Individual & Family Direct-Enrollment Form

Things to know or have handy before you start:

• If you choose to direct enroll through us, Blue Cross and Blue Shield of Vermont, you are not eligible for any subsidies (like premium tax credits, reduced cost-sharing plans or Vermont premium assistance). Please use the Vermont Health Connect Subsidy Estimator to see if you may be eligible for subsidies before proceeding.
• Determine what Qualified Health Plan (QHP) you would like to enroll in for 2021 coverage. Not sure? Use our Find a Plan Tool to see what plan best meets your needs.
• Social security numbers (SSNs) for you and any covered dependents. NOTE: SSNs will NOT appear on any outgoing material, including your ID card. This number is only used required reporting to the federal government.
• If you or any of your covered dependents will be covered with additional health (including Medicare or Medicaid) or dental insurance, you will need to supply the following information:
  • company name and address
  • policy holder name
  • policy number
  • effective date
  • type of coverage