Need help?

• This information is available in other ways for people with disabilities or who need it translated into another language by calling 1-800-531-6685 (toll free). For TTY, call 711.
• Need help choosing a plan or completing this application?
  • For in-person help: Visit bluecrossmn.com/advisors to connect with a Blue Cross Advisor
  • If you work with an insurance agent/producer: Contact your agent/producer for assistance or call 1-800-531-6685 and a Blue Cross representative will be happy to assist you. Hours: 8 a.m. to 6 p.m. Central Time, Monday through Friday.

Who can enroll in the products on this application?

• You must be a resident of Minnesota. You must obtain our Residency Policy at bluecrossmn.com/residencypolicy or call 1-800-531-6685 and one of our Blue Cross representatives will be happy to assist you.
• If you are applying for new coverage as a contract holder, you must be over the age of 18. If you are under the age of 18, you must have a parent or guardian listed as the contract holder.
• If eligible, coverage will be provided under an individual contract. Blue Cross does not issue individual coverage through any arrangement with an employer.
• These plans do not meet the minimum essential health benefit requirements for pediatric oral health and pediatric vision coverage as required under the Affordable Care Act.

Who can pay my premium?

• Generally, you pay your own premium.
• Please note, Blue Cross may, in its sole discretion and in accordance with applicable law and regulatory guidance, decline to accept premium and cost-sharing payments made directly or indirectly by ineligible third parties. "Ineligible third parties" include any person or entity from which Blue Cross is not required by law to accept such third-party payments. This may include, for example, commercial entities, healthcare providers and suppliers, and other persons or entities with direct or indirect financial interests. "Payments" include those made by any means (e.g., cash, check, money order, credit card payment, electronic fund transfer, etc.). If you have questions about this third party payment policy or whether Blue Cross will accept premium and/or cost-sharing payments made by a specific person or entity, please contact Customer Service at 1-800-531-6685 before you complete this application.

How do I submit this application?

• Complete this entire application including all explanations as requested and all required documents.
• E-sign and date this application.
• Once submitted, please print a copy for your records.