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Accident and Health Product Filing

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Model Language

SubjectModel Language

Cover Page

04/24/2015

Individual- Table of Contents

04/24/2015

Group- Table Of Contents

04/24/2015

Definitions

04/24/2015

How This Coverage Works (Introduction, Selecting a Primary Care Provider, Preauthorization, Medically Necessary)

04/24/2015

Access to Care and Transitional Care (Referrals, Specialty Care Provider as PCP)

04/24/2015

Cost-Sharing Expenses and Allowed Amount

06/18/2015

Individual-Who is Covered (Eligibility)

08/26/2015

Group-Who is Covered (Eligibility)

04/24/2015

Primary and Preventive Care (Well-Baby and Well-Child Care, Adult Annual Physical Examinations, Adult Immunizations, Well-Woman Examinations, Mammograms, Family Planning & Reproductive Health Services, Bone Mineral Density Measurements or Testing, Screening for Prostate Cancer)

06/25/2015

Pre-Hospital Emergency Medical Services

04/24/2015

Emergency and Urgent Care

04/24/2015

Outpatient and Professional Services (Acupuncture, Advanced Imaging Services, Allergy Testing and Treatment, Ambulatory Surgery Center, Chemotherapy, Chiropractic Services, Clinical Trials, Dialysis, Habilitation Services, Home Health Care, Infertility Treatment, Infusion Therapy, Interruption of Pregnancy, Laboratory Procedures, Diagnostic testing and Radiology Services, Maternity and Newborn Care, Medications for Use in the Office, Office Visits, Outpatient Hospital Services, Preadmission Testing, Rehabilitation Services, Second Opinions, Surgical Services, Oral Surgery, Reconstructive Breast Surgery, Other Reconstructive and Corrective Surgery, Transplants)

06/25/2015

Additional Benefits (Autism Spectrum Disorder, Diabetic Equipment, Supplies and Self-Management Education, Durable Medical Equipment and Braces, Hearing Aids, Hospice, Prosthetics, Orthotics)

06/12/2015

Inpatient Services (Hospital Services, Observation Services, Inpatient Medical Services, Inpatient Stay for Maternity Care, Inpatient Stay for Mastectomy Care, Autologous Blood Banking Services, Rehabilitation Services, Skilled Nursing Facility, End of Life Care)

04/24/2015

Mental Health and Substance Use

04/24/2015

Prescription Drugs

04/24/2015

Wellness

04/24/2015

Pediatric Vision

04/24/2015

Pediatric Dental

04/24/2015

Exclusions

04/24/2015

Claims Determinations

04/24/2015

Grievance

07/23/2015

Utilization Review

08/26/2015

External Appeal

04/24/2015

Coordination of Benefits (Group Only)

04/24/2015

Termination

04/24/2015

Extension of Benefits

04/24/2015

Continuation (Group Only - includes Temporary Suspension Rights for Members of Armed Forces)

04/24/2015

Conversion

04/24/2015

Temporary Suspension Rights for Members of the Armed Forces (Individual Only)

04/24/2015

General Provisions (Incontestability, Legal Actions, Subrogation, Unilateral Modification)

04/24/2015

Schedule of Benefits

05/01/2015

Age 29 Rider

04/24/2015

Out-of-Network Rider

04/24/2015

Family Planning Rider

06/25/2015

Domestic Partner Rider

04/24/2015

Updated 08/26/2015

 

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