Accident and Health Product Filing

2022-2023 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

12/07/2021

Table of Contents

12/07/2021

Definitions

12/07/2021

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

12/07/2021

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

12/07/2021

Cost-Sharing Expenses and Allowed Amount

12/07/2021

Who Is Covered (Eligibility)

12/07/2021

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)

12/07/2021

Ambulance and Pre-Hospital Emergency Medical Services

12/15/2021

Emergency Services and Urgent Care

12/15/2021

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)

12/07/2021

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)

12/07/2021

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)

12/07/2021

Mental Health Care and Substance Use Services

12/07/2021

Prescription Drug Coverage

12/07/2021

Wellness Benefits

12/07/2021

Pediatric Vision Care

12/07/2021

Pediatric Dental Care

12/07/2021

Exclusions

12/07/2021

Claim Determinations

12/07/2021

Grievance

12/07/2021

Utilization Review

12/07/2021

External Appeal

12/07/2021

Termination

12/07/2021

Extension of Benefits

12/07/2021

Continuation

12/07/2021

Temporary Suspension Rights for Members of the Armed Forces

12/07/2021

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

12/07/2021

Schedule of Benefits

12/07/2021

Age 29 Rider

12/07/2021