Liberty
Plan
Underwritten by The United States Life Insurance
Company in the City of New York, a
member company of American International Group,
Inc. and rated A++ by A.M. Best.
PLAN PROVISIONS
| Group Size: |
2 + employees |
| Plan Type: |
PPO |
| Calendar Year Deductible: |
In Network: None; Out of Network: $50 on
all services. |
| Calendar Year Maximum: |
$1000 or $1500 maximum per calendar year. |
| Waiting Period: |
12 months on Major; 12 months on Orthodontia |
| Waiting Period Waiver (Optional): |
5% Load – Takeover groups only. |
| Orthodontia (Optional): |
$1000 Lifetime maximum per person ($1500
on groups 51 or more).
Child Only or Full Family Coverage available
(children to age 19, students to age 25). |
| Effective Date: |
1st or 15th of the month. |
| Initial Rate Guarantee: |
12 months. |
|
 |
UNDERWRITING / ELIGIBILITY
| Minimum Contribution: |
35% of employee premium or 25% of
employee and dependent premium |
| Minimum Participation: |
Non-contributory: 100% of all eligible employees;
Contributory: 2-5 employees 100%; 6-8 employees
all but 1; 9 or more employees 75% required. |
| Administrator: |
AmeriSecure Division/Insurers Administrative
Corporation (IAC). |
| Additional Fees: |
$15 per month. |
| Enrollment Requirements: |
First month’s premium check payable to The
American Plans; Group App; employee apps/waivers;
State Wage and Tax Summary; prior carrier bill/cert.
if replacement. |
| Subject to Administrator: |
10 days prior to requested effective date. |
| BENEFIT
SUMMARY |
| |
IN NETWORK |
OUT OF
NETWORK* |
Preventative
Services
Exam
X-rays
Cleaning
Fluoride Treatment |
100% |
90% |
Basic
Services
Fillings
Simple Extractions
Oral
Surgery
Recementing
Repair
to Full and Partial Dentures |
90% |
70% |
Major
Services
Root Canals**
Endodontics, Periodontics**
Restorative
Services
Prosthetic Services |
60% |
50% |
Optional
Orthodontic Services
(Child Only or Full Family) |
50% |
50% |
| |
|
|
*Out-of-Network reimbursements
are paid based on Usual & Customary Rates.
**Option: Endodontics & Periodontics may be considered
as Basic Services for groups of 10 or more enrolling
employees.
This is a brief description of coverage provided under
policy form series G-19000 and is subject to the terms,
limitations, and exclusions of the group policy. Please
see the certificate for details.
This information is intended as a summary only. Benefits
may be subject to limitations and exclusions. This does
not replace the master policy or the plan brochure.
It is as accurate as possible, but we cannot be responsible
for errors and make no warranty of any kind. For full
details, refer to certificate of coverage.
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