Accident and Health Product Filing

Stand-Alone Dental Model Language

The following is model language for all individual and small group stand-alone dental coverage sold both inside the NYSOH and NYSOH-certified coverage sold outside the NYSOH.
The documents available in this table are in Word format.

Subject	Model Language Date
Cover Page	04/15/2020
Individual - Table of Contents	03/30/2016
Group - Table of Contents	03/30/2016
Definitions	04/15/2020
How This Coverage Works (Introduction, Selecting a Primary Care Dentist, Preauthorization, Medically Necessary)	04/15/2021
Access to Care and Transitional Care (Referrals, Specialty Care Provider as a PCD)	04/15/2019
Cost-Sharing Expenses and Allowed Amount	04/15/2021
Individual - Who Is Covered (Eligibility) (pediatric only coverage)	04/15/2020
Individual - Who Is Covered (Eligibility)	04/15/2020
Group - Who Is Covered (Eligibility) (pediatric only coverage)	04/15/2020
Group - Who Is Covered (Eligibility)	04/15/2020
Pediatric Dental	03/30/2016
Exclusions	04/15/2021
Claim Determinations	04/15/2021
Grievance	04/15/2021
Utilization Review	05/28/2021
External Appeal	03/30/2016
Coordination of Benefits (Group Only)	03/30/2016
Termination	04/15/2021
Extension of Benefits	03/30/2016
Continuation (Group Only)	03/30/2016
Temporary Suspension Rights for Members of the Armed Forces (Individual Only)	03/30/2016
General Provisions (Incontestability, Legal Actions, Subrogation, Unilateral Modification)	04/15/2020
Schedule of Benefits	04/15/2021
Domestic Partner Rider (Group Only)	04/15/2020