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Accident and Health Product Filing

Return to Health Information for Insurers

2018-2019 Model Language

Subject Model Language

Cover Page

12/19/2017

Table of Contents

12/19/2017

Definitions

12/19/2017

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

12/19/2017

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

12/19/2017

Cost-Sharing Expenses and Allowed Amount

12/19/2017

Who Is Covered (Eligibility)

12/19/2017

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)

12/19/2017

Ambulance and Pre-Hospital Emergency Medical Services

12/19/2017

Emergency Services and Urgent Care

12/19/2017

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)

12/19/2017

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)

12/19/2017

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)

12/19/2017

Mental Health Care and Substance Use Services

12/19/2017

Prescription Drug Coverage

01/23/2018

Wellness Benefits

12/19/2017

Pediatric Vision Care

12/19/2017

Pediatric Dental Care

12/19/2017

Exclusions

12/19/2017

Claim Determinations

12/19/2017

Grievance

12/19/2017

Utilization Review

12/19/2017

External Appeal

12/19/2017

Termination

12/19/2017

Extension of Benefits

12/19/2017

Continuation

12/19/2017

Temporary Suspension Rights for Members of the Armed Forces

12/19/2017

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

12/19/2017

Schedule of Benefits

12/19/2017

Age 29 Rider

12/19/2017

Updated 01/23/2018

Department of Financial Services

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