalculationMedical 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 PartnershipDomestic Partner Coverage
Group Membership Update FormMembership Changes
Adult Dependent Coverage RequestRequest for coverage, and medical certification
MSP Step-by-Step Guide for Small Group ExceptionStep-by-step guidance on how to apply for a small employer exception from Medicare coordination of benefits contractor.
Waiver of Group Health InsuranceUsed by spouses or partners to opt-out of Blue Cross and Blue Shield of Vermont coverage.

Go to Member Forms

FormsPurpose
Credibility AnalysisImportant notice concerning prescription drug coverage
Creditable Coverage Simplified DeterminationImportant notice concerning prescription drug coverage
Creditable Notice TemplateImportant notice concerning prescription drug coverage
Non-Creditable Notice TemplateImportant notice concerning prescription drug coverage
CMS Creditable Coverage GuidanceImportant notice concerning prescription drug coverage
Vermont Blue 65 Group Enrollment Application and Change FormForm 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.