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

04/15/2020

Individual - Table of Contents

03/30/2016

Group - Table of Contents

03/30/2016

Definitions

04/20/2022

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

04/20/2022

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

04/20/2022

Cost-Sharing Expenses and Allowed Amount

04/20/2022

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

04/15/2020

Individual - Who Is Covered (Eligibility)

04/20/2022

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

04/15/2020

Group - Who Is Covered (Eligibility)

04/20/2022

Pediatric Dental

03/30/2016

Exclusions

04/15/2021

Claim Determinations

04/15/2021

Grievance

04/15/2021

Utilization Review

05/28/2021

External Appeal

03/30/2016

Coordination of Benefits (Group Only)

03/30/2016

Termination

04/20/2022

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)

04/20/2022

Schedule of Benefits

04/15/2021

Domestic Partner Rider (Group Only)

04/15/2020