Forms

General Employer Tools & Resources

• Employer Forms

  General

  • MVP Spending Account Application (PDF)
  • Health Benefits Administrator and Plan Sponsor Designation (PDF)

  New York

  • NY Small Group Silver 4 Application (PDF)
  • NY Vision Plan Selection Form (PDF)

  Vermont

  • VT Vision Plan Selection Form (PDF)

  
  

• Large Group Information

  General

  • MVP Core Analytics (PDF)

  New York Large Group

  • New York Large Group Billing & Contact Form (PDF)
  • Enrollment/Change Form — New York Large Group (PDF)

  Vermont Large Group

  • Enrollment/Change Form — Vermont Group Plans (PDF)

  
  

• Small Group Information

  New York Small Group

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

  Healthy New York

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

  Vermont Small Group

  • Vermont Small Group Application Form (PDF)
  • Vermont Small Group Recertification Form (PDF)
  • Enrollment/Change Form — Vermont Group Plan (PDF)
  • Vermont Small Group Plan Selection Form (PDF)

  
  

Creditable Coverage

• 2022 Creditable Coverage Materials

  • 2022 Creditable Coverage Determinations (PDF)
  • 2022 Creditable Coverage Template Letter for Employers (PDF)
  • 2022 Non-Creditable Coverage Template Letter for Employers (PDF)
  • 2022 Overview of Creditable Coverage Information (PDF)

  
  

• 2021 Creditable Coverage Materials

  • Creditable Coverage Determinations 2021 (PDF)
  • Creditable Coverage Template Letter for Employers 2021 (PDF)
  • Non-Creditable Coverage Template Letter for Employers 2021 (PDF)
  • Overview of Creditable Coverage Information 2021 (PDF)

  
  

• 2020 Creditable Coverage Materials

  • Creditable Coverage Determinations 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)

   

  
  

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)