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Accident and Health Product Filing

Return to Health Information for Insurers

2015-2016 Model Language

Subject Model Language

Cover Page

04/02/2015

Table of Contents

04/02/2015

Definitions

04/02/2015

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

04/02/2015

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

04/02/2015

Cost-Sharing Expenses and Allowed Amount

04/02/2015

Who Is Covered (Eligiblity)

04/02/2015

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)

04/02/2015

Ambulance and Pre-Hospital Emergency Medical Services

04/02/2015

Emergency Services and Urgent Care

04/02/2015

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)

04/02/2015

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)

04/02/2015

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)

04/02/2015

Mental Health Care and Substance Use Services

04/02/2015

Prescription Drug Coverage

04/02/2015

Wellness Benefits

04/02/2015

Pediatric Vision Care

04/02/2015

Pediatric Dental Care

04/02/2015

Exclusions

04/02/2015

Claim Determinations

04/02/2015

Grievance

04/02/2015

Utilization Review

04/02/2015

External Appeal

04/02/2015

Termination

04/02/2015

Extension of Benefits

04/02/2015

Continuation

04/02/2015

Temporary Suspension Rights for Members of the Armed Forces

04/02/2015

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

04/02/2015

Schedule of Benefits

04/02/2015

Age 29 Rider

04/02/2015

Updated 04/02/2015

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