Accident and Health Product Filings

Model Language

Model language for all comprehensive individual and small group hospital, surgical, medical health insurance products sold both inside and outside of the NY Health Benefits Exchange.

  • The following is model language for all comprehensive individual and small group hospital, surgical, medical health insurance products sold both inside and outside of the NY Health Benefits Exchange. 
  • Please select Model Language - Specific Coverage for a listing of model language for specific types of insurance sold inside and outside of the New York Health Benefits Exchange.
Subject (in MS Word .doc format)Date Issued
Cover Page04/13/2022
Individual - Table of Contents05/01/2024
Group - Table Of Contents05/01/2024
Definitions06/21/2023
How This Coverage Works (Introduction, Selecting a Primary Care Provider, Preauthorization, Medically Necessary)05/01/2024
Access to Care and Transitional Care (Referrals, Specialty Care Provider as PCP)05/01/2024
Cost-Sharing Expenses and Allowed Amount05/01/2024
Individual - Who is Covered (Eligibility)05/01/2024
Group - Who is Covered (Eligibility)05/01/2024
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)05/01/2024
Ambulance and Pre-Hospital Emergency Medical Services05/01/2024
Emergency and Urgent Care04/13/2022
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, Office Visits, Outpatient Hospital Services, Pre-admission Testing, Prescription Drugs for Use in the Office, Rehabilitation Services, Second Opinions, Surgical Services, Oral Surgery, Reconstructive Breast Surgery, Other Reconstructive and Corrective Surgery, Telemedicine, Transplants)05/01/2024
Additional Benefits (Diabetic Equipment, Supplies and Self-Management Education, Durable Medical Equipment and Braces, Hearing Aids, Hospice, Prosthetics, Orthotics)05/01/2024
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)05/01/2024
Mental Health and Substance Use07/25/2023
Prescription Drugs Coverage05/01/2024
Wellness05/01/2024
Pediatric Vision04/13/2022
Pediatric Dental04/13/2022
Exclusions04/13/2022
Claims Determinations05/01/2024
Grievance04/13/2022
Utilization Review05/01/2024
External Appeal04/13/2022
Coordination of Benefits (Group Only)04/13/2022
Termination05/01/2024
Extension of Benefits04/13/2022
Continuation (Group Only - includes Temporary Suspension Rights for Members of Armed Forces)04/13/2022
Conversion04/13/2022
Temporary Suspension Rights for Members of the Armed Forces (Individual Only)04/13/2022
General Provisions (Incontestability, Legal Actions, Subrogation, Unilateral Modification)05/01/2024
Schedule of Benefits05/01/2024
Age 29 Rider04/13/2022
Out-of-Network Rider05/01/2024
Family Planning Rider05/01/2024
Domestic Partner Rider04/13/2022
Abortion Services Rider06/08/2023
Large Group Prescription Drug Rider for Certain Drugs05/07/2024
Reimbursement for Travel and Lodging Expenses Rider09/21/2022
Payment of Cost-Sharing for Certain Covered Services.05/16/2023