Individual Direct Enroll 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 2019 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