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Accident and Health Product Filing

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Model Language

SubjectModel Language

Cover Page

04/15/2016

Individual- Table of Contents

04/15/2016

Group- Table Of Contents

04/15/2016

Definitions

04/15/2016

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

04/15/2016

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

04/15/2016

Cost-Sharing Expenses and Allowed Amount

04/15/2016

Individual-Who is Covered (Eligibility)

08/12/2016

Group-Who is Covered (Eligibility)

08/12/2016

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)

08/12/2016

Pre-Hospital Emergency Medical Services

04/15/2016

Emergency and Urgent Care

04/15/2016

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)

08/12/2016

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

04/15/2016

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)

04/15/2016

Mental Health and Substance Use

04/15/2016

Prescription Drugs

08/12/2016

Wellness

04/15/2016

Pediatric Vision

04/15/2016

Pediatric Dental

04/15/2016

Exclusions

04/15/2016

Claims Determinations

04/15/2016

Grievance

04/15/2016

Utilization Review

08/12/2016

External Appeal

04/15/2016

Coordination of Benefits (Group Only)

04/15/2016

Termination

04/15/2016

Extension of Benefits

04/15/2016

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

04/15/2016

Conversion

04/15/2016

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

04/15/2016

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

04/15/2016

Schedule of Benefits

08/12/2016

Age 29 Rider

04/15/2016

Out-of-Network Rider

04/15/2016

Family Planning Rider

04/26/2016

Domestic Partner Rider

04/15/2016

Updated 08/12/2016

 

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