Forms

Collateral

Download Helpful Information for You and Your Employees
- Medicare Advantage Employer Handbook
  Information to help manage Medicare Advantage health plans, including the ABC’s of Medicare, eligibility, enrollment and billing
  Download —Information to help manage Medicare Advantage health plans, including the ABC’s of Medicare, eligibility, enrollment and billing
- MVP Core Analytics
  Introducing MVP’s new reporting tool for qualifying employers
  Download —Introducing MVP’s new reporting tool for qualifying employers
- MVP Wellness Features
  An overview of online wellness tools and activities and programs to help your employees reach their health improvement goals
  Download —An overview of online wellness tools and activities and programs to help your employees reach their health improvement goals
- myMVP Mobile App
  An overview of MVP’s member app, providing access to important health plan information
  Download —An overview of MVP’s member app, providing access to important health plan information
- Pharmacy Benefits Overview
  A general summary of MVP’s 2017 pharmacy benefits and Pharmacy Benefits Manager, CVS/Caremark
  Download —A general summary of MVP’s 2017 pharmacy benefits and Pharmacy Benefits Manager, CVS/caremark®
- myVisitNow—24/7 Online Doctor Visits
  An overview of the new 2017 benefit, that allows members to access health care professionals, 24/365 from their computer or mobile device.
  Download —Key features of the new 2017 telemedicine benefit, that allows members to access health care professionals from a computer, tablet, or smartphone.
- Treatment Cost Calculator
  An overview of MVP’s treatment calculator, helping employees search, review, and compare health services
  Download —An overview of MVP’s treatment calculator, helping employees search, review, and compare health services

Creditable Coverage

2017 Creditable Coverage Materials
- Creditable Coverage Determinations 2017 Download
- Creditable Coverage Template Letter for Employers 2017 Download
- Non-Creditable Coverage Template Letter for Employers 2017 Download
- Overview of Creditable Coverage Information 2017 Download
2016 Creditable Coverage Materials
- Creditable Coverage Determinations 2016 Download
- Creditable Coverage Template Letter for Employers 2016 Download
- Non-Creditable Coverage Template Letter for Employers 2016 Download
- Overview of Creditable Coverage Information 2016 Download

Forms

2017 Enrollment/Change Forms
Download forms to enroll, make changes or cancel a health plan subscriber.
- 2017 Dental Enrollment/Change Form—Small Group Download
- 2017 Enrollment/Change Form—NY Large Group Download
- 2017 Enrollment/Change Form—NY Small Group Download
- 2017 Enrollment/Change Form—VT Large Group Download
- 2017 Small Group Application – NY Download
- 2017 Small Group Application - VT Download
- 2017 Group Medicare Enrollment Form Download
2016 Enrollment/Change Forms
Download forms to enroll, make changes or cancel a health plan subscriber.
- 2016 Dental Enrollment/Change Form—Small Group Download
- 2016 Enrollment/Change Form—Group Medicare
  Enroll, change, or cancel group Medicare subscribers
  Download
- 2016 Enrollment/Change Form—NY Large Group
  Enroll, change, or cancel health plan for NY subscribers
  Download
- 2016 Enrollment/Change Form—NY Small Group
  Enroll, change, or cancel health plan for NY subscribers
  Download
- 2016 Enrollment/Change Form—VT Large Group
  Enroll, change, or cancel health plan for VT subscribers
  Download

Product Placemats

2017 NY Small Group Off-Exchange Product Placemats
Download regional summaries of benefits and rates for Small Group Off-Exchange (Liberty) plans. Rates effective July 1, 2017 – September 30, 2017.
- Q3 2017 NY Liberty Plans—Albany (Off) Download
- Q3 2017 NY Liberty Plans—Buffalo (Off) Download
- Q3 2017 NY Liberty Plans—Mid-Hudson (Off) Download
- Q3 2017 NY Liberty Plans—New York City (Off) Download
- Q3 2017 NY Liberty Plans—Rochester (Off) Download
- Q3 2017 NY Liberty Plans—Syracuse (Off) Download
- Q3 2017 NY Liberty Plans—Utica/Watertown (Off) Download
Download regional summaries of benefits and rates for Small Group Off-Exchange (Liberty) plans. Rates effective October 1, 2017 – December 31, 2017.
- Q4 2017 NY Liberty Plans—Albany (Off)
  NY Liberty Plans at a glance for the Albany Region Off-Exchange
  Download
- Q4 2017 NY Liberty Plans—Buffalo (Off)
  NY Liberty Plans at a glance for the Buffalo Region Off-Exchange
  Download
- Q4 2017 NY Liberty Plans—Mid-Hudson (Off)
  NY Liberty Plans at a glance for the Mid-Hudson Region Off-Exchange
  Download
- Q4 2017 NY Liberty Plans—New York City (Off)
  NY Liberty Plans at a glance for the New York City Region Off-Exchange
  Download
- Q4 2017 NY Liberty Plans—Rochester (Off)
  NY Liberty Plans at a glance for the Rochester Region Off-Exchange
  Download
- Q4 2017 NY Liberty Plans—Syracuse (Off)
  NY Liberty Plans at a glance for the Syracuse Region Off-Exchange
  Download
- Q4 2017 NY Liberty Plans—Utica/Watertown (Off)
  NY Liberty Plans at a glance for the Utica/Watertown Region Off-Exchange
  Download
2017 NY Small Group On-Exchange Product Placemats
Download regional summaries of benefits and rates for Small Group On-Exchange (Premier) plans. Rates effective July 1, 2017 – September 30, 2017.
- Q3 2017 NY Premier Plans—Albany (On) Download
- Q3 2017 NY Premier Plans—Buffalo (On) Download
- Q3 2017 NY Premier Plans—Mid-Hudson (On) Download
- Q3 2017 NY Premier Plans—New York City (On) Download
- Q3 2017 NY Premier Plans—Rochester (On) Download
- Q3 2017 NY Premier Plans—Syracuse (On) Download
- Q3 2017 NY Premier Plans—Utica/Watertown (On) Download
Download regional summaries of benefits and rates for Small Group On-Exchange (Premier) plans. Rates effective October 1, 2017 – December 31, 2017.
- Q4 2017 NY Premier Plans—Albany (On)
  NY Premier Plans at a glance for the Albany Region On-Exchange
  Download
- Q4 2017 NY Premier Plans—Buffalo (On)
  NY Premier Plans at a glance for the Buffalo Region On-Exchange
  Download
- Q4 2017 NY Premier Plans—Mid-Hudson (On)
  NY Premier Plans at a glance for the Mid-Hudson Region On-Exchange
  Download
- Q4 2017 NY Premier Plans—New York City (On)
  NY Premier Plans at a glance for the New York City Region On-Exchange
  Download
- Q4 2017 NY Premier Plans—Rochester (On)
  NY Premier Plans at a glance for the Rochester Region On-Exchange
  Download
- Q4 2017 NY Premier Plans—Syracuse (On)
  NY Premier Plans at a glance for the Syracuse Region On-Exchange
  Download
- Q4 2017 NY Premier Plans—Utica/Watertown (On)
  NY Premier Plans at a glance for the Utica/Watertown Region On-Exchange
  Download
2017 VT Small Group and Individual Product Placemat
Download a summary of benefits and rates for Small Group and Individual plans. Rates effective January 1, 2017 – December 31, 2017.
- 2017 Vermont Plans Product Placemat Download