Group Health Plans

Group Health Plans

Choose the Plan That's Right for You!

All 3 plans provide the same quality you would expect from the American Association of Orthodontists. Plus, all plans cover eligible expenses* up to $2,000,000 while insured!

*Plans differ in the amounts of co-insurance and deductibles you would pay in a calendar year.

Health Savings Account Qualified Traditional and PPO Health Insurance Plans may allow you to open a Health Saving Account (HSA) with all its tax advantages. You may invest pre-tax dollars and get tax-free earnings like an IRA...choose a high deductible to help keep coverage costs down.

Traditional Plan Deductibles
PPO Plan Deductibles:
HSA-Qualified Traditional Plan (Plan 1)
HSA-Qualified PPO Plans (Plans 3 and 4)
Pre-Certify Hospital Stays with Utilization Review (PPO Plans Only)
Wellness Benefits
Premium Savings Through One of the Leading National Networks of Health Care Providers (PPO Plans Only)
Eligible Expenses
Coverage Outside the United States
Exclusions and Limitations
Pre-Existing Conditions
Who Is Eligible?
Additional Dependents
How Your Insurance Coordinates with Other Medical Plans
When Will Coverage Become Effective?
Can Your Plan Be Changed or Terminated?
What If Your Status Changes?
How and When Can Your Coverage End?
How Will You Know You're Covered?
Definitions to Know
Group Health Plans Rate Chart
Important Information about the AAO HSA-Qualified Health Insurance Plans

Traditional Plan Deductibles
Plan 1 - Individual $2,250 / $4,500 Family
PPO Plan Deductibles:
Plan 3 - Individual $3,000 / $6,000 Family
Plan 4 - Individual $5,000 / $10,000 Family

About the Individual Deductible Amount
Under the Individual Deductible Plans, the insured member must incur the applicable deductible amount of eligible expenses in a calendar year before benefits will be paid.

The Individual Deductible Plans are only available to members.

About the Family Deductible Amount
Under the Family Deductible Plans, the member and his/her insured family members must incur the applicable deductible amounts of eligible expenses in a calendar year before benefits will be paid. The Family Deductible Plans are available to member and spouse, member and children, and member, spouse and children. The Individual Deductible does not apply under the Family Deductible Plan.
HSA-Qualified Traditional Plan (Plan 1)
Deductible: $2,250 for individual, or $4,500 for family. Under the individual plan, the insured must first satisfy the $2,250 deductible; then the plan pays 80% of eligible expenses incurred in the calendar year until the member’s “out-of-pocket” (including the deductible) totals $3,250.

Under the family plan, the insured family members must first satisfy the $4,500 deductible; then the plan pays 80% of eligible expenses incurred in the calendar year until the family’s “out-of-pocket” (including the deductible) totals $5,500. Please note that the Individual Deductible is not applicable under the Family Deductible Plan.
HSA-Qualified PPO Plan 3 - $3,000 Individual Deductible/$6,000 Family Deductible PPO Plan

In-Network Expenses – after the deductible (either individual or family) has been satisfied; then the plan pays 80% of eligible expenses incurred in a calendar year until the “out-of-pocket” (including the deductible) totals $5,000 for an individual or $10,000 for a family.

Out-of-Network Expenses - after the deductible (either individual or family) has been satisfied; then the plan pays 60% of eligible expenses incurred in a calendar year until the “out-of-pocket” (including the deductible) totals $6,000 for an individual or $12,000 for a family.

HSA-Qualified PPO Plan 4 - $5,000 Individual Deductible/$10,000 Family Deductible PPO Plan

In-Network Expenses – after the deductible (either individual or family) has been satisfied; then the plan pays 100% of eligible expenses incurred in a calendar year.

Out-of-Network Expenses - after the deductible (either individual or family) has been satisfied; then the plan pays 80% of eligible expenses incurred in a calendar year until the “out-of-pocket” (including the deductible) totals $7,500 for an individual or $15,000 for a family.

NOTE: For ALL PLANS, some eligible expenses for treatment of psychiatric conditions, drug abuse and alcoholism are paid at 50% .
Pre-Certify Hospital Stays with Utilization Review (PPO Plans Only)
Prior to hospital confinement, it is necessary to call the PHCS toll-free number,
800-239-5523, to receive pre-certification. Failure to notify and receive the necessary certification will result in the first $500 of expenses not being covered under this plan (in addition to the deductible) and it will not count toward the out-of-pocket maximum. For a non-emergency hospital admission, pre-certification must be requested at least 7 days prior to the planned admission; the member or someone they appoint must notify PHCS within 2 business days, or as soon as reasonably possible, after admission.

Please note that the pre-certification is the plan utilized by New York Life to determine if in-patient treatment is medically necessary and appropriate under the terms of this plan. The final decision regarding hospitalization rests with the member and their physician. In addition, pre-certification does not guarantee benefit payment under the plan.
Wellness Benefits
Adult Physical Exam Benefit A routine adult physical examination benefit is included. Insureds age 18 or over may submit charges for a physical, routine immunizations (except those required for foreign travel), and x-ray or laboratory services ordered as part of the examination with a maximum of $250 per calendar year. This benefit is subject to the plan deductible and co-insurance requirements.

Annual Gynecological Exam Benefit An annual gynecological examination benefit makes certain charges eligible for reimbursement each calendar year. These include one gynecological examination, a pap smear, mammogram, and x-ray or laboratory services given or ordered as part of the examination with a maximum of $200 per calendar year. This benefit is subject to the plan deductible and co-insurance requirements.

Children's Routing Preventative Care Benefit In addition, for children under 18, eligible child health supervision services will include 18 physicians’ visits at the following age intervals: birth, 2, 4, 6, 9, 12, 15 and 18 months; 2, 3, 4, 5, 6, 8, 10, 12, 14 and 16 years. Included are physical examinations, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests. This benefit is subject to the plan deductible and co-insurance requirements.
Premium Savings Through One of the Leading National Networks of Health Care Providers (PPO Plans Only)
This plan offers premium savings from discounted fees offered by hospitals, physicians and other medical care providers participating in the PHCS Preferred Provider Network.

The PHCS Preferred Provider Network specializes in medical care coordination and management, with experience in in-patient treatment of all medical situations.

It is one of the largest directly contracted PPO networks in the United States —
  • More than 3,100 hospitals, 335,000 physicians and other out-patient care providers nationwide.
  • 90% of the entire US population has access to hospitals and doctors in the PHCS Network.
  • The PHCS Network hospitals and physicians must meet and maintain rigorous quality standards.
  • Network providers offer a full range of services including primary and specialty care, hospital-based services, freestanding surgery centers, radiology and pathology.


You can find the network provider nearest you by calling:
1-800-239-5523 or visit their website at www.phcs.com.
Eligible Expenses
Hospital Charges for Room and Board - Up to the hospital’s average semi-private room rate, but not more than $700 a day.

Hospital Miscellaneous Charges - Other hospital charges for medical care and treatment, such as pre-admission testing, emergency room, intensive care unit, out-patient testing, operating or recovery room expenses, second surgical opinion, therapeutic facilities, anesthesia, lab tests, x-rays, drugs and other medical services and supplies.

Physicians’ and Surgeons’ Fees - Charges of doctors and surgeons incurred in the hospital, at home or in the office. (Benefits for correcting body distortion are limited to $35 per visit and a $500 calendar year maximum. The limit does not apply to open surgery on the vertebral column or to treatments for arthritis, scoliosis, fractures or herniated discs.)

Anesthetists, Physical Therapists - Charges by anesthetist or licensed physical therapist for giving anesthesia or physical therapy.

Nursing Expenses - Charges for a registered graduate nurse or a licensed practical nurse when private duty nursing is needed at the hospital or at home up to a maximum of $10,000 each calendar year.

Convalescent Nursing Home - Semi-private room and board charges for up to 120 days each calendar year. Confinement begins within 14 days after a minimum 3-day hospitalization for the same cause. But the charge on which this benefit is based may not exceed the lesser of 50% of the daily average semi-private room rate or $350.

Home Health Care Benefit - Charges by a hospital for a home health agency for up to 40 home care visits in a calendar year, if the visits begin within 14 days after a hospital or nursing home stay and if the insured’s physician certifies that the home care was necessary to treat the illness which caused the stay or in lieu of a hospital confinement.

Medical Supplies and Equipment - Charges for prescription drugs, blood or blood plasma not replaced on behalf of the person, artificial limbs and eyes for initial replacement, casts, splints, crutches, oxygen, trusses, braces, prosthetic devices, rental of durable medical or surgical equipment as specified in the policy, x-rays, lab tests and radiation treatments.

Other Medical Services - Certain ambulance and transportation charges, charges for radium therapy, radioactive isotope therapy, x-ray examinations, microscopic tests, laboratory tests and analyses for diagnostic or treatment purposes.

Cosmetic Surgery - Charges for cosmetic surgery, including rhinoplasty or other nasal reconstruction, and related medical care if surgery is due to injuries in an accident while insured and begun within 90 days of the accident and charges are incurred within 24 months of the injury; and for congenital anomalies of a child born to an insured parent.

Dental Treatment - Dental charges for removal of tumors or cysts and for repair of damage to sound and natural teeth resulting from injury if treatment is begun within 90 days of the injury and charges are incurred within 24 months of the injury. The cost of surgery for impacted third molars is also covered.

Speech and Hearing Treatment - Charges by a physician, speech pathologist, licensed or certified speech therapist or audiologist to treat loss or impairment of speech or hearing.

Complications of Childbirth - Charges for surgery and related medical care required for caesarean section, extrauterine pregnancy, complications requiring intra-abdominal surgery after termination of pregnancy, and pernicious vomiting or toxemia and convulsions while hospitalized.

Medical Care of the Feet - Charges for an open cutting of metatarsalgia or bunions or for partial or complete removal of nail roots; cutting, removal or treatment of corns, calluses or toenails but only in connection with diabetes or vascular disease, and other specialized medical care of the feet.

Mammography - Charges for one routine examination per calendar year.

Newborn Infant Care - Medical charges before an infant is discharged from the hospital in which he or she was born will be covered if a patient is insured. Once you have dependent child care coverage, a newborn child will become insured on the date of their birth. If you do not carry this coverage, the newborn will become insured for a period of 31 days from the date of birth, provided you make a request to continue such coverage within that period of 31 days.

Hospice Benefits - After the deductible, benefits will be payable at 100% for Eligible Expenses subject to certain limitations on number of visits and certain dollar maximums for services of physicians, nurses, health aides and social workers for care of a terminally ill patient. Details are contained in the Certificate of Insurance.
Coverage Outside the United States
Benefits will be payable for Eligible Expenses incurred while traveling outside the U.S., Puerto Rico and Canada for a period of 90 days.
Exclusions and Limitations
No benefit is provided unless the expense is incurred at a physician's recommendation to treat an injury or sickness. Moreover, the charge must be for customary and reasonable treatments, services and supplies for the condition being treated, and the person must incur it while insured. Charges which the insured is not obligated to pay and those in excess of what is reasonable and customary, are not eligible expenses. Eligible expenses do not include charges incurred in connection with:
  • War or military service
  • Routine eye examinations, eyeglasses, contact lenses (or their fittings), eye refractions, radial keratotomy or hearing aids
  • Out-patient charges by a physician, hospital or state-approved drug treatment facility for the treatment of chemical dependency and drug addiction in excess of $2,000 per calendar year
  • Treatment of alcoholism in excess of 30 days in each calendar year (in or out of hospital)
  • Out-patient physician charges for the treatment of mental, nervous and emotional disorders in excess of 20 visits each calendar year; moreover, the benefit percentage applied to such services is always 50%
  • In-patient treatment ordered by a physician for treatment of mental, nervous and emotional disorders in excess of 60 days each calendar year
  • Those losses for which benefits are payable by a Worker’s Compensation Act or similar law
  • Pregnancy except certain complications of pregnancy such as are indicated under Eligible Expenses
  • Care in a hospital run by the federal government or its agencies unless you are legally obligated to pay
  • Services or supplies which may be obtained without cost in accordance with applicable laws
  • Experimental surgery or research charges
  • Custodial care
  • Any charges made by the insured or by his or her immediate family
  • Voluntary abortions, artificial insemination, in vitro fertilization, any other method of artificial conception or implantation and infertility treatment
  • Sexual transformations
  • Charges which would not be made in the absence of this insurance
  • Artificial kidney equipment for home use
Benefits for certain illnesses and conditions are limited as specified elsewhere.
Pre-Existing Conditions
Benefits will not be paid for an illness or injury due to a pre-existing condition, as indicated below, until the end of 12 consecutive months during which the person has been unsured under the plan.

Pre-Existing Condition - means a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period immediately preceding the coverage effective date.

However, the pre-existing condition exclusion will not apply if the applicant can prove that this coverage is replacing creditable coverage that was in force on him/herself or any other person applying for coverage for at least 18 months without a break in coverage of more than 63 days.

Creditable Coverage - is coverage provided under a group health plan or individual plan which includes COBRA and Medicare coverage. Hospital Indemnity coverage does not qualify as creditable coverage. A certificate of creditable coverage or some other satisfactory proof will be required as evidence that creditable coverage was in force. This certificate should be secured from the Plan Administrator of your current or last health plan.
Who Is Eligible?
You must be an AAO member under age 65 who resides in the U.S.* and works at least 20 hours a week as an orthodontist or a full-time student member. You may also apply for your spouse and single, dependent children under age 25. If both parents are insured members, only one may request child coverage.

* These plans are not available to members who reside in Idaho, Kentucky, Maine, Massachusetts, New Hampshire, New Jersey, North Dakota, Vermont, Washington and Canada. Only the Traditional HSA-Qualified Plan is available to members residing in North Carolina.
Additional Dependents
If you have any dependent medical care insurance in force, newborn children are automatically covered from birth to 31 days. This coverage will be continued if there is medical care insurance in force on other dependent children. You must inform the Plan Administration Office in writing of the child's name and date of birth. If there is no dependent coverage in force and if you want to continue this automatic medical coverage, you must notify the Plan Administration Office within 31 days and remit the extra Premium needed.
How Your Insurance Coordinates with Other Medical Plans
In order to avoid duplicate payments, payments from this plan will be coordinated with benefits the insured receives or is eligible to receive from any other group or blanket insurance plan, Medicare or any similar government program so that total payments do not exceed the covered medical expenses actually incurred.

When you or your insured dependent spouse attain age 65 your coverages will coordinate benefits with Medicare as if you are insured for both Medicare parts A and B.

Please note that if you or any of your dependents are covered under another health insurance program, it could affect your eligibility for a tax-advantaged Health Savings Account (HSA). You should consult with your accountant or tax advisor to determine if your are eligible for an HSA.
When Will Coverage Become Effective?
Insurance will take effect on the first day of the month following 30 days after the date of receipt of your application, provided the initial contribution is paid to the Plan Administration Office within 31 days of that date. Coverage will be issued regardless of health status; however, applicants who have been issued modified coverage based on former underwriting guidelines will pay the Standard Plus 25 premium rates, which are 25% higher in cost than the standard high deductible rates. Applicants who would have been declined will be charged the Standard 50 Plus premium rates, which are 50% higher. The Plan Administration Office will continue to review medical history in order to ascertain which rate applies to an individual. Do not send your premium with your application. You will be notified of the appropriate charges upon the completion of the review.
Can Your Plan Be Changed or Terminated?
Future benefits are subject to change by agreement between New York Life and the policyholder. Rates may be changed by New York Life on any premium due date and on any date on which benefits are changed. New York Life has agreed not to exercise its right to terminate the Group Policy as long as the American Association of Orthodontists continues to endorse only the New York Life Plan. AAO incurs certain expenses in connection with this sponsored plan. To provide and maintain this valuable membership benefit, it is reimbursed for such expenses.
What If Your Status Changes?
If a member ceases to be an AAO member, the insured's major medical coverage will be automatically continued but his or her premium class will change. Premium rates for this class of insureds will be significantly higher than the AAO active member rates. Also, the change in status applies to dependent coverage (1) for a spouse upon divorce; (2) for a dependent child when he or she becomes self-supporting, marries or reaches age 25 (in this case any coverage that is continued will be charged at the child's actual attained age); (3) when an insured member terminates his/her membership in the AAO.

NOTE: Special provisions apply for continuation of Medical Care Insurance on a child beyond age 25 if mentally or physically incapable of self-support. These details are included in the Certificate of Insurance furnished to each AAO Member and are also available upon request from the Plan Administration Office.
How and When Can Your Coverage End?
New York Life cannot terminate coverage or change benefits or premiums on an individual basis; it may do so on a class-wide basis. AAO Major Medical coverage ends when an insured fails to pay insurance charges on time or requests the coverage to end or the Master Policy terminates AND replacement coverage is provided.
How Will You Know You're Covered?
Each insured member will receive a Certificate describing your coverage issued under Group Policy Form GMR.
Definitions to Know
Each insured person receives a Certificate of Insurance which describes his or her coverage in detail and describes some important terms.

Here are a few of the more important terms:

Hospital - means an institution for the care and treatment of sick and injured persons. It must provide 24-hour nursing by graduate registered nurses and have organized facilities for diagnosis and surgery. But none of these qualify as a hospital:
  • An institution owned or run by national or state government (other than a facility of the United States Uniformed Services)
  • An institution, or part of it, used mainly as a facility for rest, nursing, convalescing, the aged, or for remedial education or training.
Home Health Agency - means a hospital, public agency or private non-profit organization, or a subdivision of such an entity, which primarily engages in providing skilled nursing service. It must be either licensed by the state or federally certified to participate in Medicare as a Home Health Agency.

Home Health Care Plan - means one which meets these standards:
  • A physician must establish and approve the Plan in writing
  • The Plan must cover a condition which would otherwise require confinement in a Hospital or a Convalescent Nursing Home.
Home Health Care Visit - refers to visit by a member of a Home Health Care Team other than a home health aid and counts as one Home Health Care Visit.

Convalescent Nursing Home - is an institution for skilled nursing care of sick and injured persons. It must meet these standards:
  • It must be supervised 24 hours a day by a physician, registered nurse or licensed practical nurse;
  • It must have a physician’s services available at all times
  • It must have enough nurses to give continuous patient care
  • It must keep a daily medical record for each patient.


Hospice - means a public agency or private organization that provides a coordinated plan of home, out-patient and in-patient care for a terminally ill person and emotional support and bereavement services for the family. It must:
  • Provide care by a team of trained medical personnel and counselors acting under an independent hospice administration
  • Meet all the licensing requirements of the state in which it operates
  • Be accredited by the Joint Commission on Accreditation
    of Hospitals if a hospital-based Hospice.
Group Health Plans Rate Chart
Click here * for Group Health Plans Rate Chart.
* For California residents Click here.
Important Information about the AAO HSA-Qualified Health Insurance Plans
THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT of 1996 (HIPAA) dealt with the federal government’s regulations on health insurance for individuals and small groups. Included in this bill was the concept of Medical Savings Accounts (MSAs) for self-employed individuals with less than 60 employees. This past December (2003), Congress passed the Medicare Prescription Drug legislation, which includes a similar concept called Health Savings Accounts (HSAs). This new approach should help to make medical care insurance more affordable while offering significant tax advantages to all individuals or families, not just to those who are self-employed.

The Concept
HSAs are designed to make health insurance more affordable by requiring people to purchase a higher deductible (less expensive) plan; the significant tax advantages help offset the higher out-of-pocket costs. HSAs are now available to anyone, not just those who are self-employed, which was the case under MSAs. Here’s how it works: You first buy an insurance plan that is HSA-qualified, then you go to a bank or an investment firm and open a private Health Savings Account with your own money (just like an IRA). You can then withdraw your own money at any time to pay for all medical expenses not covered by your insurance plan (e.g., dental, eyeglasses, deductibles, elective procedures, even long-term nursing care premiums).

The most appealing advantage to many is that if you decide not to use your annual HSA deposits and just accumulate the funds, you have now developed another retirement fund. Read on.

Tax advantage
An HSA is a personal savings account in which you may deposit pre-tax dollars to eventually pay for eligible medical expenses not normally covered by your health insurance plan. From here on, think of an HSA in the same terms you would think of an IRA. Here are the tax advantages associated with an HSA:
  • Contributions to your HSA are funded with pre-tax income so you save the income tax you would normally pay on the contribution.
  • The money in your interest-bearing HSA grows tax-free.
  • You can make tax-free, penalty-free withdrawals to pay for eligible medical expenses.
  • If you do not use the money in your account, it will roll over for future years. It is NOT a use-it-or-lose-it scenario.
  • The balance in the HSA at age 65 can be used and withdrawn as retirement dollars even if you have other qualified retirement plans (IRAs, 401Ks) subject to normal federal income tax.
Step 1 - Insurance
Before you open an HSA, you must be enrolled in an HSA-qualified medical insurance plan, which is characterized as a high-deductible medical care insurance plan under the recent legislation. If a company is offering what they call an HHSA-qualified plan, then they have met the minimum requirements set by the legislation. Here are some of the benefit requirements:
  • Minimum deductible of $1,000 for an individual and $2,000 for family coverage. No maximum deductible. All members of the family contribute toward the deductible for the calendar year until it is satisfied and then the plan begins payment of eligible expenses.
  • Out-of-pocket maximum - $5,000 for individuals and $10,000 for families. (Maximums could be higher for out-of-network expenses)
  • PPO out-of-network penalties are not counted toward the deductible. Premium savings occur when purchasing a higher deductible plan because you will pay more affordable premiums and can use your HSA dollars to offset the higher deductible and out-of-pocket costs.
Step 2 - Open the account
After you are enrolled in the appropriate insurance plan, you may then open an HSA. You select the “trustee” (financial institution) in which to facilitate the account. Just like an IRA there will be fees associated with opening this account. How much can you deposit each year?
  • Annual contributions to an HSA are capped at $2,600 for individuals and $5,150 for families (not to exceed your deductible). Contributions can be made up to age 65.
  • Current MSA funds may be transferred to the new HSA fund.
  • There is no minimum amount required each year; however, certain trustees may require a minimum deposit to open an account.
  • Your annual contribution will be prorated starting on January 1 based on when you establish your HSA. For example, if you open an HSA on July 1, you may then deposit 50 percent of the maximum amount in the HSA for that calendar year because you are halfway into that calendar year.
Withdrawals
Each year as you incur medical expenses that are not paid under your HSA-qualified health insurance plan, such as deductibles or co-insurance payments, you may withdraw funds from your HSA to reimburse yourself for these expenses. If you incur expenses for medically related charges not covered under your health insurance, these may also be reimbursed through your HSA. However, any withdrawal you make is optional. If you decide not to reimburse yourself for these expenses, the funds may remain in your HSA and accumulate interest, tax-free, just like an IRA.

Your trustee (bank) should provide you with the guidelines and procedures on what constitutes qualified expenses for reimbursement and what submissions are necessary to obtain your reimbursements. Here are examples of the types of withdrawals you may decide to take:
  • During the year, your family accumulates a variety of medical bills including doctor visits, prescription drugs and clinical care totaling $900. These are all eligible expenses but do not exceed your family deductible so you’ve paid them out-of-pocket. You may withdraw $900 from your HSA as reimbursement of these expenses without penalty or taxation.
  • You have a routine eye exam and buy prescription glasses with a total cost of $250. Next, you visit the dentist for your annual checkup and cleaning and incur expenses of $150. Although these expenses are not covered under your health insurance plan, they are considered eligible medical expenses, and the $400 is fully reimbursable through your HSA.
  • Over the years you accumulate $15,000 in your HSA and decide to withdraw the entire amount to pay for college expenses. You may withdraw the money, but, similar to an IRA, the withdrawn funds are subject to federal income tax, plus a 10% early withdrawal penalty if you are under age 65. At age 65 or older, you are subject to federal income tax only.
THE AMERICAN ASSOCIATION OF ORTHODONTISTS endorses a group health program that offers, for all members under age 65, several health insurance plans designed to be HSA-qualified. The AAO endorsed HSA-Qualified health insurance plans are not available to residents of Idaho, Kentucky, Maine, Massachusetts, New Hampshire, New Jersey, New York, North Dakota, Vermont, and Washington nor in Canada. The Traditional HSA-Qualified Plan (Plan 1) is the only plan available to residents of North Carolina. Neither the AAO nor plan underwriter New York Life Insurance Company bear any responsibility for the establishment or administration of any Health Savings Accounts you may open. For more information about HSA-qualified health plans, call the Plan Administration Office at 800-622-0344.

Find out more about your member benefits today!


Administered by:

Affinity Insurance Services, Inc.
Michael Loughran licensed in Arkansas (License#: 233963)

 

© 2006 Affinity Insurance Services, Inc.