ACA-Compliant Plans
Forms, Documents & Enrollment Materials
Companies with 1 to 50 Employees
For Employers
- CBIA Membership Application
- Eligibility Guidelines 1-50 Employees
- Enrollment Statement (for owners not appearing on UC5a)
- Employee Count Worksheet
- Direct Debit Form
- Binder Payment Form
- Open Enrollment Information
- Partial Month Termination Credit
- Registration for Online Account Access
- HealthEquity HRA/HSA Setup
For Employees
- Enrollment/Change Form 1-50 Employees
(for groups renewing January 2023 through May 2023) - Enrollment/Change Form 1-50 Employees
(for groups effective or renewing January 2022 through December 2022) - Waiver of Coverage Form
- Domestic Partner Affidavit
- Domestic Partner Termination
- Mail Order Pharmacy Form
- Prescription Drug Reimbursement Form
- Out of Network Reimbursement Form
- Personal Health Application (for amounts exceeding Guarantee Issue and late entrants)
- Application for Continuation of Coverage for a Disabled Dependent Child
- Authorization to Use or Disclose Protected Health Information
- Language and Non-Discrimination Notice
Companies with 51 or More Employees (non-medical coverages only)
For Employers
- CBIA Membership Application
- Eligibility Guidelines 51+ Employees
- Employer Participation Agreement 51+ Employees
- Enrollment Checklist 51+ Employees
For Employees
- Enrollment/Change Form 51+ Employees
- Waiver of Coverage Form
- Domestic Partner Affidavit
- Domestic Partner Termination
- Personal Health Application (for amounts exceeding Guarantee Issue and late entrants)
Life & Disability forms
Dental forms