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Accident and Health Product Filing

Return to Health Information for Insurers

2019-2020 Model Language

Subject Model Language

Cover Page

12/06/2018

Table of Contents

12/06/2018

Definitions

12/06/2018

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

12/06/2018

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

12/06/2018

Cost-Sharing Expenses and Allowed Amount

12/06/2018

Who Is Covered (Eligibility)

12/06/2018

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)

12/06/2018

Ambulance and Pre-Hospital Emergency Medical Services

12/06/2018

Emergency Services and Urgent Care

12/06/2018

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, Preadmission Testing, Rehabilitation Services, Second Opinions, Surgical Services, Oral Surgery, Reconstructive Breast Surgery, Other Reconstructive and Corrective Surgery, Transplants)

12/06/2018

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)

12/06/2018

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)

12/06/2018

Mental Health Care and Substance Use Services

12/06/2018

Prescription Drug Coverage

12/06/2018

Wellness Benefits

12/06/2018

Pediatric Vision Care

12/06/2018

Pediatric Dental Care

12/06/2018

Exclusions

12/06/2018

Claim Determinations

12/06/2018

Grievance

12/06/2018

Utilization Review

12/06/2018

External Appeal

12/06/2018

Termination

12/06/2018

Extension of Benefits

12/06/2018

Continuation

12/06/2018

Temporary Suspension Rights for Members of the Armed Forces

12/06/2018

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

12/06/2018

Schedule of Benefits

12/06/2018

Age 29 Rider

12/06/2018

Updated 12/10/2018

Department of Financial Services

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