Eligibility

Step 1: Eligibility

Age Verification *

Are you or your spouse under the age of 19? Yes No

Are you 65 or older? Yes No

Are you enrolling dependents between the ages of 26 and 29? Yes No

Special Eligibility Certification *

Which of the following events have occurred in the past 60 days? COVID-19 Special Enrollment Period for Uninsured Individuals/Families
I lost my employer health plan
My marital status changed (married or divorced)
I moved to New York from another state
I welcomed a new child into my family
Pregnancy - to continue enrollment please contact us at 1-800-TALK-MVP for assistance
Other
None of these apply

Special Eligibility Event *

Please select the date of your most recent qualifying event (selected in the above list)

Note: Voluntarily ending coverage or losing coverage that doesn't qualify as minimum essential coverage DOES NOT qualify you for a special enrollment period. If you lose coverage because your premiums are not paid on a timely basis, the next opportunity to sign up will be during open enrollment starting November 2017 for coverage beginning January 1, 2018. If you're unsure whether or not you qualify for a special enrollment period, please call MVP at 1-800-TALK-MVP (825-5687) to learn more about your options.

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.

I have read and understand the above.

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 Plus Platinum 2

NY-HMO-DP-002-N (2017)

State:	New York	Annual INN Deductible:	N/A	Primary Care Visit:	$5 copay No Deductible.
Plan Type:	HMO	Annual ONN Deductible:	N/A	Specialist Visit:	$35 copay No Deductible.
Exchange:	Off	Annual INN OOP Limits:	$2,700 person / $5,400 family	Rx Coverage: (Generic / Preferred / Non Preferred)	$5 copay / $30 copay / $50 copay
Metal Level:	Platinum	Annual OON OOP Limits:	N/A	Availability:	2017

Rate Class Verification *

Single $853.06 /month
Double $1,706.12 /month
Parent $1,450.20 /month
Family $2,431.22 /month

Effective Start Date *

We are unable to process your online enrollment at this time due to questions on your effective date. Please call 1-844-865-0250 and an MVP Representative will be happy to help get you enrolled.

Monthly Premium Summary *

Monthly Medical Plan Premium	$853.06
Monthly Pediatric Dental Plan Premium	$0.00
Total Monthly Premium	$853.06

* = required.

Account & Billing Information

Step 3: Account & Billing Information

Primary Account Holder / Enrollee Home Address

First Name *

Middle Initial

Last Name *

Suffix

Address 1 *

Address 2

City *

State

County

Zip Code

Preferred Phone *

(i.e. xxx-xxx-xxxx)

Alternate Phone

(i.e. xxx-xxx-xxxx)

Email Address *

Billing Address

Are your home and billing address the same?

I am the enrollee paying the ONE TIME DIRECT DEBIT. Please send future billing statements to the address listed above
I am paying for someone else's coverage, Please use the information below for ONE TIME DIRECT DEBIT.

First Name *

Middle Initial

Last Name *

Suffix

Address 1 *

Address 2

City *

State *

County *

Zip Code *

Preferred Phone *

(i.e. xxx-xxx-xxxx)

Alternate Phone

(i.e. xxx-xxx-xxxx)

Email Address *

Bank Information

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

Bank / Financial Institution Name *

Bank / Financial Institution Location *

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

Account Number *

Account Routing Number *

Contract Holder / Dependent Information

Relationship to Primary Applicant *

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

First Name *

Middle Initial

Last Name *

Suffix

Gender *

Date of Birth *

(i.e. MM/DD/YYYY)

Social Security Number *

(i.e. xxx-xx-xxxx)

Primary Care Physician Provider Search Tool

First Name of PCP *		Last Name of PCP *

Phone Number of PCP	(i.e. xxx-xxx-xxxx)	Current Patient

MVP Provider ID

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.

* = required.

Confirm Your Information

Step 4: Confirm Your Information

Rate Class Edit

Pediatric Dental Edit Rate Class - Parent/Family:

Total Monthly Premium:

Effective Start Date Edit

Primary Account Holder / Enrollee Home Address Edit

Name
Address 1
Address 2
City/State/Zip:
County
Preferred Ph.
Alternate Ph.
Email Address

Billing Address & Information Edit

Are your home and billing address the same? Y

Name
Address 1
Address 2
City/State/Zip:
County
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

Relationship to primary applicant: Primary Enrollee

Name
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.)

Broker First Name *		Broker Last Name *

Agency Name *		Private Exchange Name

Broker Phone Number *	(i.e. xxx-xxx-xxxx)	Broker Email Address *	(i.e. abc@email.com)

MVP Agency Number		Customer Name	I am a broker enrolling on behalf of the individual identified above

EnrollNowPortlet

ENROLL NOW

Age Verification *

Special Eligibility Certification *

Special Eligibility Event *

Direct Purchase Reminder *

MVP Premier Plus Platinum 2

NY-HMO-DP-002-N (2017)

Rate Class Verification *

Pediatric Dental Qualified Health Plan Compliance *

Effective Start Date *

Monthly Premium Summary *

Primary Account Holder / Enrollee Home Address

Billing Address

Bank Information

Contract Holder / Dependent Information

Primary Care Physician Provider Search Tool

Broker Information

Primary Account Holder / Enrollee Home Address Edit

Billing Address & Information Edit

Enrollees Edit

Contract Holder / Dependent 1

Benefits Summary Attestation *

Authorization Of Direct Payment *

ACH (Direct Debit) Acknowledgement

Step 5!

Online Enrollment Help

Company Providing Pediatric Dental Policy

Policy Number