Accident and Health Product Filings

Model Language

Model language for all comprehensive individual and small group hospital, surgical, medical health insurance products sold both inside and outside of the NY Health Benefits Exchange.

  • The following is model language for all comprehensive individual and small group hospital, surgical, medical health insurance products sold both inside and outside of the NY Health Benefits Exchange. 
  • Please select Model Language - Specific Coverage for a listing of model language for specific types of insurance sold inside and outside of the New York Health Benefits Exchange.
Subject (in MS Word .doc format) Date Issued

Cover Page

04/13/2022

Individual - Table of Contents

04/13/2022

Group - Table Of Contents

04/13/2022

Definitions

04/13/2022

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

04/13/2022

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

04/13/2022

Cost-Sharing Expenses and Allowed Amount

04/13/2022

Individual - Who is Covered (Eligibility)

04/13/2022

Group - Who is Covered (Eligibility)

04/13/2022

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)

04/13/2022

Pre-Hospital Emergency Medical Services

04/13/2022

Emergency and Urgent Care

04/13/2022

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, Office Visits, Outpatient Hospital Services, Pre-admission Testing, Prescription Drugs for Use in the Office, Rehabilitation Services, Second Opinions, Surgical Services, Oral Surgery, Reconstructive Breast Surgery, Other Reconstructive and Corrective Surgery, Telemedicine, Transplants)

05/16/2022

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

04/13/2022

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)

04/13/2022

Mental Health and Substance Use

04/13/2022

Prescription Drugs Coverage

04/13/2022

Wellness

04/13/2022

Pediatric Vision

04/13/2022

Pediatric Dental

04/13/2022

Exclusions

04/13/2022

Claims Determinations

04/13/2022

Grievance

04/13/2022

Utilization Review

04/13/2022

External Appeal

04/13/2022

Coordination of Benefits (Group Only)

04/13/2022

Termination

04/13/2022

Extension of Benefits

04/13/2022

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

04/13/2022

Conversion

04/13/2022

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

04/13/2022

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

04/13/2022

Schedule of Benefits

05/16/2022

Age 29 Rider

04/13/2022

Out-of-Network Rider

04/13/2022

Family Planning Rider

04/13/2022

Domestic Partner Rider

04/13/2022

Medically Necessary Abortion Rider

05/16/2022

Large Group Prescription Drug Rider for Certain Drugs

08/05/2022