QHP Direct Enroll

We're here to help! If you have any questions or need help completing this form, contact a BCBSVT exchange specialist at (800) 255-4550, Monday - Friday, 8:00 a.m. to 4:30 p.m.


*Indicates a required field.

Business Information:

*Effective Date: January 1, 2017

*Benefit Plan(s) Selection:

Click on any benefit plan below to view the Summary of Benefits and Coverage (SBC) or click here to compare all our qualified health plan offerings.

Covered Employees & Plan Selection:

Please list all currently covered employees and their plan selection.

*First Name of Covered Employee *Last Name of Covered Employee Employee Date of Birth *Plan Selection
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Note: Employees will transfer to their current plan type (i.e. single or family).

You will need to complete and submit a Small Group Change Form for any of the changes listed below.
Follow the instructions on the form to submit the completed form.

  • Add new employee/hire
  • Change plan type (e.g. single to family)
  • Add/remove dependents
  • Cancel existing coverage

Sign and Submit

By typing my name in the "Authorized by" field below, I confirm the following:

  • This business qualifies as a small group according to Vermont state law. I have at least 1 employee, who is not myself or my spouse, and an average of 100 or fewer full time employees equivalent as calculated pursuant to IRS code ยง 4980H(c)(2).
  • I am authorized to make these benefit selections for the group.
  • All the information provided herein is complete and accurate to the best of my knowledge.
  • I will provide each employee with a copy of the Summary of Benefits and Coverage (SBC) for their selected plan.
  • I authorize the electronic submission of this form.
*Authorized by:

NOTICE: Discrimination is Against the Law

Blue Cross and Blue Shield of Vermont (BCBSVT) complies with applicable federal and state civil rights laws and does not discriminate, exclude people or treat them differently on the basis of race, color, national origin, age, disability, gender identity or sex. 

BCBSVT provides free aids and services to people with disabilities to communicate effectively with us. We provide, for example, qualified sign language interpreters and written information in other formats (e.g., large print, audio or accessible electronic format).

BCBSVT provides free language services to people whose primary language is not English. We provide, for example, qualified interpreters and information written in other languages.

If you need these services, please call (800) 247-2583. If you would like to file a grievance because you believe that BCBSVT has failed to provide services or discriminated on the basis of race, color, national origin, age, disability, gender identity or sex, contact:

Civil Rights Coordinator
Blue Cross and Blue Shield of Vermont
PO Box 186
Montpelier, VT 05601
(802) 371-3394
TDD/TTY: (800) 535-2227
civilrightscoordinator@bcbsvt.com

You can file a grievance by mail, or email at the contacts above. If you need assistance, our civil rights coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human  Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
(800) 368-1019
(800) 537-7697 (TDD)

Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.