Participating employers are asked to select one option from each group: Employee Only, Employee Plus 1 / Employee Plus Child(ren), and Family. Options for each group, along with explanations regarding how these cost tiers were developed, are outlined in this reference document.

Fill out one form per legal entity; parishes with schools must make the same contribution elections for both (under the Parish Corp ID). Note: as the cost for Employee Plus 1 and Employee Plus Child(ren) are the same, this year participating employers will select one contribution amount that will apply to both groups.

Please complete the 2020 Contribution Election Form below and submit by Friday, August 23.


  • Participating Employer Contact Information

  • This is the email address at which you will receive a cost-listing sheet confirming your elections.
  • Contribution Elections for BlueCross and BlueShield of Minnesota Health Plans

    Please select one amount per group listed below. The amounts represent the contribution to be paid by the employer.
    *All applicable large employers (ALEs) with 50 or more full-time equivalents (FTEs) must contribute $571.00 or more for each benefit-eligible employee, in order to comply with Affordable Care Act (ACA) requirements for the Federal Poverty Line Safe Harbor. **If the employer elects the $779.00 cost-share level for employee only coverage, and an employee elects Option 3 or 4, the cost-share will default to $671.00 or $718.00, respectively (100% of the employee only premium).
  • Contribution Elections for Delta Dental Plans

    Please select one amount per group listed below. The amounts represent the contribution to be paid by the employer. Participating employers may not opt out of dental coverage.
  • Authorization