Forms

General Employer Tools & Resources

• Employer Forms

  • 2019 NY Small Group Silver 4 Application (PDF)
  • 2019 MVP Spending Account Application (PDF)
  • 2020 NY Small Group Silver 4 Application (PDF)
  • 2020 MVP Spending Account Application (PDF)

  
  

• Large Group Information

  • New York Large Group Billing & Contact Form (PDF)
  • Enrollment/Change Form—New York Large Group (PDF)
  • Enrollment/Change Form—Vermont Group Plans (PDF)
  • MVP Core Analytics (PDF)

  
  

• Small Group Information

  • New York Small Group Application HMO (PDF)
  • Enrollment/Change Form—New York Small Group HMO (PDF)
  • New York Small Group Application EPO/PPO (PDF)
  • Enrollment/Change Form—New York Small Group EPO/PPO (PDF)
  • Enrollment/Change Form—Vermont Group Plans (PDF)
  • Vermont Group Plan Enrollment Form (PDF)
  • New York Small Group Recertification Form (PDF)
  • Vermont Small Group Recertification Form (PDF)
  • Healthy New York Recertification Form (PDF)

  
  

Creditable Coverage

• 2020 Creditable Coverage Materials

  • Creditable Coverage Determinations 2020 (PDF)
  • Creditable Coverage Template Letter for Employers 2020 (PDF)
  • Non-Creditable Coverage Template Letter for Employers 2020 (PDF)
  • Overview of Creditable Coverage Information 2020 (PDF)

  
  

• 2019 Creditable Coverage Materials

  • Creditable Coverage Determinations 2019 (PDF)
  • Creditable Coverage Template Letter for Employers 2019 (PDF)
  • Non-Creditable Coverage Template Letter for Employers 2019 (PDF)
  • Overview of Creditable Coverage Information 2019 (PDF)

   

  
  

• 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)

  
  

Medicare Employer Tools & Resources

• Medicare Group Information

  • Medicare Advantage Employer Handbook (PDF)
  • Medicare Group Comprehensive Part D Formulary (PDF)
  • Medicare Actively Employed Information Form (PDF)
  • Medicare Employer Group Enrollment Form (PDF)