Forms

Collateral

• Download Helpful Information for You and Your Employer Groups

  • 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
  • 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)—An overview of the new 2017 benefit, that allows members to access health care professionals, 24/365 from their computer or mobile device
  • Treatment Cost Calculator (PDF)—An overview of MVP’s treatment calculator, helping employees search, review, and compare health services

  
  

Creditable Coverage

• 2018 Creditable Coverage Materials

  • Creditable Coverage Determinations 2018 (PDF)
  • Creditable Coverage Template Letter for Employers 2018 (PDF)
  • Non-Creditable Coverage Template Letter for Employers 2018 (PDF)
  • Overview of Creditable Coverage Information 2018 (PDF)

  
  

• 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

• Broker Administration Forms

  • Authorization to Disclose Information (PDF)
  • Broker of Record for Individuals (PDF)
  • Broker of Record Letter (PDF)
  • Medicare Advantage Certification Course (PDF)—Instructions on obtaining certification to sell MVP Health Care’s Advantage Employer Group Plans for the 2018 Plan Year
  • Medicare Broker of Record Letter (PDF)

  
  

• 2018 Enrollment/Change Forms

  • 2018 Enrollment/Change Form—NY Individual (PDF)
  • 2018 Enrollment/Change Form—NY Large Group (PDF)
  • 2018 Enrollment/Change Form—NY Small Group (PDF)
  • 2018 Enrollment/Change Form—VT Individual (PDF)
  • 2018 Enrollment/Change Form—VT Large Group (PDF)
  • 2018 Small Group Application—NY (PDF)
  • 2018 Small Group Application—VT (PDF)

  
  

• 2017 Enrollment/Change Forms

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

  • 2017 Enrollment/Change Form—NY Individual (PDF)
  • 2017 Enrollment/Change Form—NY Large Group (PDF)
  • 2017 Enrollment/Change Form—NY Small Group (PDF)
  • 2017 Enrollment/Change Form—VT Individual (PDF)
  • 2017 Enrollment/Change Form—VT Large Group (PDF)
  • 2017 Small Group Application—NY (PDF)
  • 2017 Small Group Application—VT (PDF)

  
  

• 2016 Enrollment/Change Forms

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

  • 2016 Enrollment/Change Form—Group Medicare (PDF)
  • 2016 Enrollment/Change Form—NY Individual (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)