Privacy Notices
- Privacy Notice (PDF) — MVP’s Privacy Notice has been updated to reflect: Disclosures to a third-party application. You may direct MVP to provide specific information it maintains about you, including health information, through a third-party application chosen by you. If so, MVP may disclose your information to one or more third party applications as directed by you. Review PDF for the full Privacy Notice.
- Privacy Notice – Spanish (PDF)
- Nonpublic Personal Financial Information Policy (PDF)
- Politica de Información Financiera Personal No Pública (PDF)
- Electronic Communications Disclosure (PDF)
Forms
Legal Notices/Reports
Annual Notices/Reports—Commercial
- Member (PDF)
- Provider – New York (PDF)
- Provider – Vermont (PDF)
- VT Report (PDF)
Rate Filing—Narrative Summaries
- 2022 New York Individual HMO (PDF)
- 2022 New York Small Group HMO (PDF)
- 2022 New York Small Group EPO and PPO (PDF)
- 2022 New York Large Group HMO (PDF)
Protocols for Domestic Violence and Endangered Victims
- Protocols for Domestic Violence Victims and Endangered Victims (PDF)
- Protocolos de Confidencialidad para Victimas de Violencia Domestica y Victimas en Peligro (PDF)
New York State Out-of-Network (OON) Law (Effective 3/30/15)
- Independent Dispute Resolution Process for Emergency and Surprise Bills—Member (PDF)
- Independent Dispute Resolution Process for Emergency and Surprise Bills—Health Care Providers (PDF)
- Out-of-Network Reimbursement Examples (PDF)
2022 Certificates of Coverage (COC)
New York
Individual- FRNY44 INDV HMO COC 2022 CAT (PDF)
- FRNY44 INDV HMO COC 2022 CHILD ONLY (PDF)
- FRNY44 INDV HMO COC 2022 NSTD (PDF)
- FRNY44 INDV HMO COC 2022 NSTD AGG-EMB (PDF)
- FRNY44 INDV HMO COC 2022 NSTD PCP (PDF)
- FRNY44 INDV HMO COC 2022 STD (PDF)
- FRNY44 INDV HMO COC 2022 STD PCP (PDF)
- NY44 INDV HMO COC 2022 CAT (PDF)
- NY44 INDV HMO COC 2022 CHILD ONLY (PDF)
- NY44 INDV HMO COC 2022 NSTD (PDF)
- NY44 INDV HMO COC 2022 NSTD AGG-EMB (PDF)
- NY44 INDV HMO COC 2022 NSTD PCP (PDF)
- NY44 INDV HMO COC 2022 STD (PDF)
- NY44 INDV HMO COC 2022 STD PCP (PDF)
- 2022 EP Subscriber Contract 1&2 (PDF)
- 2022 EP Subscriber Contract 3&4 (PDF)
Small Group
- NY43 SG EPO COC 2022 (PDF)
- NY43 SG EPO COC 2022-Q (NoFP) (PDF)
- NY43 SG EPO COC 2022 AGG-EMB (PDF)
- NY43 SG EPO COC 2022 AGG-EMB-Q (NoFP) (PDF)
- NY43 SG EPO COC 2022 PCP (PDF)
- NY43 SG EPO COC 2022 PCP-Q (NoFP) (PDF)
- NY44 SG HMO COC 2022 HNY (PDF)
- NY44 SG HMO COC 2022 HNY-Q (NoFP) (PDF)
Large Group
- NY43 PPO COC GF 2022 (PDF)
- NY43 PPO COC GF NoFP 2022 (PDF)
- NY43 HDHP EPO COC GF 2022 (PDF)
- NY43 EPO COC GF 2022 (PDF)
- NY43 LG 7 EPO COC 2022 T1RX EMB (PDF)
- NY43 LG 7 EPO COC 2022 T1RX EMB NoFP (PDF)
- NY43 LG 7 EPO COC 2022 T1RX AggEmb (PDF)
- NY43 LG 7 EPO COC 2022 T1RX AggEmb NoFP (PDF)
- NY43 LG 7 EPO COC 2022 IntRX AGG (PDF)
- NY43 LG 7 EPO COC 2022 IntRX AGG NoFP (PDF)
- NY43 LG 7 EPO COC 2022 IntRX AggEmb (PDF)
- NY43 LG 7 EPO COC 2022 IntRX AggEmb NoFP (PDF)
- NY43 LG 7 EPO COC 2022 IntRX EMB (PDF)
- NY43 LG 7 EPO COC 2022 IntRX EMB NoFP (PDF)
- NY43 LG 7 EPO COC 2022 NoRX AGG (PDF)
- NY43 LG 7 EPO COC 2022 NoRX AGG NoFP (PDF)
- NY43 LG 7 EPO COC 2022 NoRX EMB (PDF)
- NY43 LG 7 EPO COC 2022 NoRX EMB NoFP (PDF)
- NY43 HMOPOS COC 2022 IntRX FP (PDF)
- NY43 HMOPOS COC 2022 IntRX NoFP (PDF)
- NY43 HMOPOS COC 2022 NoRX FP (PDF)
- NY43 HMOPOS COC 2022 NoRX NoFP (PDF)
- NY43 HMOPOS COC GF 2022 (PDF)
- NY44 HMO COC GF 2022 (PDF)
- NY44 LG 7 HMO COC 2022 IntRX (PDF)
- NY44 LG 7 HMO COC 2022 IntRX NoFP (PDF)
- NY44 LG 7 HMO COC 2022 NoRX (PDF)
- NY44 LG 7 HMO COC 2022 NoRX NoFP (PDF)
Vermont
Small Group & Individual- FRVT HMO STANDARD CTR (2022) (PDF)
- FRVT HMO NON-STANDARD CTR (2022) (PDF)
- FRVT HMO HDHP STANDARD CTR (2022) (PDF)
- FRVT HMO HDHP NON-STANDARD CTR (2022) (PDF)
Large Group
- VT 3 HMO 2022 COC (PDF)
- VT 3 HMO 2022 COC INTRX HDHP (PDF)
- VT 3 HMO 2022 COC INTRX NQHDHP (PDF)
2021 Certificates of Coverage (COC)
2022 Dental Schedules of Benefits
New York
- Individual Adult Dental COC 2022 (PDF)
- Individual Family Dental COC 2022 (PDF)
- Individual Pediatric Dental COC 2022 (PDF)
Vermont
- Small Group Adult Dental COC 2022 (PDF)
- Small Group Family Dental COC 2022 (PDF)
- Small Group Pediatric Dental COC 2022 (PDF)
2020/2021 Dental Schedules of Benefits
2022 Vision Schedules of Benefits
New York
- NY43 VISION CTR INDIVIDUAL 2022 (PDF)
- NY43 VISION COC GROUP 2022 SMALL (PDF)
- NY43 VISION COC GROUP 2022 LARGE (PDF)
Vermont
- VT44 VISION CTR INDIVIDUAL 2022 (PDF)
- VT44 VISION COC GROUP 2022 SMALL (PDF)
- VT44 VISION COC GROUP 2022 LARGE (PDF)
Member Rights and Responsibilities
Menu