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
- 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)—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
2017 Creditable Coverage Materials
2016 Creditable Coverage Materials
Documents
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 2017 Plan Year
- Medicare Broker of Record Letter (PDF)
Forms
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)
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 April 1, 2017 — June 30, 2017.
- Q2 2017 NY Liberty Plans—Albany (Off) (PDF)
- Q2 2017 NY Liberty Plans—Buffalo (Off) (PDF)
- Q2 2017 NY Liberty Plans—Mid-Hudson (Off) (PDF)
- Q2 2017 NY Liberty Plans—New York City (Off) (PDF)
- Q2 2017 NY Liberty Plans—Rochester (Off) (PDF)
- Q2 2017 NY Liberty Plans—Syracuse (Off) (PDF)
- Q2 2017 NY Liberty Plans—Utica/Watertown (Off) (PDF)
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)
2017 NY Individual Off-Exchange Product Placemats
Download regional summaries of benefits and rates for Individual Off-Exchange (Premier) plans. Rates effective January 1, 2017 – December 31, 2017.
- 2017 NY Premier Individual Plans—Albany (Off) (PDF)
- 2017 NY Premier Individual Plans—Buffalo (Off) (PDF)
- 2017 NY Premier Individual Plans—Mid-Hudson (Off) (PDF)
- 2017 NY Premier Individual Plans—New York City (Off) (PDF)
- 2017 NY Premier Individual Plans—Rochester (Off) (PDF)
- 2017 NY Premier Individual Plans—Syracuse (Off) (PDF)
- 2017 NY Premier Individual Plans—Utica/Watertown (Off) (PDF)
2017 NY Small Group On-Exchange Product Placemats
Download regional summaries of benefits and rates for Small Group Off-Exchange (Liberty) plans. Rates effective April 1, 2017 — June 30, 2017.
- Q2 2017 NY Premier Plans—Albany (On) (PDF)
- Q2 2017 NY Premier Plans—Buffalo (On) (PDF)
- Q2 2017 NY Premier Plans—Mid-Hudson (On) (PDF)
- Q2 2017 NY Premier Plans—New York City (On) (PDF)
- Q2 2017 NY Premier Plans—Rochester (On) (PDF)
- Q2 2017 NY Premier Plan Plans—Syracuse (On) (PDF)
- Q2 2017 NY Premier Plan Plans—Utica/Watertown (On) (PDF)
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)
2017 NY Individual On-Exchange Product Placemats
Download regional summaries of benefits and rates for Individual On-Exchange (Premier) plans. Rates effective January 1, 2017 – December 31, 2017.
- 2017 NY Premier Individual Plans—Albany (On) (PDF)
- 2017 NY Premier Individual Plans—Buffalo (On) (PDF)
- 2017 NY Premier Individual Plans—Mid-Hudson (On) (PDF)
- 2017 NY Premier Individual Plans—New York City (On) (PDF)
- 2017 NY Premier Individual Plans—Rochester (On) (PDF)
- 2017 NY Premier Individual Plans—Syracuse (On) (PDF)
- 2017 NY Premier Individual 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.