Notice of Privacy Practices and Compliance

• Privacy Notice (PDF)
• Nonpublic Personal Financial Information Policy (PDF)
• Electronic Communications Disclosure (PDF)
• Website and Mobile Privacy Policy (PDF)
  
  

En Espanol

• Privacy Notice – Spanish (PDF)
• Politica de Información Financiera Personal No Pública (PDF)

• Authorization to Disclose Information (PDF)
• Authorization to Disclose Information — Spanish (PDF)

Annual Notices/Reports—Commercial

• Member (PDF)
• Provider – New York (PDF)
• Provider – Vermont (PDF)
• Vermont Report (PDF)
  
  

Rate Filing—Narrative Summaries

• 2023 New York Individual HMO (PDF)
• 2023 New York Small Group HMO (PDF)
• 2023 New York Small Group EPO and PPO (PDF)
• 2023 New York Large Group HMO (PDF)
• 2022 New York Individual HMO (PDF)
• 2022 New York Small Group HMO (PDF)
• 2022 New York Small Group EPO and PPO (PDF)
• 2022 New York Large Group HMO (PDF)
  
  

Protocols for Domestic Violence and Endangered Victims

• Protocols for Domestic Violence Victims and Endangered Victims (PDF)
• Protocolos de Confidencialidad para Victimas de Violencia Domestica y Victimas en Peligro (PDF)
  
  

New York State Out-of-Network (OON) Law (Effective 3/30/15)

• Independent Dispute Resolution Process for Emergency and Surprise Bills—Member (PDF)
• Independent Dispute Resolution Process for Emergency and Surprise Bills—Health Care Providers (PDF)
• Out-of-Network Reimbursement Examples (PDF)

• NY No Surprises Act Disclosure Notice (PDF)
• VT No Surprises Act Disclosure Notice (PDF)

New York

Individual 

• FRNY EP 1&2 COC (2023) (PDF)
• FRNY EP 3&4 COC (2023) (PDF)
• FRNY44 INDV HMO COC 2023 CAT (PDF)
• FRNY44 INDV HMO COC 2023 CHILD ONLY (PDF)
• FRNY44 INDV HMO COC 2023 NSTD (PDF)
• FRNY44 INDV HMO COC 2023 NSTD AGG-EMB (PDF)
• FRNY44 INDV HMO COC 2023 NSTD PCP (PDF)
• FRNY44 INDV HMO COC 2023 STD (PDF)
• FRNY44 INDV HMO COC 2023 STD PCP (PDF)
• NY44 INDV HMO COC 2023 CAT (PDF)
• NY44 INDV HMO COC 2023 CHILD ONLY (PDF)
• NY44 INDV HMO COC 2023 NSTD (PDF)
• NY44 INDV HMO COC 2023 NSTD AGG-EMB (PDF)
• NY44 INDV HMO COC 2023 NSTD PCP (PDF)
• NY44 INDV HMO COC 2023 STD (PDF)
• NY44 INDV HMO COC 2023 STD PCP (PDF)

Small Group

• NY43 SG EPO COC 2023 (PDF)
• NY43 SG EPO COC 2023 AGG-EMB (PDF)
• NY43 SG EPO COC 2023 AGG-EMB-Q (NoFP) (PDF)
• NY43 SG EPO COC 2023 PCP (PDF)
• NY43 SG EPO COC 2023 PCP-Q (NoFP) (PDF)
• NY43 SG EPO COC 2023-Q (NoFP) (PDF)
• NY44 SG HMO COC 2023 (PDF)
• NY44 SG HMO COC 2023 AGG-EMB (PDF)
• NY44 SG HMO COC 2023 AGG-EMB-Q No FP (PDF)
• NY44 SG HMO COC 2023 HNY (PDF)
• NY44 SG HMO COC 2023 HNY-Q (NoFP) (PDF)
• NY44 SG HMO COC 2023 PCP (PDF)
• NY44 SG HMO COC 2023 PCP-Q (NoFP) (PDF)
• NY44 SG HMO COC 2023- Q (NoFP) (PDF)

Large Group

• NY43 EPO COC GF 2023 (PDF)
  
• NY43 PPO COC GF 2023 (PDF)
  
• NY43 HMOPOS COC GF 2023 (PDF)
  
• NY43 LG 7 EPO COC 2023 IntRX AGG (PDF)
  
• NY43 LG 7 EPO COC 2023 IntRX AggEmb (PDF)
  
• NY43 LG 7 EPO COC 2023 IntRX EMB (PDF)
  
• NY43 LG 7 EPO COC 2023 NoRX EMB (PDF)
  
• NY43 HMOPOS COC 2023 IntRX FP (PDF)
  
• NY43 HMOPOS COC 2023 NoRX FP (PDF)
  
• NY44 HMO COC GF 2023 (PDF)
  
• NY44 LG 7 HMO COC 2023 IntRX (PDF)
  
• NY44 LG 7 HMO COC 2023 NoRX (PDF)

Vermont

Small Group & Individual

• FRVT HMO HDHP NON-STANDARD CTR (2023) (PDF)
• FRVT HMO HDHP STANDARD CTR (2023) (PDF)
• FRVT HMO NON-STANDARD CTR (2023) (PDF)
• FRVT HMO STANDARD CTR (2023) (PDF)

Large Group

• VT 3 HMO 2023 COC (PDF)
• VT 3 HMO 2023 COC INTRX HDHP (PDF)
• VT 3 HMO 2023 COC INTRX NQHDHP (PDF)

Dental

Individual

• Individual Adult Dental COC 2023 (PDF)
• Individual Family Dental COC 2023 (PDF)
• Individual Pediatric Dental COC 2023 (PDF)

Small Group

• Small Group Adult Dental COC 2023 (PDF)
• Small Group Family Dental COC 2023 (PDF)
• Small Group Pediatric Dental COC 2023 (PDF)

frvt-hmo-standard-ctr-2022New York

Individual

• FRNY44 INDV HMO COC 2022 CAT (PDF)
• FRNY44 INDV HMO COC 2022 CHILD ONLY (PDF)
• FRNY44 INDV HMO COC 2022 NSTD (PDF)
• FRNY44 INDV HMO COC 2022 NSTD AGG-EMB (PDF)
• FRNY44 INDV HMO COC 2022 NSTD PCP (PDF)
• FRNY44 INDV HMO COC 2022 STD (PDF)
• FRNY44 INDV HMO COC 2022 STD PCP (PDF)
• NY44 INDV HMO COC 2022 CAT (PDF)
• NY44 INDV HMO COC 2022 CHILD ONLY (PDF)
• NY44 INDV HMO COC 2022 NSTD (PDF)
• NY44 INDV HMO COC 2022 NSTD AGG-EMB (PDF)
• NY44 INDV HMO COC 2022 NSTD PCP (PDF)
• NY44 INDV HMO COC 2022 STD (PDF)
• NY44 INDV HMO COC 2022 STD PCP (PDF)
• 2022 EP Subscriber Contract 1&2 (PDF)
• 2022 EP Subscriber Contract 3&4 (PDF)

Small Group

• NY43 SG EPO COC 2022 (PDF)
• NY43 SG EPO COC 2022-Q (NoFP) (PDF)
• NY43 SG EPO COC 2022 AGG-EMB (PDF)
• NY43 SG EPO COC 2022 AGG-EMB-Q (NoFP) (PDF)
• NY43 SG EPO COC 2022 PCP (PDF)
• NY43 SG EPO COC 2022 PCP-Q (NoFP) (PDF)
• NY44 SG HMO COC 2022 HNY (PDF)
• NY44 SG HMO COC 2022 HNY-Q (NoFP) (PDF)
• NY44 SG HMO COC 2022 (PDF)
• NY44 SG HMO COC 2022-Q (NoFP) (PDF)
• NY44 SG HMO COC 2022 AGG-EMB (PDF)
• NY44 SG HMO COC 2022 AGG-EMB-Q No FP (PDF)
• NY44 SG HMO COC 2022 PCP (PDF)
• NY44 SG HMO COC 2022 PCP-Q (NoFP) (PDF)

Large Group

• NY43 PPO COC GF 2022 (PDF)
  
• NY43 PPO COC GF NoFP 2022 (PDF)
  
• NY43 HDHP EPO COC GF 2022 (PDF)
  
• NY43 EPO COC GF 2022 (PDF)
  
• NY43 LG 7 EPO COC 2022 T1RX EMB (PDF)
  
• NY43 LG 7 EPO COC 2022 T1RX EMB NoFP (PDF)
  
• NY43 LG 7 EPO COC 2022 T1RX AggEmb (PDF)
  
• NY43 LG 7 EPO COC 2022 T1RX AggEmb NoFP (PDF)
• NY43 LG 7 EPO COC 2022 IntRX AGG (PDF)
  
• NY43 LG 7 EPO COC 2022 IntRX AGG NoFP (PDF)
  
• NY43 LG 7 EPO COC 2022 IntRX AggEmb (PDF)
  
• NY43 LG 7 EPO COC 2022 IntRX AggEmb NoFP (PDF)
  
• NY43 LG 7 EPO COC 2022 IntRX EMB (PDF)
  
• NY43 LG 7 EPO COC 2022 IntRX EMB NoFP (PDF)
• NY43 LG 7 EPO COC 2022 NoRX AGG (PDF)
  
• NY43 LG 7 EPO COC 2022 NoRX AGG NoFP (PDF)
  
• NY43 LG 7 EPO COC 2022 NoRX EMB (PDF)
  
• NY43 LG 7 EPO COC 2022 NoRX EMB NoFP (PDF)
  
• NY43 HMOPOS COC 2022 IntRX FP (PDF)
  
• NY43 HMOPOS COC 2022 IntRX NoFP (PDF)
• NY43 HMOPOS COC 2022 NoRX FP (PDF)
  
• NY43 HMOPOS COC 2022 NoRX NoFP (PDF)
  
• NY43 HMOPOS COC GF 2022 (PDF)
  
• NY44 HMO COC GF 2022 (PDF)
  
• NY44 LG 7 HMO COC 2022 IntRX (PDF)
  
• NY44 LG 7 HMO COC 2022 IntRX NoFP (PDF)
  
• NY44 LG 7 HMO COC 2022 NoRX (PDF)
  
• NY44 LG 7 HMO COC 2022 NoRX NoFP (PDF)

Vermont

Small Group and Individual

• FRVT HMO STANDARD CTR (2022) (PDF)
• FRVT HMO NON-STANDARD CTR (2022) (PDF)
• FRVT HMO HDHP STANDARD CTR (2022) (PDF)
• FRVT HMO HDHP NON-STANDARD CTR (2022) (PDF)

Large Group

• VT 3 HMO 2022 COC (PDF)
• VT 3 HMO 2022 COC INTRX HDHP (PDF)
• VT 3 HMO 2022 COC INTRX NQHDHP (PDF)

Individual

• Individual Adult NY PPO DD 003 A (PDF)
• Individual Family NY PPO DD 002 F (PDF)
• Individual Pediatric NY PPO DD 001 P (PDF)

Small Group

• Small Group Adult NY PPO SD 003 A (PDF)
• Small Group Family NY PPO SD 002 F (PDF)
• Small Group Pediatric NY PPO SD 001 P (PDF)

New York

• NY43 VISION CTR INDIVIDUAL 2022 (PDF)
• NY43 VISION COC GROUP 2022 SMALL (PDF)
• NY43 VISION COC GROUP 2022 LARGE (PDF)

Vermont

• VT44 VISION CTR INDIVIDUAL 2022 (PDF)
• VT44 VISION COC GROUP 2022 SMALL (PDF)
• VT44 VISION COC GROUP 2022 LARGE (PDF)

• Commercial Member Rights and Responsibilities (PDF)
  
• Medicaid Member Rights and Responsibilities (PDF)
  
• Medicare Member Rights and Responsibilities (PDF)