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 Page | 05/07/2025 |
| Individual - Table of Contents | 05/01/2024 |
| Group - Table Of Contents | 05/01/2024 |
| Definitions | 06/21/2023 |
| How This Coverage Works (Introduction, Selecting a Primary Care Provider, Preauthorization, Medically Necessary) | 05/07/2025 |
| Access to Care and Transitional Care (Referrals, Specialty Care Provider as PCP) | 05/01/2024 |
| Cost-Sharing Expenses and Allowed Amount | 05/01/2024 |
| Individual - Who is Covered (Eligibility) | 05/07/2025 |
| 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) | 05/07/2025 |
| Ambulance and Pre-Hospital Emergency Medical Services | 05/01/2024 |
| Emergency and Urgent Care | 05/07/2025 |
| 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) | 05/07/2025 |
| 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) | 05/07/2025 |
| Mental Health and Substance Use | 05/07/2025 |
| Prescription Drugs Coverage | 05/07/2025 |
| Wellness | 05/01/2024 |
| Pediatric Vision | 05/07/2025 |
| Pediatric Dental | 04/13/2022 |
| Exclusions | 05/07/2025 |
| Claims Determinations | 05/01/2024 |
| Grievance | 04/13/2022 |
| Utilization Review | 05/07/2025 |
| External Appeal | 04/13/2022 |
| Coordination of Benefits (Group Only) | 04/13/2022 |
| Termination | 05/07/2025 |
| Extension of Benefits | 04/13/2022 |
| Continuation (Group Only - includes Temporary Suspension Rights for Members of Armed Forces) | 04/13/2022 |
| Conversion | 04/13/2022 |
| 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 Benefits | 05/07/2025 |
| Age 29 Rider | 05/07/2025 |
| Out-of-Network Rider | 05/01/2024 |
| Family Planning Rider | 05/01/2024 |
| Domestic Partner Rider | 04/13/2022 |
| Abortion Services Rider | 05/07/2025 |
| Large Group Prescription Drug Rider for Certain Drugs | 05/07/2025 |
| Reimbursement for Travel and Lodging Expenses Rider | 09/21/2022 |
| Payment of Cost-Sharing for Certain Covered Services | 05/16/2024 |
| Network Adequacy Model Language Rider | 05/07/2025 |