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Accident and Health Product Filing

Return to Health Information for Insurers

Model Language

Subject Model Language

Cover Page

05/22/2014

Table of Contents

05/22/2014

Definitions

05/22/2014

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

05/22/2014

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

05/22/2014

Cost-Sharing Expenses and Allowed Amount

05/22/2014

Who Is Covered (Eligiblity)

05/22/2014

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)

05/22/2014

Ambulance and Pre-Hospital Emergency Medical Services

05/22/2014

Emergency Services and Urgent Care

05/22/2014

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)

05/22/2014

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)

05/22/2014

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)

05/22/2014

Mental Health Care and Substance Use Services

05/22/2014

Prescription Drug Coverage

05/22/2014

Wellness Benefits

05/22/2014

Pediatric Vision Care

05/22/2014

Pediatric Dental Care

05/22/2014

Exclusions

05/22/2014

Claim Determinations

05/22/2014

Grievance

05/22/2014

Utilization Review

05/22/2014

External Appeal

05/22/2014

Termination

05/22/2014

Extension of Benefits

05/22/2014

Continuation

05/22/2014

Temporary Suspension Rights for Members of the Armed Forces

05/22/2014

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

05/22/2014

Schedule of Benefits

05/22/2014

Age 29 Rider

05/22/2014

Updated 05/29/2014