Forms

Collateral

• Download Helpful Information for You and Your Employees

  • Medicare Advantage Employer Handbook (PDF)—Information to help manage Medicare Advantage health plans, including the ABC’s of Medicare, eligibility, enrollment and billing
  • MVP Core Analytics (PDF)—Introducing MVP’s new reporting tool for qualifying employers
  • MVP Wellness Features (PDF)—An overview of online wellness tools and activities and programs to help your employees reach their health improvement goals
  • myMVP Mobile App (PDF)—An overview of MVP’s member app, providing access to important health plan information
  • Pharmacy Benefits Overview (PDF)—A general summary of MVP’s 2017 pharmacy benefits and Pharmacy Benefits Manager, CVS/caremark®
  • myVisitNow—24/7 Online Doctor Visits (PDF)—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 (PDF)—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 (PDF)
  • Creditable Coverage Template Letter for Employers 2017 (DOCX)
  • Non-Creditable Coverage Template Letter for Employers 2017 (DOCX)
  • Overview of Creditable Coverage Information 2017 (PDF)

  
  

• 2016 Creditable Coverage Materials

  • Creditable Coverage Determinations 2016 (PDF)
  • Creditable Coverage Template Letter for Employers 2016 (DOCX)
  • Non-Creditable Coverage Template Letter for Employers 2016 (DOCX)
  • Overview of Creditable Coverage Information 2016 (PDF)

  
  

Forms

• 2017 Enrollment/Change Forms

  Download forms to enroll, make changes or cancel a health plan subscriber.

  • 2017 Dental Enrollment/Change Form—Small Group (PDF)
  • 2017 Enrollment/Change Form—NY Large Group (PDF)
  • 2017 Enrollment/Change Form—NY Small Group (PDF)
  • 2017 Enrollment/Change Form—VT Large Group (PDF)
  • 2017 Small Group Application – NY (PDF)
  • 2017 Small Group Application - VT (PDF)
  • 2017 Group Medicare Enrollment Form (PDF)

  
  

• 2016 Enrollment/Change Forms

  Download forms to enroll, make changes or cancel a health plan subscriber.

  • 2016 Dental Enrollment/Change Form—Small Group (PDF)
  • 2016 Enrollment/Change Form—Group Medicare (PDF)
  • 2016 Enrollment/Change Form—NY Large Group (PDF)
  • 2016 Enrollment/Change Form—NY Small Group (PDF)
  • 2016 Enrollment/Change Form—VT Large Group (PDF)

  
  

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) (PDF)
  • Q3 2017 NY Liberty Plans—Buffalo (Off) (PDF)
  • Q3 2017 NY Liberty Plans—Mid-Hudson (Off) (PDF)
  • Q3 2017 NY Liberty Plans—New York City (Off) (PDF)
  • Q3 2017 NY Liberty Plans—Rochester (Off) (PDF)
  • Q3 2017 NY Liberty Plans—Syracuse (Off) (PDF)
  • Q3 2017 NY Liberty Plans—Utica/Watertown (Off) (PDF)

  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) (PDF)
  • Q4 2017 NY Liberty Plans—Buffalo (Off) (PDF)
  • Q4 2017 NY Liberty Plans—Mid-Hudson (Off) (PDF)
  • Q4 2017 NY Liberty Plans—New York City (Off) (PDF)
  • Q4 2017 NY Liberty Plans—Rochester (Off) (PDF)
  • Q4 2017 NY Liberty Plans—Syracuse (Off) (PDF)
  • Q4 2017 NY Liberty Plans—Utica/Watertown (Off) (PDF)

  
  

• 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) (PDF)
  • Q3 2017 NY Premier Plans—Buffalo (On) (PDF)
  • Q3 2017 NY Premier Plans—Mid-Hudson (On) (PDF)
  • Q3 2017 NY Premier Plans—New York City (On) (PDF)
  • Q3 2017 NY Premier Plans—Rochester (On) (PDF)
  • Q3 2017 NY Premier Plans—Syracuse (On) (PDF)
  • Q3 2017 NY Premier Plans—Utica/Watertown (On) (PDF)

  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) (PDF)
  • Q4 2017 NY Premier Plans—Buffalo (On) (PDF)
  • Q4 2017 NY Premier Plans—Mid-Hudson (On) (PDF)
  • Q4 2017 NY Premier Plans—New York City (On) (PDF)
  • Q4 2017 NY Premier Plans—Rochester (On) (PDF)
  • Q4 2017 NY Premier Plans—Syracuse (On) (PDF)
  • Q4 2017 NY Premier Plans—Utica/Watertown (On) (PDF)

  
  

• 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 (PDF)