Step 1: Eligibility

Age Verification *

Yes   No
Yes   No

Yes   No

Direct Purchase Reminder *

Only plans purchased through the New York State of Health™ Marketplace are eligible for financial assistance from the government such as Advanced Premium Tax Credits (APTC) or Cost-Sharing Reductions (CSR). I understand that I am enrolling in a plan that is NOT eligible for APTC, CSR or any financial assistance from the government. I understand that the subsidy calculation on this website is just an estimation and is not an official determination of eligibility and that it is my responsibility to confirm my official eligibility for subsidies at the New York State of Health Marketplace at nystateofhealth.ny.gov.


For more information or to calculate your potential eligibility for financial assistance, use the MVP Plan Selector or visit the New York State of Health.

* = required.

Review Plan
Step 2: Review Plan

MVP Premier Gold 1

NY-HMO-DG-001-S (2021)

State: New York Annual INN Deductible: $600 person / $1,200 family Primary Care Visit: $25 copay
Deductible applies.
Plan Type: HMO Annual ONN Deductible: N/A Specialist Visit: $40 copay
Deductible applies.
Exchange: Off Annual INN OOP Limits: $4,000 person / $8,000 family Rx Coverage:
(Generic / Preferred /
Non Preferred)
$10 copay / $35 copay /
$70 copay
Metal Level: Gold Annual OON OOP Limits: N/A Availability: 2021

Rate Class Verification *

 Single $643.21 /month
 Double $1,286.42 /month
 Parent $1,093.46 /month
 Family $1,833.15 /month

Pediatric Dental Qualified Health Plan Compliance *

Notice: Pediatric dental coverage is required by the Affordable Care Act (ACA), and is included as part of this quote and enrollment process. If you certify that you already have pediatric dental coverage, then this coverage can be removed from your current quote:

Pediatric Dental: [Rate Class - Parent/Family] $29.57 /month


Effective Start Date *

November 01, 2021

Your effective plan start date is contingent upon our timely receipt of your 1st month's payment.

Monthly Premium Summary *

Monthly Medical Plan Premium $643.21
Monthly Pediatric Dental Plan Premium $0.00
Total Monthly Premium $643.21

* = required.

Account & Billing Information
Step 3: Account & Billing Information

Primary Account Holder / Enrollee Home Address 

(i.e. xxx-xxx-xxxx)

(i.e. xxx-xxx-xxxx)

Billing Address 

(i.e. xxx-xxx-xxxx)

(i.e. xxx-xxx-xxxx)

Bank Information

Web checkout is only available with online payment (one time automatic).

(i.e. Address, City, State, Zip)

Contract Holder / Dependent Information


(Enter everyone to be covered by health plan here.)


(i.e. MM/DD/YYYY)


(i.e. xxx-xx-xxxx)


Primary Care Physician Provider Search Tool


(i.e. xxx-xxx-xxxx)


Broker Information

I do not have a broker and/or have not received assistance from a broker for this application.
I have a broker and/or have received assistance from a broker as of the application effective date.
I am a broker enrolling on behalf of my client as of the application effective date.


(i.e. xxx-xxx-xxxx)

(i.e. abc@email.com)


I am a broker enrolling on behalf of the
individual identified above


* = required.

Confirm Your Information
Step 4: Confirm Your Information

Primary Account Holder / Enrollee Home Address Edit

Address 1
Address 2
Preferred Ph.
Alternate Ph.
Email Address

Billing Address & Information Edit

Address 1
Address 2
Preferred Phone
Alternate Phone
Email Address
Payment Information One time automatic payment
Financial Institution Name
Financial Institution Location
Account Number
Account Routing Number

Enrollees Edit

Contract Holder / Dependent 1

Primary Enrollee
Gender Date of Birth
Social Security Number    
First Name of PCP Last Name of PCP
Phone Number of PCP Current Patient?
MVP Provider ID    


I understand that my plan effective date and successful plan enrollment will be contingent upon MVP's timely receipt of my 1st month's payment along with the verification of enrollment information I have provided.

Anti-Fraud Declaration: I attest that I have not knowingly and with intent to defraud any insurance company or person by filing an application for insurance containing any materially false or misleading information. Insurance fraud is a crime and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Benefits Summary Attestation *


I have read the Summary of Benefits and Coverage* (SBC) outlining my plan coverage and benefits Download PDF for Summary of Benefits & Coverage document


Please email me a copy of my SBC document

Authorization Of Direct Payment *


I hereby authorize MVP Health Care to withdraw the amount due to MVP Health Care for the provision of health benefits. That in the case of an automatic bank debit form of payment, it shall be the Customer's responsibility to verify whether these payments are properly debited to their authorized bank account, and the Customer will undertake to notify MVP Health Care of any change in information relating to the Customer's bank account for purposes of ensuring the proper application of payments.

ACH (Direct Debit) Acknowledgement


I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have canceled it in writing to MVP Health Care.

Purchase Plan
Step 5: Thank You for Choosing MVP

Step 5!

If you or your spouse are under the age of 19 then your application will require manual processing. For enrollment assistance please contact 800-TALK-MVP (825-5687). Thank you.

If you are 65 or older, for information on how to enroll in Medicare through MVP, please visit www.joinmvpmedicare.com or call 1-888-280-6205. Thank you.

Enrolling dependents between the ages of 26 and 29 will require manual processing (a plan rider will need to be purchased). For enrollment assistance please contact 800-TALK-MVP (825-5687). Thank you.

If you have more than 9 dependents (not including yourself), your enrollment will need to be processed manually. Please call 800-TALK-MVP (825-5687) for assistance.

For Double Rate Class you can add only one dependent (not including yourself).

Online Enrollment Help

To continue, you must fill out all required information.

(Please note: Based on your responses, there may be cases where you will not be able to continue with online enrollment if you do not meet certain requirements.)

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