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Accident and Health Product Filing

Return to Health Information for Insurers

2017-2018 Model Language

Subject Model Language

Cover Page

12/19/2016

Table of Contents

04/01/2016

Definitions

04/01/2016

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

04/01/2016

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

04/01/2016

Cost-Sharing Expenses and Allowed Amount

12/19/2016

Who Is Covered (Eligibility)

12/19/2016

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)

12/19/2016

Ambulance and Pre-Hospital Emergency Medical Services

04/01/2016

Emergency Services and Urgent Care

01/15/2016

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)

12/19/2016

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

04/01/2016

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)

04/01/2016

Mental Health Care and Substance Use Services

12/19/2016

Prescription Drug Coverage

12/19/2016

Wellness Benefits

04/01/2016

Pediatric Vision Care

04/01/2016

Pediatric Dental Care

04/06/2016

Exclusions

01/20/2017

Claim Determinations

04/01/2016

Grievance

01/15/2016

Utilization Review

12/19/2016

External Appeal

04/01/2016

Termination

01/12/2017

Extension of Benefits

04/01/2016

Continuation

04/01/2016

Temporary Suspension Rights for Members of the Armed Forces

04/01/2016

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

12/19/2016

Schedule of Benefits

12/19/2016

Age 29 Rider

04/02/2015

Updated 02/22/2017

 

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