Broker Forms and Resources

• Employer Large Group Size Attestation
• Employer Large Group Size Attestation (Fillable)
• Large Group HMO Attestation
• Large Group HMO Attestation (Fillable) 

New York Large Group 

• New York Large Group Billing and Contact Form
• Enrollment/Change Form — New York Large Group

Vermont Large Group 

• Enrollment/Change Form — Vermont Group Plans

• Attestation for Eligibility For Small Group Products
• Attestation for Eligibility For Small Group Products (Fillable)
• Grandfathered Plan Status Certification
• Grandfathered Plan Status Certification (Fillable)

New York Small Group 

• New York Small Group Application HMO
• New York Small Group Application EPO/PPO
• New York Small Group Recertification Form (Fillable)
• Enrollment/Change Form — New York Small Group HMO
• Enrollment/Change Form — New York Small Group EPO/PPO

Healthy New York

• Healthy New York Small Group Application
• Healthy New York Small Group Recertification Form
• Healthy New York Small Group Recertification Form (Fillable)
• Enrollment/Change Form — Healthy New York

Vermont Small Group

• Vermont Small Group Application Form
• Vermont Small Group Recertification Form
• Vermont Small Group Recertification Form (Fillable)
• Enrollment/Change Form — Vermont Group Plan
• 2022 Vermont Small Group Plan Selection Form
• 2023 Vermont Small Group Plan Selection Form 

• 2022 Individual HSA Enrollment Packet
• One-Time Direct Payment Form

New York Individual 

• Enrollment/Change Form — New York Individual
• Dental Enrollment/Change Form — Individual 

Vermont Individual 

• Enrollment/Change Form — Vermont Individual 

See below for forms related to individual and employer group Medicare plans.

• Scope of Sales Appointment Confirmation Form (Static)
• Authorization to Disclose Information (ADI) Form
• Medicare Part D Comprehensive Formulary
• Plan Recommendation Tool
• Medicare Advantage Certification Course

Online Enrollment Tools 

• MVP Medicare Advantage and UVM Health Advantage plans
• SmartFund MSA
• MVP DualAccess (HMO D-SNP)

2023 Benefits at a Glance 

• Capital District/Central/Southern Tier Region
• Hudson Valley RegionMVP Medicare Secure Plus and Preferred Gold without Part D (HMO-POS)
• Rochester/Buffalo Region
• Optional Supplemental Dental Rider (All Regions) 

Supplemental Benefit Information

• SilverSneakers
• Eyewear Allowance
• TruHearing
• Mom's Meals
• GetSetUp

2023 Summary of Benefits

Capital District/Central/Southern Tier Region Plans

• MVP Medicare Secure and Preferred Gold with Part D (HMO-POS)
• MVP Medicare WellSelect Plus with Part D (PPO)

Vermont and Northern New York Region Plans

• UVM Health Advantage Preferred, Secure, and Select with Part D (PPO)
• MVP Medicare Secure Plus and Preferred Gold without Part D (HMO-POS)
• MVP Medicare WellSelect with Part D (PPO)

Hudson Valley Region Plans

• MVP Medicare Secure Plus and Preferred Gold without Part D (HMO-POS)
• MVP Medicare WellSelect and WellSelect Plus with Part D (PPO)
• MVP Medicare Patriot Plan with Part D (PPO)

Rochester/Buffalo Plans

• MVP Medicare Secure, Preferred Gold with Part D, and Preferred Gold without Part D (HMO-POS)
• MVP® Medicare WellSelect® with Part D (PPO)
• MVP Medicare Patriot Plan with Part D (PPO)

Other

• MVP DualAccess (HMO D-SNP)

2023 Enrollment Applications 

• Capital District/Central/Southern Tier Region
• Hudson Valley Region
• Rochester/Buffalo Region
• Vermont and Northern New York Region
• MVP DualAccess
• UVM Health Advantage

Medicare Star Ratings 

• MVP Medicare Secure (HMO-POS), MVP Medicare Secure Plus (HMO-POS), MVP Preferred Gold with Part D (HMO-POS), MVP Preferred Gold without Part D (HMO-POS), and MVP DualAccess (HMO D-SNP)
• MVP WellSelect with Part D (PPO), MVP WellSelect Plus with Part D (PPO), MVP Medicare Patriot Plan (PPO), UVM Health Advantage Preferred, Secure, and Select with Part D (PPO)
   

• Medicare Advantage Employer Handbook
• Medicare Advantage Certification Course
• Medicare Broker of Record Letter
• Medicare Group Comprehensive Part D Formulary