Other Information About Flexible Spending Accounts
Effect on Social Security and Other Benefits
Participation will reduce the amount of your taxable compensation. Accordingly, there could be a slight decrease in your Social Security benefits.
Rehired Employees
If you leave the participating employer and you are rehired by any participating employer within 30 days of your termination, your monthly contributions and levels of coverage, including any Health Care FSA amounts carried over from the previous calendar year, will continue as if you never left employment, unless you have experienced a qualified change in status that permits an election change. Upon your return, your prior annual contribution level will be reinstated and your per-paycheck deduction amount adjusted accordingly.
However, if you are rehired after being gone for more than 30 days, you may make new elections for the remainder of the year. Furthermore, if you are rehired in a later calendar year, then you may make new enrollment elections in the same manner as a new employee.
If your participation ceases for part of a calendar year due to termination and rehire (or in some cases a leave of absence), your expenses during such period may not be eligible for reimbursement under the FSAs.
IRS Compliance
The Plan Administrator may modify your election(s) downward during the calendar year if you are a "key employee" or "highly compensated individual" (as defined by the Internal Revenue Code), if it is necessary to comply with federal law or to prevent the FSAs or the Alliance Coal, LLC Flexible Benefits Plan from becoming discriminatory within the meaning of the federal income tax law.
Benefit Determinations
Please note: For purposes of the Plan’s claims and appeals procedures, a claim does not include the following:
- Casual inquiries about benefits or the circumstances under which benefits might be paid under the terms of the Plan;
- Mere requests for advance information on the Plan’s possible coverage of items or services or advance approval of covered items or services that do not require preauthorization; and
- The submission of a prescription to a pharmacy or a pharmacist.
Once the claims administrator (Navia) receives a properly filed claim from you or your provider, a benefit determination will be made within 30 days. This period may be extended one time for up to 15 additional days, if the claims administrator determines that additional time is necessary.
If the claims administrator determines that additional time is necessary, you will be notified, in writing, prior to the expiration of the original 30-day period, that the extension is necessary, along with an explanation of the circumstances requiring the extension of time and the date by which the claims administrator expects to make the determination.
Upon receipt of your claim, if the claims administrator determines that additional information is necessary in order for it to be a properly filed claim, the claims administrator will provide you with written notice of the specific information needed prior to the expiration of the initial 30-day period. You will have 45 days from receipt of the notice to provide the additional information. The claims administrator will notify you of its benefit determination within 15 days following receipt of the additional information.
If a claim for benefits is denied, in whole or in part, you will receive written notice of the decision. The written notice will include the following:
- The specific reason(s) for the denial or decision
- Specific reference to the Plan provision(s) on which the denial or decision was based
- A description of any additional material or information necessary to perfect the claim and an explanation of why it is necessary
- For Health Care FSA benefits, an explanation of the claim review procedure including a statement that you may bring a civil action under section 502(a) of ERISA only after a benefit denial on review of your appeal
- For Health Care FSA benefits, if an internal rule, guideline, or protocol, or other similar criterion ("criterion") was relied upon in making the denial, either the:
- Specific criterion used, or
- A statement that such criterion was relied upon in making the benefit denial and that a copy of such criterion will be provided free of charge upon request.
Appeal Procedure
The following processes are required through the FSAs to review any dissatisfactions, complaints, and appeals. If you have designated an authorized representative, that person may act on your behalf in the appeal process.
Questions and Complaints
If you have a question or complaint, an initial attempt should be made to resolve the problem by directly communicating with a representative of the claims administrator. In most cases, the claims administrator will be able to provide you with a satisfactory solution to your problem. However, if a resolution cannot be reached in an informal exchange, you may request an administrative review of the problem through the appeal process described below. You must use the Level One and Level Two Appeal processes below before seeking a review of your claim in court.
You may request to review information used to make any adverse determination. Copies will be provided free of charge.
How to File a Level One or Level Two Appeal
Any appeal under the following procedures must be filed by submitting a written request by email, fax, or mail to the addresses or fax numbers below. Indicate either Level One or Level Two appeal on the email, fax, or letter.
- Email: claims@naviabenefits.com
- Fax: (425) 451-7002 or (866) 535-9227
- Mail: Navia Benefit Solutions, Inc., PO Box 53250 Bellevue, Washington 98015
As part of the appeal process, you have the right to be provided, upon request and free of charge, reasonable access to or copies of all documents, records, and other information relevant to the claim. The appeal process will take into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.
Level One Appeal
How and When to File an Appeal
If you are not satisfied with the initial attempt to resolve your problem, or if you wish to request a review of a benefit determination, you must request a Level One appeal within 180 days from the date you received notice of the adverse benefit determination.
The written request for a Level One appeal should include your name and identification number, the nature of the request, the facts upon which the request is based, and the resolution you are seeking. Necessary facts are: dates and places of services, names of providers of services, and types of services or procedures received (if applicable). You should include any documentation that you want to become a part of the review file. The claims administrator may request further information if necessary. You may review pertinent documents and submit issues and comments in writing.
The Level One Appeal Process
The claims administrator’s staff will review your Level One appeal, provided that the appeal will be conducted by a person or committee who is not subordinate to (does not "report to") the previous decision-maker for the initial claim. In deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the claims administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. You have the right to know the identity of any medical or vocational experts whose advice was obtained on behalf of the claims administrator in connection with an adverse benefit determination.
Timing for Decisions on Level One Appeals
The claims administrator will provide you a written decision on your appeal no later than 30 days following the date your appeal is received.
Adverse Decision on Level One Appeals
If your Level One appeal is denied, then you will generally receive the following information about the denial of the appeal:
- The specific reason(s) for the denial or decision
- Specific reference to the Plan provision(s) on which the denial or decision was based
- A statement that you may have access to or copies of all documents or records that are relevant to your claim (without charge)
- For Health Care FSA benefits, a description of the claim review procedure and any voluntary appeal procedures offered by the Plan and a statement of your right to bring a court action under section 502(a) of ERISA instead of using the voluntary appeal procedure
- For Health Care FSA benefits, if an internal rule, guideline, or protocol, or other similar criterion ("criterion") was relied upon in making the denial, either the:
- Specific criterion used, or
- A statement that such criterion was relied upon in making the benefit denial and that a copy of such criterion will be provided free of charge upon request
Level Two Appeal
When to File an Appeal
If you disagree with the Level One appeal decision, you may submit a request for a Level Two appeal to be determined by the Plan Administrator. You must submit a written request for a Level Two appeal within 60 days from the date you received notice of an adverse determination of your Level One appeal.
Your written request for a Level Two appeal should include the same type of information that was submitted with your Level One appeal request, including any additional information that you believe is relevant to the appeal.
The Level Two Appeal Process
The Plan Administrator will review your Level Two appeal. In deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the Plan Administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. You have the right to know the identity of any medical or vocational experts whose advice was obtained on behalf of the Plan Administrator in connection with an adverse benefit determination.
Timing for Decisions on Level Two Appeals
The Plan Administrator will provide you a written decision on your Level Two appeal no later than 30 days following the date your Level Two appeal request is received by the claims administrator.
If your Level Two appeal is denied, the decision will include the same type of information included in a Level I response (described above).
Effect of Appeal Decision
Decisions on appeals will be made at the sole discretion of the claims administrator and the Plan Administrator, in their respective roles, and will be final and binding on all persons.
You must properly file a claim for benefits and request a Level One and Level Two appeal of any complete or partial claim denial before seeking a review of your benefit claim in court. A decision on a Level Two appeal of a claim denial will be the final decision of the Plan. For Health Care FSA appeals, after the final decision is made by the Plan, you may seek judicial remedies in accordance with your rights under section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA).
Any claim in court for benefits must be filed no later than 365 days after the date of the final decision on your appeal.
Amendment or Termination of the Plan
The Company reserves the right to amend the Plan at any time. The Company further reserves the right to terminate the Plan at any time and for any reason without the consent of any employee.
Plan Information
Official Plan Name | Alliance Coal Dental, Vision, and Flexible Benefits Plan |
Plan Sponsor | Alliance Coal, LLC (the "Company") |
Employer Identification Number | 73-0956034 |
Plan Number | 504 |
Type of Plan | The Flexible Benefits Plan is a cafeteria plan and a dependent care assistance program within the meaning of Internal Revenue Code sections 125 and 129. The Health Care Flexible Spending Account (FSA) is a welfare plan that provides reimbursement of medical expenses and is a part of the Alliance Coal Dental, Vision, and Flexible Benefits Plan (number 504). |
Plan Administrator | Alliance Coal, LLC |
Plan Year | January 1 through December 31 |
Claims Administrator | Navia Benefit Solutions |
Agent for Service of Legal Process | Legal process may be served on the Plan Administrator. |
Financial Facts | The Health Care and Dependent Care Flexible Spending Accounts (FSAs) are self-funded, which means the participating employers pay for the benefits from their general assets. |
Participating Employers as of January 1, 2023 | Alliance Coal, LLC |
