Accident and Health Product Filing

2020-2021 Student 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.
Subject Date

Cover Page

12/11/2019

Table of Contents

12/11/2019

Definitions

12/11/2019

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

12/11/2019

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

12/11/2019

Cost-Sharing Expenses and Allowed Amount

12/11/2019

Who Is Covered (Eligibility)

12/11/2019

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)

12/11/2019

Ambulance and Pre-Hospital Emergency Medical Services

12/11/2019

Emergency Services and Urgent Care

12/11/2019

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)

12/11/2019

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)

12/11/2019

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)

12/11/2019

Mental Health Care and Substance Use Services

12/11/2019

Prescription Drug Coverage

12/11/2019

Wellness Benefits

12/11/2019

Pediatric Vision Care

12/11/2019

Pediatric Dental Care

12/12/2019

Exclusions

12/11/2019

Claim Determinations

12/11/2019

Grievance

12/11/2019

Utilization Review

12/11/2019

External Appeal

12/11/2019

Termination

1211/2019

Extension of Benefits

12/11/2019

Continuation

12/11/2019

Temporary Suspension Rights for Members of the Armed Forces

12/11/2019

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

12/11/2019

Schedule of Benefits

12/11/2019

Age 29 Rider

12/11/2019