Accident and Health Product Filing

Stand-Alone Dental Model Language

  • The following is model language for all individual and small group stand-alone dental coverage sold both inside the NYSOH and NYSOH-certified coverage sold outside the NYSOH.
  • The documents available in this table are in Word format.
Subject Model Language Date

Cover Page

04/15/2019

Individual - Table of Contents

03/30/2016

Group - Table of Contents

03/30/2016

Definitions

04/15/2019

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

04/15/2019

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

04/15/2019

Cost-Sharing Expenses and Allowed Amount

04/15/2019

Individual - Who Is Covered (Eligibility) (pediatric only coverage)

04/15/2019

Individual - Who Is Covered (Eligibility)

04/15/2019

Group - Who Is Covered (Eligibility) (pediatric only coverage)

04/15/2019

Group - Who Is Covered (Eligibility)

04/15/2019

Pediatric Dental

03/30/2016

Exclusions

03/30/2016

Claim Determinations

04/12/2018

Grievance

03/30/2016

Utilization Review

04/12/2018

External Appeal

03/30/2016

Coordination of Benefits (Group Only)

03/30/2016

Termination

04/15/2019

Extension of Benefits

03/30/2016

Continuation (Group Only)

03/30/2016

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

03/30/2016

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

04/15/2019

Schedule of Benefits

04/15/2019

Domestic Partner Rider (Group Only)

03/30/2016