Forms

Collateral

• Download Helpful Information for You and Your Employees

  • 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 pharmacy benefits and Pharmacy Benefits Manager, CVS Caremark®
  • myVisitNow®—24/7 Online Doctor Visits (PDF)—Key features of the telemedicine benefits that allows members to access health care professionals from a smartphone, tablet, or computer with a web cam
  • Treatment Cost Calculator (PDF)—An overview of MVP’s treatment calculator, helping employees search, review, and compare health services

  
  

Creditable Coverage

• 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)

  
  

• 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

• 2019 Enrollment/Change Forms

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

  • 2019 Enrollment/Change Form—New York Individual (PDF)
  • 2019 Enrollment/Change Form—New York Large Group (PDF)
  • 2019 Enrollment/Change Form—New York Small Group HMO (PDF)
  • 2019 Enrollment/Change Form—New York Small Group EPO/PPO (PDF)
  • 2019 Enrollment/Change Form—Vermont Individual (PDF)
  • 2019 Enrollment/Change Form—Vermont Group Plans (PDF)
  • 2019 Vermont Small Group Application (PDF)
  • 2019 Group Medicare Enrollment Form (PDF)

  
  

• 2018 Enrollment/Change Forms

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

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

  
  

• Medicare Actively Employed Information Form

  • Medicare Actively Employed Information Form (PDF)