Frequently Asked Questions

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View the list of preventive health services covered in full under federal health care reform.

View the list of services requiring prior authorization.

General FAQs

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.

    You may search for participating doctorshospitals and labs, and pharmacies.

    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 Provider (PCP)?

    Yes. If you chose a PCP as a required part of your health plan coverage, you may change your PCP at any time. Please 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 Provider (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

What’s covered?

  • 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.

  • 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.

  • 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 1-866-832-8077 .

  • What are Children and Family Treatment Support Services (CFTSS)?

  • What are “in lieu of services” (ILS)?

    New York State approves medically appropriate alternatives to some services included in your Medicaid Managed Care benefit package—these alternative services are called “in lieu of services” (ILS).

    What you should know about ILS:

    • Medicaid managed care plans can only offer an ILS if they have state approval.
    • ILS is voluntary. You do not have to use the ILS if you would rather have the regular covered Medicaid service.
    • ILS may be limited to members who meet certain criteria, limited in quantity or duration, and/or limited to a specific setting.
    • MVP may decide to stop offering the ILS. We will contact you if this happens.

    MVP is approved to offer the following In Lieu of Service (ILS)

    • Inpatient Psychiatric admission in an Institution for Mental Disease (IMD)

    Learn more information about ILS


Emergency and Coverage Away From Home

  • Am I covered by MVP when I am away from home?

    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.

    Medicaid Members:
    Services Outside of the United States
    If you travel outside of the United States, you can get urgent and emergency care only in the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. If you need medical care while in any other country, including Canada and Mexico, you will have to pay for it.

    Child Health Plus Members:
    Services Outside of the United States.
    We will not provide benefits for any services, including emergency services, provided outside of the United States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa or the countries of Canada and Mexico.

  • 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 doctorshospitals 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.

Need help?

  • 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:

    • Create an online member account for access to important plan information.
    • 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.

  • 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.

Prescription Drug Coverage

Get answers to your questions regarding prescription drug coverage.