Accident and Health Product Filing

2023-2024 Student Medical Model Language

  • The following is model language for all student accident and health insurance coverage issued in New York State.
  • The documents available in this table are in Word format.
Cover Page12/21/2023
Table of Contents12/21/2023
How This Coverage Works (Introduction, Selecting a Primary Care Provider, Preauthorization, Medically Necessary)12/21/2023
Access to Care and Transitional Care (Referrals, Specialty Care Provider as a PCP)12/21/2023
Cost-Sharing Expenses and Allowed Amount12/21/2023
Who Is Covered (Eligibility)12/21/2023
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)12/21/2023
Ambulance and Pre-Hospital Emergency Medical Services12/21/2023
Emergency Services and Urgent Care12/21/2023
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, Pre-admission Testing, Rehabilitation Services, Second Opinions, Surgical Services, Oral Surgery, Reconstructive Breast Surgery, Other Reconstructive and Corrective Surgery, Transplants)04/03/2024
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)12/21/2023
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)12/21/2023
Mental Health Care and Substance Use Services12/21/2023
Prescription Drug Coverage12/21/2023
Wellness Benefits12/21/2023
Pediatric Vision Care12/21/2023
Pediatric Dental Care12/21/2023
Claim Determinations12/21/2023
Utilization Review12/21/2023
External Appeal12/21/2023
Extension of Benefits12/21/2023
Temporary Suspension Rights for Members of the Armed Forces12/21/2023
General Provisions (Incontestability, Legal Actions, Subrogation, Unilateral Modification)12/21/2023
Schedule of Benefits12/21/2023
Age 29 Rider12/21/2023
Travel and Lodging Rider12/21/2023