Download Forms for Group Markets

Form Name

Digital Form

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2025 Benefit Program Application (BPA) for New Small Groups
For new accounts effective January 1, 2025.

2024 Enrollment Package for New Small Groups
Includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/24 and after.

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2024 Small Group Enrollment Application/Change Form
Use this form to apply for small group coverage effective January 1, 2024.

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2024 Small Group Enrollment Application/Change Form - Spanish

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2024 Benefit Program Application (BPA) for New Small Groups
For new accounts effective January 1, 2024.

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2024 Benefit Program Application (BPA) Amendment for Renewing Small Groups
For renewing accounts with anniversary dates after January 1, 2024; use this form to amend the original BPA.

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Employer Group Information (EGI) Form – this form must be submitted with the BPA

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Affidavit of Domestic Partnership Instructions

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Blue Balance Funded Quoting Eligibility Checklist

Blue Balance Funded RFP Producer Application Form

Composite Billing Guide and FAQs
For fully insured accounts (1-50 employees).

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Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA elections if sending enrollment through BCBSMT to BenefitWallet, HealthEquity or HSA Bank.

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Consumer Directed Health Accounts How-To Set Up Guide – Use this guide to learn details about setting up accounts that include HSA, FSA or HRA with vendor integration.

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Disabled Dependent Authorization Form (for Group Plans)
Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSMT (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).

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FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA integration with Flex.

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HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex.

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HSA/FSA Employer Setup Form – HealthEquity^® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HealthEquity.

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HSA/FSA Employer Setup Form – HSA Bank^® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HSA Bank.

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Initial Premium EFT Payment Form

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Small Group Underwriting Reference Guide

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Small Group Submission Checklist

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Summary of Benefits and Coverage (SBC) Notice for Small Groups

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Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA and/or HRA elections if sending enrollment through BCBSMT to BenefitWallet, HealthEquity or HSA Bank.

Consumer Directed Health Accounts How-To Set Up Guide – Use this guide to learn details about setting up accounts that include HSA, FSA or HRA with vendor integration.

FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with Flex.

HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex.

HSA/FSA Employer Setup Form – HealthEquity^® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HealthEquity.

HSA/FSA Employer Setup Form – HSA Bank^® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HSA Bank.