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Accident and Health Product Filing

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Model Language

SubjectModel Language

Cover Page

04/13/2017

Individual- Table of Contents

04/13/2017

Group- Table Of Contents

04/13/2017

Definitions

04/13/2017

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

04/13/2017

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

04/13/2017

Cost-Sharing Expenses and Allowed Amount

04/13/2017

Individual-Who is Covered (Eligibility)

05/05/2017

Group-Who is Covered (Eligibility)

04/13/2017

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)

04/13/2017

Pre-Hospital Emergency Medical Services

04/13/2017

Emergency and Urgent Care

04/13/2017

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)

09/05/2017

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

04/13/2017

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)

04/13/2017

Mental Health and Substance Use

04/13/2017

Prescription Drugs

09/05/2017

Wellness

04/13/2017

Pediatric Vision

04/13/2017

Pediatric Dental

04/13/2017

Exclusions

04/13/2017

Claims Determinations

04/13/2017

Grievance

04/13/2017

Utilization Review

04/13/2017

External Appeal

04/13/2017

Coordination of Benefits (Group Only)

04/13/2017

Termination

04/13/2017

Extension of Benefits

04/13/2017

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

04/13/2017

Conversion

04/13/2017

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

04/13/2017

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

04/13/2017

Schedule of Benefits

09/05/2017

Age 29 Rider

04/13/2017

Out-of-Network Rider

04/13/2017

Family Planning Rider

09/05/2017

Domestic Partner Rider

04/13/2017

Medically Necessary Abortion Rider

09/05/2017

Updated 09/05/2017

 

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