Frequently Asked Questions
View the list of preventive health services covered in full under federal health care reform.
View the list of services requiring prior authroization.
- Prior Authorization (PDF)
Where is MVP offered?
MVP Health Care provides health insurance through employers and directly to individuals and sole proprietors in western and upstate New York, Vermont and New Hampshire. We offer health plans through the NY State of HealthTM Marketplace and the Vermont Health Connect Marketplace. Not all plan types are offered in all states or counties. See our service area maps for details.
Large Group Plans (101+ employees)
Small Group Plans (1-100 employees)
- NY Small Group On-Exchange HMO (PDF)
- NY Small Group Off-Exchange EPO/PPO (PDF)
- VT Small Group HMO (PDF)
Medicaid & Child Health Plus Plans
Medicare Advantage Plans
- HMO-POS—Employer Group (PDF)
- HMO-POS Plans—Direct Bill (PDF)
- MSA—Medical Savings Account (PDF)
- PPO—Employer Group (PDF)
- PPO Plans—Direct Bill (PDF)
What do I need to know about my MVP Member ID card?
Your MVP member identification (ID) card shows your plan type (sometimes called your “plan name”), group number, member number and basic payment information. On the back, you’ll find important contact information.
Within 14 days of your enrollment date, we’ll send you a welcome letter and your MVP Health Care ID card. Your card has your Primary Care Physician’s (PCP) name and phone number, and your client identification number on it. If there are any errors, call us right away. Show your MVP ID card each time you go for care.
Keep your card in a safe place. You will need to present it for services, and to reference information such as your Member ID number.
Seeing a Provider
How do I know what health care providers are in the MVP network and what I will pay out of my own pocket when I need care?
MVP offers many different health plans to meet the needs of employers and individuals. There are important differences between each of our health plans. Members may pay a co-pay or co-insurance toward a deductible for certain services. Health plans can include a network of health care providers that is local, regional (MVP’s service area includes New York, Vermont and New Hampshire), or national. Ask your employer or look at your health plan materials for more information about your network, benefits, out-of-pocket costs and other important details.
If you have any specific questions about using your MVP benefits, please call 1-888-687-6277 .
Can I go to any doctor or hospital I want, or must I use MVP-participating doctors and hospitals?
MVP has made arrangements with a large number of physicians, hospitals, laboratories and other health care organizations to provide services to our members. When you use a health care provider who is part of the MVP network (in-network), your health plan benefits will be applied to the cost of the medical care you get.
Some health plans include coverage for medical care you get from health care providers who are not part of the MVP network. These are called “out-of-network benefits”. If your health plan does not include out-of-network benefits, the MVP Medical Director may make arrangements for you to receive care with non-participating physicians and/or hospitals when it is medically necessary. In such cases, prior written approval must be obtained.
Also, MVP will cover emergency care for members at non-participating hospitals or health care facilities, but you must seek any necessary follow-up care from MVP-participating providers.
For coverage details, please look at your health plan materials or ask your employer if your health plan has out-of-network benefits.
Can I change my Primary Care Physician (PCP)?
Yes. If you chose a PCP as a required part of your health plan coverage, you may change your PCP at any time. Simply sign in to your account to change your PCP or call the Customer Care Center at the phone number on the back of your Member ID card.
Do I have to contact my Primary Care Physician (PCP) and request a referral before I see a specialist?
MVP plans do not require referrals for specialists. Whether or not your health plan requires you to choose a PCP to coordinate your care, it is a good idea to talk with your doctor about any medical concern you have. Your doctor may then offer treatment or help you by recommending a specialist (not a formal referral).
Do women who enroll in MVP need to choose an Obstetrician/Gynecologist (OB/GYN)?
You may see any MVP-participating OB/GYN for appropriate, covered services without a referral from a PCP. Some MVP-participating OB/GYNs are also listed as Primary Care Physicians; you can choose to select one of them as your PCP. Visit our Doctor Search to find an OB/GYN or PCP.
How can I enhance communications with my providers?
Written or verbal communication between Primary Care Physicians (PCPs), specialists and other practitioners helps provide effective follow-up care and improved patient safety.
Here are some tips that you can follow to help facilitate this process:
- Always keep the name, phone number and address of your PCP handy. Even if the information is not asked for, offer to provide this information to other health care professionals you see.
- Ask your health care professionals to send pertinent information to your PCP.
- Keep copies of the following items from your medical record and bring them to each office visit in case the practitioner has not obtained them from your PCP:
- Medication list
- Recent physical exam
- Important test results
How can I get help choosing the right hospital or facility?
There are several organizations that collect information on hospital quality efforts to help patients make informed decisions about where to receive care:
- The Leapfrog Group—Promotes improvement in hospital safety and an informed health care consumer
- Institute for Healthcare Improvement—Focuses on safe and effective health care, working with health care providers and leaders throughout the world
- Home Health Compare—Allows an individual to compare the quality of care provided by home health agencies
- Nursing Home Compare—Allows an individual to compare the quality of care provided by nursing homes
- The Joint Commission—Obtains information about accredited organizations not only through direct observations by its employees but also through direct communications from those accredited organizations and from measurement companies hired by accredited organizations and accepted by The Joint Commission as sources for performance measure data
- Hospital Report Cards—Available to compare hospitals in Vermont in various categories that include quality, patient satisfaction and finances
My plan includes preferred provider facilities. What are these facilities and where do I find them?
MVP’s preferred provider facilities can help you save money on ambulatory/outpatient surgery, laboratory, and radiology services.
If you have a deductible, medically necessary and covered services at one of these facilities are covered in full once your deductible is met.
- Learn more about MVP Preferred Provider Facilities (PDF)
For a listing of preferred provider facilities, select Find a Doctor on the top menu bar, and select Find a Facility. The listing is located on the right side of the page under Additional Resources.
24/7 Online Doctor Visits
What is MVP’s new myVisitNow service?
Beginning January 1, 2017, MVP will offer a new benefit—myVisitNow, covering 24/7 online doctor visits—to eligible MVP members, upon renewal. Eligible MVP members will be able to access doctors and other health care professionals—including behavioral health specialists, dieticians, and lactation consultants—from across the country, through a mobile device or computer with a web camera.
Who can access this benefit?
Beginning January 1, 2017, MVP members of fully insured plans will be able to access the benefit, upon renewal. Please note, VT Small Group and Individual plans are an exception and will include this benefit upon renewal, beginning January 1, 2018.
MVP will also be including this benefit in Medicare, Medicaid, and Essential Plans upon renewal, beginning January 1, 2017 (some restrictions apply), and self-funded (ASO) groups may choose to add this benefit at an additional cost.
How do I access the service?
Visit the myVisitNow website listed on the back of your MVP Member ID card to register and get started.
What can myVisitNow be used for?
If your plan offers myVisitNow, you can use it to access non-emergency care, keeping in mind it is not intended to replace your Primary Care Physician (PCP). Most common urgent care and behavioral diagnoses include: sinusitis, upper respiratory infections/flu, pharyngitis, skin disorders, Urinary Tract Infections (UTI), bronchitis, conjunctivitis, earache, back pain, stress, mood disorders, insomnia, and eating disorders.
What does each visit cost?
For fully insured plans, Medicare plans and Essential Plans, in general, the cost for a visit will follow the same cost share as a sick visit to a PCP. For self-funded (ASO) plan members, the cost will be customized by group. For members of fully insured plans, Essential Plans, and Medicaid plans, lactation consultations will be available at no cost.
For high deductible health plan (HDHP) members who have not yet met their annual deductible, urgent care visits are $39; behavioral health visits are $79 or $95 (for visits with Masters- or Doctorate-level providers, respectively); and nutrition consultations are $25.
Medicaid members will be able to access the benefit at no cost.
How do I pay for each visit?
The first time you sign in to myVisitNow to access care, you will be required to provide credit card information in order to pay for the visit. You will be presented with the cost before the visit begins. Once you authorize the payment, you will be directed to the virtual “waiting room” before your visit begins. Members who have a card tied to a Health Savings Account (HSA) can use it as a form of payment like any debit/credit card.
Following your visit, a claim will be generated, and you’ll receive an Explanation of Benefits (EOB) from MVP. If you have questions on myVisitNow billing or claims, you can call the MVP Customer Care Center listed on the back of your MVP Member ID card.
myVisitNow from MVP Health Care is powered by American Well. It is available upon renewal and is subject to regulatory approval and regulatory restrictions. It is not available with Vermont Individual and Vermont Small Group plans, and restrictions apply to Medicare and other government programs.
What preventive health services are covered in full as part of my plan?
The Affordable Care Act (ACA) is about insuring more preventive health services for more Americans. MVP Health Care is committed to implementing all provisions of the health care reform law and working to create the healthiest communities in the nation.
What is an Explanation of Benefits (EOB)?
An EOB is a document to keep you informed of the health care claims that have been submitted on your behalf. You will receive an EOB after a claim for health care service has been received and processed. It shows what your health plan has paid to the provider, what the health plan has reimbursed to you (if applicable), any financial responsibility you may have for services provided, and if services were not paid for by your health plan. Please note, this is not a bill.
You have the option to sign up to receive electronic EOBs, which means less mail from MVP delivered to your home. Once you sign up for eEOBs, you will receive an email notification when your Explanation of Benefits is available to view online instead of receiving the paper copy in the mail. This feature provides easier access to your documents when you need them, if you have access to a computer. The paperless option applies to EOB related to medical and dental claims only. To sign up, Sign In/Register to your MVP online account and select Claims Status & History under Your Plan.
What dental plan options are available through MVP Health Care?
MVP offers Individual and Small Group dental plan options for kids, families, and adults! Learn more about our dental plans and rates.
Emergency and Coverage Away From Home
Am I covered by MVP when I am away from home?
MVP members have 24-hour worldwide emergency coverage. If you have a medical emergency while you are outside the service area, you should seek care from the nearest doctor or hospital emergency room. Please let MVP know about the emergency within 48 hours, or as soon as physically possible.
MVP reserves the right to retrospectively determine if the visit is of an emergency nature. In plain language, MVP can look at information from your emergency room visit after you are treated there and let you know that your care will not be covered as emergency care. Please look at your plan materials or ask your employer for details about your emergency coverage, including deductibles or co-pays.
For non-emergency medical needs when you are traveling outside the MVP service area, please call 1-888-687-6277 to talk with the Customer Care Center about what to do.
If I know I need care, but it's not really an emergency—what should I do?
For medical help, you often have less expensive, more convenient options than the emergency room:
- Call Your Doctor—many practices offer urgent appointments! Need a doctor? Call 1-888-687-6277 and we will help you find one.
- Get Help From a Registered Nurse For Free—24 hours a day, 7 days a week. Call our Customer Care Center at 1-888-687-6277 , or sign in to your member account to email us. Already logged in? Use our secure online form to get a response from a nurse within 24 hours.
- If Your Doctor is Not Available—consider an urgent care center for sore throats, headaches, sprains or strains, minor cuts or burns, the flu and more—you will pay less (and usually wait less) than at the emergency room. Check our Doctor Search for a list of in-network Urgent Care Centers near you.
If you think you need immediate life-saving care, you should go to the emergency room.
Does MVP cover my kids when they’re away at college?
If your employer’s plan provides benefits for covered dependents when they’re away at college, your children will be covered for sick care and emergencies—just as they would be when they’re at home.
You may need to submit a Medical or Dental College Student Waiver Form and make sure that your children seek care from health care providers in MVP’s national network, depending on the details of your plan. Please look at your plan materials or ask your employer for more information. You can search for participating doctors, hospitals and labs, and pharmacies.
Health Management Programs
What if I need a little extra help managing a medical condition?
MVP offers free condition management programs to help you. We invite you to learn about these programs and contact us to see if you qualify.
How can I get more information or answers to questions about my own situation?
We make it easy to get in touch with our Customer Care Center for more information about MVP. We also can help you get answers to your questions. Here is how you can contact us:
- Call the Customer Care Center. You can find the phone number on the Contact Us page of our website or on the back of your Member ID card.
- Send us an email. To make sure that your personal health information is safe, please use our secure email form to email the Customer Care Center.
- Try our Live Chat feature.
If I get a bill for medical services that I don’t understand, what should I do?
Please call the Customer Care Center at the phone number on the back of your Member ID card if you have questions about a bill.
How can I get help to understand some of the health plan or medical words that I see in communications from MVP?
If you have questions about a communication from MVP, you can use our glossary or please call the Customer Care Center at the phone number on the back of your Member ID card.
What is a generic drug?
A generic drug is a copy that is the same as a brand-name drug in dosage, safety, strength, how it is taken, quality, performance, and intended use. For example, ibuprofen is the generic for both Motrin® and Advil®.
What if my physician does not write the prescription so I can get a generic drug?
While the use of generic drugs is encouraged to help you save money, you are not required to receive a generic drug. You will pay more for brand name drugs when there is a generic equivalent available. Generally, generic drugs are covered at your lowest tier co-payment and brand name drugs that have a generic equivalent are covered at your highest tier co-payment. If your physician feels that a brand name drug is the right choice for you, you will have a higher tier co-payment. Some of MVP’s prescription benefits may require you to pay the difference in cost between the generic and the brand name drug plus your Tier 1 co-payment if you receive a brand name drug when there is a generic equivalent available.
Can I order prescriptions through the mail?
If your benefit allows, medications that are taken on a regular basis, including contraceptives, thyroid medications, cholesterol and blood pressure medications, and many more, are available by mail order. CVS Caremark® is MVP’s contracted Pharmacy Benefit Manager and also our mail order pharmacy vendor.
Using the mail order pharmacy lets you buy MVP-approved maintenance drugs in larger quantities and, at the same time, save trips to the pharmacy because prescriptions are delivered right to your door. Your co-pay for a 90-day supply of medication will generally be less than going to a retail pharmacy for the same amount of medication. You can refer to the MVP Formulary to identify which medications are available through your mail order benefit.
Are there any additional requirements on prescription drugs?
For certain prescription drugs, MVP Health Care has additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our health plans to help us provide quality coverage to our members. Certain drugs may need prior authorization, have a formulary exception, or require step therapy. Quantity limits may also apply. If you have questions on additional drug requirements, call the phone number listed on the back of your MVP Member ID card.
Are my prescriptions covered by MVP?
If you have prescription drug coverage with MVP, you are covered for all prescriptions on your plan’s approved list of medications. In cases where we do not cover a certain drug, we usually cover an alternative drug that does the same thing but may cost less.
Review our Drug Coverage (Formularies) to find a specific drug on this list, which is called a formulary. The medication you need may require prior authorization or be subject to step therapy or quantity limits. This information can also be found on the formulary. You may have a co-pay, co-insurance or deductible to pay out of your own pocket for prescriptions. Please look at your health plan materials.
What is a formulary?
A formulary is an extensive list of drugs, both generic and name brand, that are covered by MVP Health Care for plans that offer prescription drug coverage. Each formulary is a comprehensive guide that is developed based on sound clinical evidence and is a reflection of current treatment guidelines and community practice standards.
How do I obtain specialty drugs?
Some prescription drugs must be obtained through CVS Specialty. CVS Specialty handles high touch, high cost drugs for unique and complex medical conditions and delivers them to your doorstep. To find out if your drug is one of the drugs required to be obtained through CVS Specialty, please review the formulary for your prescription plan type.
Note: MVP Medicaid Members may use CVS Specialty to obtain high-cost specialty drugs by mail. If you would prefer to obtain your specialty drugs at a local retail pharmacy, please call the pharmacy information number on the back of your ID card to get a listing of pharmacies in the MVP specialty network. Please note that prior authorization must be obtained, if required, prior to filling the specialty prescription at a network retail pharmacy or CVS Specialty.
High-deductible Health Plans
Get answers to your questions regarding high-deductible health plans.
Prescription Drug Coverage
Get answers to your questions regarding prescription drug coverage.