Skip to Content

NY.gov Portal State Agency Listing

Translate | Disclaimer

Accident and Health Product Filing

Return to Health Information for Insurers

Model Language

SubjectModel Language

Cover Page

04/21/2014

Individual- Table of Contents

04/21/2014

Group- Table Of Contents

04/21/2014

Definitions

04/21/2014

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

07/10/2014

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

04/21/2014

Cost-Sharing Expenses and Allowed Amount

07/17/2014

Individual-Who is Covered (Eligibility)

07/10/2014

Group-Who is Covered (Eligibility)

04/21/2014

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)

04/21/2014

Pre-Hospital Emergency Medical Services

04/21/2014

Emergency and Urgent Care

04/21/2014

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)

04/21/2014

Additional Benefits (Autism Spectrum Disorder, Diabetic Equipment, Supplies and Self-Management Education, Durable Medical Equipment and Braces, Hearing Aids, Hospice, Prosthetics, Orthotics)

07/10/2014

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)

04/21/2014

Mental Health and Substance Use

05/27/2014

Prescription Drugs

07/10/2014

Wellness

04/21/2014

Pediatric Vision

04/21/2014

Pediatric Dental

04/21/2014

Exclusions

04/21/2014

Claims Determinations

04/21/2014

Grievance

04/21/2014

Utilization Review

04/21/2014

External Appeal

04/21/2014

Coordination of Benefits (Group Only)

04/21/2014

Termination

04/21/2014

Extension of Benefits

04/21/2014

Continuation (Group Only - includes Temporary Suspension Rights for Members of Armed Forces)

04/21/2014

Conversion

04/21/2014

Temporary Suspension Rights for Members of the Armed Forces (Individual Only)

04/21/2014

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

07/18/2014

Schedule of Benefits

04/21/2014

Age 29 Rider

04/21/2014

Out-of-Network Rider

04/21/2014

Family Planning Rider

04/21/2014

Domestic Partner Rider

04/21/2014

Updated 07/18/2014