ENROLL NOW

Eligibility
Step 1: Eligibility

Age Verification *

Yes   No


Special Eligibility Certification *

Loss of affordable minimum essential coverage
Loss of government sponsored coverage
Gain a dependent through marriage, birth or adoption
Move to Vermont, change in citizenship/immigration status
Change in marital status
Change in income
Click here to see VT Special Enrollment Qualifying Events

Due to your special eligibility circumstances, your enrollment application will need to be processed manually with the help of an MVP representative.
Please call 800-TALK-MVP (825-5687) or Email SBIU@mvphealthcare.com for enrollment assistance. Thank you.

It does not appear that you have a qualifying life event that can be processed through online enrollment. For enrollment information or personal assistance, please call 800-TALK-MVP (825-5687). Thank you.

Special Eligibility Event *

 

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 Vermont Health Connect are eligible for subsidies from the government including 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 is just an estimation and not an official determination of eligibility and that it is my responsibility to confirm my official eligibility for subsidies on the Vermont Health Connect website.

   

For more information or to calculate your potential eligibility for financial assistance, use the MVP Plan Selector or visit Vermont Health Connect.

* = required.

Review Plan
Step 2: Review Plan

MVP VT Plus HDHP Gold 2500

FRVT-HMOH-G-003-N (2017)

State: Vermont Annual INN Deductible: $2,500 person / $5,000 family Primary Care Visit: 0% coinsurance
Deductible applies.
Plan Type: HD Annual ONN Deductible: N/A Specialist Visit: 0% coinsurance
Deductible applies.
Exchange: On Annual INN OOP Limits: $2,500 person / $5,000 family Rx Coverage:
(Generic / Preferred /
Non Preferred)
$0 copay / $0 copay /
0% coinsurance
Metal Level: Gold Annual OON OOP Limits: N/A Availability: 2017

Rate Class Verification *

 Single $530.99 /month
 Double $1,061.98 /month
 Parent $1,024.81 /month
 Family $1,492.08 /month

Effective Start Date *

Choose your start date

 April 01, 2024    May 01, 2024  

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

Monthly Premium Summary *

Monthly Medical Plan Premium $530.99
Monthly Pediatric Dental Plan Premium $0.00
Total Monthly Premium $530.99
-

* = 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)

 
   
 
 

* = required.

Confirm Your Information
Step 4: Confirm Your Information



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


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

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.)

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