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.
SubjectModel Language Date
Cover Page04/23/2024
Individual - Table of Contents03/30/2016
Group - Table of Contents03/30/2016
How This Coverage Works (Introduction, Selecting a Primary Care Dentist, Preauthorization, Medically Necessary)04/20/2022
Access to Care and Transitional Care (Referrals, Specialty Care Provider as a PCD)04/23/2024
Cost-Sharing Expenses and Allowed Amount04/23/2024
Individual - Who Is Covered (Eligibility) (pediatric only coverage)04/23/2024
Individual - Who Is Covered (Eligibility)04/23/2024
Group - Who Is Covered (Eligibility) (pediatric only coverage)04/23/2024
Group - Who Is Covered (Eligibility)04/23/2024
Pediatric Dental03/30/2016
Claim Determinations04/23/2024
Utilization Review05/28/2021
External Appeal03/30/2016
Coordination of Benefits (Group Only)03/30/2016
Extension of Benefits03/30/2016
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)04/23/2024
Schedule of Benefits04/23/2024
Domestic Partner Rider (Group Only)04/15/2020
Adult Dental Care04/23/2024