| TITLE OF MODEL |
DESCRIPTION |
VOLUME MODEL |
| Administrators, Third Party |
(MDL-90) This model establishes the status of a third-party administrator, providing definitions and guidance as to the authority and obligations of a third-party administrator. |
I-90-1 |
| Advertisements of Accident and Sickness Insurance Model Regulation |
(MDL-40) This model establishes minimum criteria to ensure proper and accurate and to protect prospective purchasers with respect to the advertisement of health insurance. This regulation applies to group and blanket, as well as individual accident and sickness insurance. |
I-40-1 |
| Advertising of Medicare Supplement Insurance |
(MDL-660) This model helps provide prospective purchasers with clear and unambiguous statements in the advertisement of Medicare supplement insurance; and ensures the clear and truthful disclosure of the benefits, limitations and exclusions of policies sold as Medicare supplement insurance. |
IV-660-1 |
| Alliances for Purchasing Health Insurance |
|
|
- Private Health Care Voluntary Purchasing Alliance Model Act
|
(MDL-82) This model helps improve fairness, efficiency and competition in the pricing and delivering of health care coverage for employers with no more than a specified number of employees. It also provides a mechanism for small employers to join together solely for the purpose of procuring health insurance and operates as an exception to existing false group or fictitious group laws. |
I-82-1 |
| Alliances for Purchasing Health Insurance (cont.) |
|
|
- Regional Health Care Voluntary Purchasing Alliance Model Act
|
(MDL-80) This model helps improve fairness, efficiency and competition in the pricing and delivering of health care coverage for employers with no more than a specified number of employees. It also provides a mechanism for small employers to join together solely for the purpose of procuring health insurance and operates as an exception to existing false group or fictitious group laws. |
I-80-1 |
- Single Health Care Voluntary Purchasing Alliance Model Act
|
(MDL-78) This model helps improve fairness, efficiency and competition in the pricing and delivering of health care coverage for employers with no more than a specified number of employees. This model also provides a mechanism for small employers to join together solely for the purpose of procuring health insurance and operates as an exception to existing false group or fictitious group laws. |
I-78-1 |
| Birthday Rule in Coordination of Benefits Provisions |
(MDL-120) This model establishes a uniform order of benefit determination under which plans pay claims; reduces duplication of benefits; and provides greater efficiency in the processing of claims when a person is covered under more than one plan. |
II-120-1 |
| Non-cancellable and Renewable Terminology, Definitions |
(MDL-139) This model defines the terms "non-cancellable" or "non-cancellable and guaranteed renewable," establishing recommended limiting ages in an effort to make the language conform as closely as possible with existing language. |
II-139-1 |
| Claim Audit Guidelines |
(MDL-32) This model provides for the reasonable standardization of claim audit guidelines of health care bills to determine whether data in a health care record is supported by services listed on the claim for payment of an insured or an institutional provider. |
I-32-1 |
| Claims Form Standards |
(MDL-30) This model standardizes the forms used in the billing and reimbursement of health care, reduces the number of forms utilized, increases efficiency in the reimbursement of health care and encourages the use of and prescribes a timetable for the implementation of electronic data interchange of health care expenses and reimbursement. |
I-30-1 |
| COB |
|
II-120-1 |
| Conversion Privilege: in Group Health Insurance |
(MDL-105) This model specifies when an employee or member of a group health plan is entitled to have a converted policy issued to him/her, without evidence of insurability, subject to the provisions of this model. |
II-105-1 |
| Coordination of Benefits Model Regulation |
|
II-120-1 |
| Credentialing Verification of Health Care Professionals Model Act |
(MDL-70) This model requires a health carrier to establish a comprehensive health care professional credentialing verification program to ensure that its participating health care professionals meet specific minimum standards of professional qualification. |
I-70-1 |
| Credit A & H: see “Credit Insurance” Heading |
|
|
| Discontinuance and Replacement Model Regulation |
(MDL-110) This regulation is applicable to all insurance policies and subscriber contracts issued or provided by a carrier on a group or group-type basis covering persons as employees of employers or as members of unions or associations. |
I-110-1 |
| Discount Medical Plan Organization Model Act |
(MDL-98) This Act helps promote the public interest by establishing standards for discount medical plan organizations to protect consumers from unfair or deceptive marketing, sales or enrollment practices and to facilitate consumer understanding of the role and function of discount medical plan organizations in providing access to medical or ancillary services. |
I-98-1 |
| Discretionary Clauses Prohibition Model Act |
(MDL-42) This models helps ensure that health insurance benefits and disability-income protection coverage are contractually guaranteed, and helps avoid the conflict of interest that occurs when the carrier responsible for providing benefits has discretionary authority to decide what benefits are due. |
I-42-1 |
| Domestic Violence: Discrimination in Health Benefit Plans |
|
VI-895-1 |
| Drug Benefit Management Model Act |
(MDL-22) This model provides standards for the establishment, maintenance and management of prescription drug formularies and other pharmaceutical benefit management procedures used by health carriers that provide prescription drug benefits. |
I-22-1 |
| Drugs for Off-Label Use |
(MDL-148) This model sets standards for payments for drugs that have been approved for indications other than those stated in the labeling approved by the FDA. |
II-148-1 |
| External Review |
(MDL-75) This model provides standards for the establishment and maintenance of external review procedures to ensure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination, as defined in this Act.(MDL-76) The purpose of this Act is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination. |
I-75-1, I-76-1 |
| Grievance Procedure Model Act: |
(MDL-72) This model provides standards for the establishment and maintenance of procedures by health carriers to ensure that covered persons have the opportunity for the appropriate resolution of grievances, as defined in this model. |
I-72-1 |
| Group Insurance: see “Group Insurance” heading |
|
|
| Guaranteed Renewable Terminology |
|
II-139-1 |
| Guidelines for Filing of Rates for Individual Health Insurance Forms |
(MDL-134) This model provides guidance for the submission and filing of individual health insurance rates and establishes standards for determining the reasonableness of the relationship of benefits to premiums. |
II-134-1 |
| Health Care Professional Credentialing Verification Model Act |
|
I-70-1 |
| Health Carrier Claim Audit Guidelines Model Act |
(MDL-32) This model provides for the reasonable standardization of claim audit guidelines of health care bills to determine whether data in a health care record is supported by services listed on the claim for payment of an insured or an institutional provider. |
I-32-1 |
| Health Carrier External Review Model Act |
|
I-75-1, I-76-1 |
| Health Carrier Grievance Procedure Model Act: |
|
I-72-1 |
| Health Carrier Prescription Drug Benefit Management Model Act |
|
I-22-1 |
| Health Information Privacy Model Act |
|
I-55-1 |
| Health Insurance for Uninsurable persons |
|
I-85-1 |
| Health Insurance Reserves Model Regulation |
(MDL-10) This model implements the NAIC Standard Valuation Law (MDL-820). It defines categories of reserves and sets forth the minimum claim, premium and contract reserve requirements. The regulation provides for gross premium valuation to evaluate adequacy of reserves. |
I-10-1 |
| Health Maintenance Organizations Model Act |
(MDL-430) This Act provides for a system of regulation for health maintenance organizations that is fair and efficient, and promotes the continued solvency of health maintenance organizations. |
III-430-1 |
| Health Maintenance Organizations Model Regulation |
(MDL-432) This regulation implements the NAIC Health Maintenance Organization Act (MDL-430). It ensures the availability, accessibility and quality of services provided by HMOs and to provide reasonable standards for terms and provisions contained in HMO group and individual contracts and evidences of coverage. |
III-432-1 |
| Home Service Disclosure Model Act |
(MDL-920) This model establishes rules that ensure meaningful information is provided to the purchasers of insurance policies distributed through the home service distribution system. |
VI-920-1 |
| Individual and Small Employer Health Insurance Availability Model Act |
(MDL-35) The purpose of this model is to enhance the availability of health insurance coverage to small employers and individuals regardless of their health status or claims experience and to improve the overall fairness and efficiency of the small group and individual health insurance markets. |
I-35-1 |
| Individual Health Insurance Portability Model Act |
(MDL-37) The purpose of this model is to promote the availability of health insurance coverage to recently insured individuals regardless of their health status or claims experience and to improve the overall fairness and efficiency of the individual health insurance market. |
I-37-1 |
| Individual Health Insurance Portability—Model Regulation to Implement |
(MDL-38) This model is intended to implement the provisions of the NAIC Individual Health Insurance Portability Model Act (MDL-37). The Portability Act and this model are intended to regulate all health benefit plans sold to individuals, whether sold directly or through associations or other groupings of individuals. |
I-38-1 |
| Language Simplification in Life and Health Policies |
(MDL-575) This Act establishes minimum standards for language used in policies, contracts and certificates of life insurance, health insurance, credit life insurance and credit health insurance delivered or issued for delivery in this state to facilitate ease of reading by insureds. Policy forms must meet certain standards in regard to readability, type size and format. |
IV-575-1 |
| Limited Health Service Organization Model Act |
(MDL-68) This model provides the means to regulate limited health service plans and to avoid unnecessary duplication of regulation for other entities that currently are authorized to provide limited health services on a prepayment or other basis or to indemnify for such services. |
I-68-1 |
| Long-Term Care Insurance Model Act |
(MDL-640) This model establishes standards for long-term care insurance and facilitates flexibility and innovation in the development of long-term care insurance coverage. Its corresponding regulation is MDL-641. |
IV-640-1 |
| Long-Term Care Insurance Model Regulation |
(MDL-641) This regulation implements the NAIC Long-Term Care Insurance Model Act (MDL-640). It sets standards for rates, non-forfeiture values and suitability. Requirements for advertising and marketing are also detailed. Several forms are included. |
IV-641-1 |
| Managed Care Plan Network Adequacy Model Act |
(MDL-74) This model establishes standards for the creation and maintenance of networks by health carriers to ensure the adequacy, accessibility and quality of health care services offered under a managed care plan. It establishes requirements for written agreements between health carriers offering managed care plans and participating providers regarding the standards, terms and provisions under which the participating provider will provide services to covered persons. |
I-74-1 |
| Medical Professional Liability Closed Claim Reporting Model Law |
(MDL-77) This Act is intended to ensure the availability of closed claim data necessary for thorough analysis and understanding of issues associated with medical professional liability claims, in order to support the establishment and maintenance of sound public policy. |
I--77-1 |
| Medicare Supplement Insurance |
|
|
- Medicare Supplement Insurance Minimum Standards Model Act
|
(MDL-650) This Act applies to all Medicare supplement policies and certificates issued under group Medicare supplement policies. It includes loss ratio standards and authority to promulgate regulations. Its corresponding model regulation is MDL-651. |
IV-650-1 |
- Medicare Supplement Insurance Minimum Standards Model Regulation
|
(MDL-651) This regulation implements the NAIC Medicare Supplement Insurance Minimum Standards Model Act (MDL-650). It provides for the reasonable standardization of coverage and simplification of terms and benefits of Medicare supplement policies; facilitates public understanding and comparison of such policies; eliminates provisions contained in such policies that may be misleading or confusing; and provides for full disclosures in the sale of health insurance coverage to persons eligible for Medicare. |
IV-651-1 |
- NAIC Model Rule Governing Advertisements of Medicare Supplement Insurance with Interpretation Guidelines
|
|
V-660-1 |
| MEWAs: see “Multiple Employer Welfare Arrangements” below |
|
|
| Minimum Standards—Accident and Sickness Insurance Minimum Standards Model Act |
(MDL-170) Along with its corresponding regulation (MDL-171), this Act standardizes the terms and coverage of individual and group health insurance policies and certificates providing hospital confinement indemnity, accident only, specified disease, specified accident or limited benefit health coverage. |
II-170-1 |
| Minimum Standards—Model Regulation to Implement the Accident and Sickness Insurance Minimum Standards Model Act |
(MDL-171) This regulation implements the NAIC Accident and Sickness Insurance Minimum Standards Model Act (MDL-170). |
II-171-1 |
| Multiple Employer Welfare Arrangements Licensee Reporting |
(MDL-220) This model helps prevent the operation of illegal multiple employer welfare arrangements (MEWAs). This regulation establishes specific standards for persons and licensees who become aware of, or are asked to assist, such an operation. |
II-220-1 |
| Network Adequacy Model Act |
|
I-74-1 |
| Newborn and Adopted Children Coverage Model Act |
(MDL-155) This model provides for uniformity of coverage requirements for newborn and newly adopted children and children placed for adoption under both group and individual health benefit plans. |
II-155-1 |
| Non-cancellable and Guaranteed Renewable Terminology Defined |
|
II-139-1 |
| Nondiscrimination in Health Insurance Coverage in the Group Market Model Regulation |
|
II-107-1 |
| Off-Label Drug Use Model Act |
|
II-148-1 |
| Overinsurance: Coordination of Benefits |
|
II-120-1 |
| Overinsurance Provisions in Uniform Individual Accident and Sickness Policy Provisions Law (UPPL) |
(MDL-180) This model establishes a uniform individual accident and sickness policy. It sets forth the definition of "policy of accident and sickness insurance" and establishes the requirements for the form of a policy, specifies particular provisions to be included, and provides for judicial review. |
II-180-1 |
| Policy Provisions Uniform Law in Simplified Language |
(MDL-185) This restatement of the required and most often used optional provisions of the Uniform Policy Provision Law (MDL-180) in simplified language is intended as a guideline for the submission and approval of individual accident and sickness policies written in simplified language. The restated provisions are intended to most accurately reflect the original intent of the UPPL and to duplicate its substantive requirements. |
II-185-1 |
| Portability: Individual Health Insurance Model Act |
|
I-37-1 |
| Portability: Model Regulation to Implement the Individual Health Insurance Model Act |
|
I-38-1 |
| Prepaid Limited Health Service Organization Model Act |
|
I-68-1 |
| Prescription Drug Benefit Management Model Act |
|
I-22-1 |
| Private Health Care Voluntary Purchasing Alliance Model Act |
|
I-82-1 |
| Prohibition on the Use of Discretionary Clauses Model Act |
(MDL-42) This model helps ensure that health insurance benefits and disability-income protection coverage are contractually guaranteed, and helps avoid the conflict of interest that occurs when the carrier responsible for providing benefits has discretionary authority to decide what benefits are due. |
I-42-1 |
| Quality Assessment and Improvement Model Act |
(MDL-71) This model establishes criteria for the quality assessment activities of all health carriers that offer managed care plans and for the quality improvement activities of health carriers issuing closed plans or combination plans that have a closed component. |
I-71-1 |
| Readability in Health Insurance |
|
IV-575-1 |
| Regional Health Care Voluntary Purchasing Alliance Model Act |
|
I-80-1 |
| Reinstatement Provision; see Uniform Policy Provision Law |
|
II-180-1 |
| Risk-Based Capital for Health Organizations Model Act |
(MDL-315) This model establishes RBC requirements and outlines the reporting requirements for health organizations. The hearing process and confidentiality concerns are addressed. It also includes provisions for exemptions, foreign health organizations and immunity. |
III-315-1 |
| Risk Pooling, Health Insurance |
|
I-85-1 |
| Shopper’s Guide for Long-Term Care Insurance (requirement) |
|
IV-641-19 |
| Single Health Care Voluntary Purchasing Alliance Model Act |
|
I-78-1 |
| Small Employer and Individual Health Insurance Availability Model Act |
|
I-35-1 |
| Small Employer Health Insurance Availability Model Act (Prospective Reinsurance With or Without an Opt-Out) |
(MDL-118) This model enhances the availability of health insurance coverage to small employers, regardless of their health status or claims experience. Along with its corresponding model regulation (MDL-119), it helps improve the overall fairness and efficiency of the small group health insurance market. |
II-118-1 |
| Small Employer Health Insurance Availability Model Regulation |
(MDL-119) This model implements the provisions of the NAIC Small Employer Health Insurance Availability Model Act (MDL-118). The Act and regulation are intended to promote broader spreading of risk in the small employer marketplace. |
II-119-1 |
| Standardized Health Claim Form Model Regulation |
|
I-30-1 |
| Stop Loss Insurance Model Act |
(MDL-92) This model establishes criteria for the issuance of stop-loss insurance policies. This model does not impose any requirement or duty on any person other than an insurer or as treating any stop-loss policy as a direct policy of health insurance. |
I-92-1 |
| Third Party Administrator Statute |
(MDL-90) This model establishes the status of a third-party administrator, providing definitions and guidance as to the authority and obligations of a third-party administrator. |
I-90-1 |
| Twenty-Four Hour Health Coverage Pilot Project |
(MDL-960) This model authorizes the establishment of up to 10 pilot projects to be administered after consulting with the workers' compensation administrator. This model enables the state legislature to determine whether the costs of the workers' compensation system and the health care delivery system can be more effectively managed. |
VI-960-1 |
| Unauthorized Transaction of Insurance Criminal Model Act |
(MDL-890) This model prescribes penalties for those engaging in the unauthorized transaction of insurance or health coverage. It also sets out penalties for assisting an unauthorized insurer, as well as for engaging in repeated violations of this Act. |
VI-890-1 |
| Unfair Discrimination Against Subjects of Abuse in Health Benefit Plans Model Act |
|
VI-895-1 |
| Uniform Individual Accident and Sickness Policy Provisions |
|
II-180-1 |
| Uninsurable Individuals Health Plan |
|
I-85-1 |
| UPPL: Uniform Policy Provision Law |
|
II-180-1 |
| UPPL in Simplified Language |
|
II-185-1 |
| Utilization Review and Benefit Determination Model Act |
(MDL-73) This model establishes standards and criteria for the structure and operation of utilization review and benefit determination processes designed to facilitate ongoing assessment and management of health care services. |
I-73-1 |
| Workers’ Compensation: Twenty-Four Hour Health Coverage Pilot Project |
|
VI-960-1 |