Definitions

The following definitions apply to the Medical Plan. See "Definitions" for the Health Care Program for additional definitions that apply.

Alliance Coal Direct - means providers that have contracted directly with the Plan to provide services and supplies at an agreed upon price as payment in full. A provider may be an Alliance Coal Direct provider for some services and supplies but not others.

Allowable Charge (AC) - see “Allowable Charge.” 

Annual Deductible - means the amount of Allowable Charges you pay out-of-pocket in a calendar year before the Plan pays any expenses. Copays do not apply to satisfy the annual deductible. See "Annual Deductible" for more information.

Annual Out-of-Pocket Limits - see “Annual Out-of-Pocket Limits.”

Assignment of Benefits - see "Assignment of Benefits."

Care Coordination - means services provided by the Plan to help members with complex or chronic health conditions receive medically necessary treatment and avoid gaps in care. These services may include making arrangements for health care services and treatment plan review and coordination. See “Preauthorization, Concurrent Review, and Care Coordination” for more information.

Center of Expertise - means a facility approved by the Plan for designated procedures, based on the facility's experience, success rate, and treatment options available. See "Centers of Expertise" for more information.

Coinsurance - means the percentage of the Allowable Charge that is your responsibility for an eligible expense. For emergency room services, any coinsurance required applies to the ER facility charge and other ER-related charges, such as physician, radiologist, and lab.

Combined Medical/Prescription Out-of-Pocket Limit - see “Annual Out-of-Pocket Limits."

Copay - means the flat-dollar amount you pay at the time you visit the provider. For emergency room services, if only a copay is specified in “Benefit Summary," the copay covers the ER facility charge and other ER-related charges, such as physician, radiologist, and lab.

Custodial care - means care that is primarily for the purpose of assisting the individual in the activities of daily living, rather than medically necessary treatment of an illness or injury. Custodial care includes:

  • Sitters' or homemakers' services,
  • Care in a place that serves you primarily as a residence when you do not require substantial skilled nursing,
  • Long-term residential or inpatient care for convalescent or chronically ill individuals whose medical condition is unlikely to substantially improve, or
  • Similar care that is not primarily therapeutic.

Experimental/Investigational - means a drug, device (or combination of drugs and/or devices), biological product, or medical treatment or procedure that the Plan determines:

  • Cannot be lawfully marketed without approval of the appropriate governmental or regulatory agency and approval for marketing has not been given at the time the drug, device, biological product, or medical treatment or procedure is furnished,
  • Is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis, or
  • Based on the prevailing opinion among evidence-based analysis or authoritative medical and scientific literature regarding the drug, device, biological product, or medical treatment or procedure, further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis.

Note: Routine patient costs, as identified under "Clinical Trials" in the "Eligible Expenses" section, may not be excluded when provided to a qualified individual in connection with an approved clinical trial.

HealthCheck - means a cardiovascular health screening, administered by Raymond D. Wells PSC and certain Alliance Coal Direct providers. All information provided through the HealthCheck will be maintained pursuant to the privacy and security policies of the Plan (see "Notice of Privacy Practices for Protected Health Information") and of Raymond D. Wells PSC, in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Members' individual information will be available to Raymond D. Wells PSC, the Plan, Trajectory HealthCare, LLC (which provides certain data analysis services) and by employees of Alliance Coal who help administer the Plan (as well as any health care providers whom the member approves for the release of information). All information from the HealthCheck results, including any indication of high-risk levels, is intended for the member’s general knowledge only and is not a substitute for medical advice, diagnosis, or treatment. Members should seek prompt medical care for any specific health issues and should consult their health care provider for confirmation of HealthCheck results.

Hospital - means a facility that:

  • Is licensed to operate as a hospital by the state (or other jurisdiction, if applicable) in which it is operating; and
  • Provides diagnostic and therapeutic facilities for the surgical or medical diagnosis, treatment, and care of injured and sick persons at the patient’s expense; and
  • Has a staff of licensed physicians available at all times; and
  • Is accredited by a recognized accrediting body (as determined by the Plan Administrator) or, if outside the United States, is licensed or approved by the foreign government or an accreditation or licensing body working in that foreign country; and
  • Continuously provides on-premises, 24-hour nursing service by or under the supervision of a registered nurse; and
  • Is not a place primarily for maintenance or custodial care.

The term “hospital” also includes an ambulatory surgical facility, which is a facility that is licensed to operate as an ambulatory surgical facility by the state (or other jurisdiction, if applicable) in which it is operating; is operating under the direction of an organized medical staff of physicians; has facilities that are equipped and operated primarily for the purpose of performing surgical procedures; has continuous physician services and registered professional nursing services available whenever a patient is in the facility; and generally does not provide inpatient services or other accommodations.

The term “hospital” also includes a birthing center, which is a facility that is licensed to operate as a birthing center in the state (or other jurisdiction, if applicable) in which it is operating; is equipped to provide immediate prenatal care, delivery services and postpartum care to the pregnant individual under the direction and supervision of one or more physicians specializing in obstetrics or gynecology or a certified nurse midwife; and which provides 24-hour nursing care provided by registered nurses or certified nurse midwives.

The term “hospital” does not include services provided in facilities operating as residential treatment centers.

Inpatient - means care as a registered bed patient in a hospital or other provider where a room and board charge is made. Preauthorization requirements apply for inpatient admissions.

Medical Coinsurance Limit - see “Annual Out-of-Pocket Limits

Medical Necessity - see “Definition of Medical Necessity

Non-Direct - means providers that have not contracted directly with the Plan with respect to a service or supply that is the subject of a benefit claim.

Observation - means charges for keeping the patient in the emergency room or observation unit for monitoring or testing.

Outpatient - see "Outpatient Care"

Period of care - means the time period beginning when a patient is admitted to a skilled nursing facility and ending when the patient has not been confined for 90 consecutive days in a hospital, skilled nursing facility, or other place that provides nursing care.

Preauthorization - means certification from the Plan Administrator before the services or products provided are rendered that, based upon the information presented by the member or his or her provider at the time preauthorization is requested, the proposed treatment meets the Plan’s guidelines for medical necessity. For more information about preauthorization (which is sometimes referred to as “precertification”), see “Preauthorization, Concurrent Review, and Care Coordination.” A separate definition of preauthorization applies for certain transplant services; see “Appendix A: Human Organ, Tissue, and Bone Marrow Transplant Services.”

Residential Treatment Center - means a facility that provides 24 hour-per-day, 7 day-per-week treatment for chemical dependency, drug and substance abuse or mental health problems on an inpatient basis. It must provide at least the following: room and board; medical services; nursing and dietary services; patient diagnosis, assessment and treatment; individual, family and group counseling; and educational and support services. A residential treatment center must be: (i) licensed to operate as residential treatment center by the state (or other jurisdiction, if applicable) in which it is operating; and (ii) accredited by a recognized accrediting body (as determined by the Plan Administrator) or, if outside the United States, licensed or approved by the foreign government or an accreditation or licensing body working in that foreign country.  The Plan’s coverage does not include services provided in a community-based residential facility or group home. Preauthorization requirements apply for inpatient admissions.

Urgently needed care - means medical care or treatment that, if substantially delayed (e.g., 15 days), could:

  • Seriously jeopardize the life or health of the covered individual or the ability for the individual to regain maximum function, or
  • Subject the covered individual (in the opinion of a physician with knowledge of the individual's medical condition) to severe pain that cannot be adequately managed without the specified care or treatment.