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Blue Shield of California has announced that their Master Group Application (MGA), Employee Enrollment Form, Request for Contract Change and Subscriber Change Request forms have been revised for Q2 2017.  These revised forms are now available on our website for April 1, 2017 and later effective dates.

Please note that underwriting will require the April 2017 version of the forms for April 1, 2017 and later effective dates. There will be no exceptions.

Changes to the forms are as follows:

Master Group Application:
  • Section 1 – Added “Business street address where most of your employees work (if different from the physical address)” which demonstrates our compliance with the SG rating rule in the 2017 NBPP (employer’s principal business address)
  • Section 3 – COBRA/Cal-COBRA info/questions – language changes
  • Section 4a – clarified language regarding which HMO plans can be offered together (it is still just Trio ACO HMO and Access+ HMO®)
Request for Contract Change:
  • Health plan selection area was changed to clarify which HMO plans can be offered together (same as MGA)
  • Removed the DE9C requirement for changing the group’s COBRA status (I&B process)
Employee Enrollment Form:
  • A new section was added on Medicare information (now Section 6). Underwriting does not require this information, it is for claims payment purposes.
  • Other sections were renumbered – “COBRA/Cal-COBRA group continuation coverage” was changed from Section 6 to Section 7 and “Disclosure of personal and health information” was changed from Section 7 to Section 8 .
  • In the life insurance section, a statement was added about community property law along with lines for spouse/domestic partner signature and name to agree to the beneficiary designation.
  • The full-time/part-time questions were reworded to try to reduce the number of EEs that answer “yes” to both questions.
Subscriber Change Request:
  • Community property laws with spouse/DP signature and name lines added that mirror the info added to the Employee Enrollment Form.