Member Maintenance

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 the date of hire	Effective date based on Group's probationary period – 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
Birth*	After 60 days following birth (small group and 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
Addition of Employee who Refused Initial Enrollment	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
2024 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	Small groups who are NEW to Blue Cross and Blue Shield of Vermont should complete this packet
2024 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.}

834 Submissions Companion Guide

Employer Forms	Purpose
Group Contact Update Form	This form allows employer groups to add or change designated contacts to receive or change information at Blue Cross VT for your organization.
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
Vermont Blue 65 Group Subscriber Medicare Supplement Enrollment 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.