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What is BCBSGa's 360° Health® program?

A total-health solution that surrounds everyone with the help they need to live healthier, feel better and save money doing it.

BCBSGa Group Enrollment Checklist

PW_A092001
 
Below please find the online version of our Group Enrollment Checklist. Quick links are provided to assist you with locating additional forms necessary for group submission.  
Please click here to print a hard copy of the Large Group Enrollment Checklist to use when submitting new groups.  
Cut Off Submission Dates:
All forms must be completed and received no later than the 20th of the month prior to the effective date.
 
Any missing information will delay members being loaded to our membership system and generation of ID cards.
Group Name:  
Requested Effective Date: 
Date Submitted:  
Agent/Broker Name: 
Agent/Broker Telephone:  
Agent/Broker Email:  
In order to process your request as quickly as possible, please submit the documents listed below.  
Premium Check payable to: Blue Cross Blue Shield of Georgia (Premium = Sold Rate X Number of Enrolled Lives)
Premium Check payable to: GGL (Separate check necessary only if selling voluntary life, STD, LTD or Term Life insurance that is based off of salary or classes.)
Group Master Application
(51+) (use for medical, dental and vision)

Section IV – Indicate the plan number for all plans elected. The HMO plan cannot be sold as a single option, the group must also select a plan with an out-of-network benefit.

Employee Waiting Period (EWP) – Indicate in days not months. EWP cannot exceed 180 days.

Effective Date

Employer contribution percentage – Must be at least 50% of the single Employee cost.

Life & Disability Forms (download the Term Life Group Master Application)
Most Current Prior Carrier Bill
Benefit Booklet: A copy of the prior Insurance Carrier’s bill, including dental & life (if applicable). A copy of Prior Insurance Benefit Certificate Booklet.
COBRA: Refer to the COBRA Implementation Paperwork Guide for instructions and forms
BCBSGa Employer Access Online Agreement (Optional, but encouraged)
Large Group Member Application 51 –99 for every full-time/eligible employee including COBRA participants.

Employees waiving coverage must complete & sign the application & check the Refusal of Coverage section. The Other Insurance Information section should also be completed. The Special Enrollment Rights form is to be left with the employer & cannot be accepted in lieu of the signed applications.

Participation requirements: The greater of 50% of the total eligible employees or 75% of eligible employees excluding those covered by spouses.

Please refer to Member Enrollment Application Tips 51-99 to assist in the completion of the application.

HMC Products Purchased (Self Insured/MPA Funded Groups Only)
Macro Spreadsheet Enrollment (if applicable)
Electronic Enrollment (EET, if applicable)
Signed Group HSA Agreement (if applicable)
Completed Group HSA Worksheet (if applicable)
Signed HRA-HIA Agreement (if applicable)
Completed HRA Blended Bank Authorization Form (if applicable)
Employee Assistance Program (EAP) Application
Employee Assistance Program (EAP) Plan Designs
 
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.