Benefits Handbook (SPD)
Health Care
Participation
Medical
Highlights of the Plan
Benefit Summary
Medical Necessity
Allowable Charge
Alliance Direct and Non-Direct Providers
Annual Deductible
Annual Out-of-Pocket Limits
Care Coordination
Centers of Expertise
Travel Benefit
Bundled Surgery Services
Eligible Expenses
Expenses That Are Not Eligible
Preauthorization, Concurrent Review, and Retrospective Review
Benefit Penalties
How to File a Claim
Definitions
Appendix A: Human Organ, Tissue, and Bone Marrow Transplant Services
Appendix B: Designated Procedures for Centers of Expertise
Appendix C: Services and Products That Require Preauthorization
Prescription Drug
Dental
Vision
Flexible Spending Accounts
Income Security
Retirement
Special Benefits
Policies

Alliance Direct and Non-Direct Providers

Each time you or a covered dependent needs medical care, you can choose any health care provider. The level of benefit coverage you receive depends on the provider’s status:

  • Alliance Direct providers are hospitals, doctors, and other health care providers that have direct contracts with the Alliance Coal Health Plan.
  • Non-Direct providers are health care providers that are not Alliance Direct providers.

Alliance Direct Providers

Alliance Direct providers are hospitals, doctors, and other health care providers that have direct contracts with the Alliance Coal Health Plan. These are individual contracts between the Plan and the provider. The Plan does not utilize networks or preferred provider organizations (PPOs).

The Plan’s online directory lists the providers that currently have an Alliance Direct agreement. In addition, you can call Member Services toll-free at (855) 979-5192 for help with working to arrange a pre-negotiated agreement (such as a “single case agreement” or “bundled care package”) with a health care provider. If the Plan is able to arrange a pre-negotiated agreement for the care you need, the eligible services and supplies included in the agreement will be covered at the Alliance Direct benefit level.

An Alliance Direct provider typically accepts the Plan's Allowable Charge as payment in full. Please note that the Alliance Direct benefit level applies only for services and supplies that the Plan considers to be eligible expenses and that are included in the provider’s contract with the Plan. Therefore, you are encouraged to ask Member Services whether a certain service or supply from a certain provider is eligible for the Alliance Direct benefit level, or if there are other restrictions with respect to a particular service or supply. For example, Cochlear (ear) implants currently are eligible for coverage only at Surgery Center of Oklahoma unless another provider is specifically preauthorized by the Plan.

Non-Direct Providers

The Non-Direct benefit level applies if you choose a provider that does not have a contract or pre-negotiated agreement with the Plan for the services or supplies you receive. Except as prohibited by law, Non-Direct providers will bill you for any deductible/coinsurance/copay amounts that are your responsibility to pay.

For a Non-Direct provider, the Allowable Charge may be different than the provider’s charge. Under the Plan’s “Assignment of Benefits” provision, a health care provider who accepts an Assignment of Benefits is deemed to agree to accept the amount paid by the Plan (together with any coinsurance, deductible, and/or copayment paid by you) as payment in full for the services rendered or supplies provided. However, some Non-Direct providers might bill you for the difference between the provider's charge and the Allowable Charge. This is called a “balance bill." If you have questions or would like to discuss your options for addressing a balance bill with your provider, contact Member Services at (855) 979-5192.

Note: When you receive emergency services or get treated by a Non-Direct provider at an Alliance Direct hospital or ambulatory surgery center, you are generally protected from balance-billing. Please see “Surprise Billing Protections” for more information about certain balance-billing protections.

Keep in mind that, even if an Alliance Direct doctor or provider refers you to a Non-Direct provider, the Non-Direct benefit level applies to services or supplies from the Non-Direct provider, except as required by law. In addition, Direct doctors or providers may be supported by Non-Direct ancillary providers (see “Surprise Billing Protections” below for information about the benefit level that applies in those situations). Before using any Non-Direct provider, you may want to call Member Services at (855) 979-5192 for assistance in identifying an Alliance Direct provider.

You pay more when . . . you choose a provider that does not have an Alliance Direct agreement for the service or supply you receive (except as otherwise required by law for certain services). Benefits are paid at the Non-Direct benefit level.

You pay less when . . . you choose an Alliance Direct provider. Benefits are paid at the Alliance Direct benefit level. For assistance in identifying Alliance Direct providers, call Member Services at (855) 979-5192.

Surprise Billing Protections

Effective for dates of service on or after January 1, 2022, the Medical Plan incorporates new legal requirements that are intended to prevent surprise billing when you are not able to choose who provides your care.  Following is a summary of these surprise billing protections.

Emergency Services

If you have an emergency medical condition and get emergency services from a Non-Direct provider or facility, the most the Non-Direct provider or facility may bill you is the Medical Plan’s Alliance Direct cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain Services Provided by Non-Direct Providers at Alliance Direct Facilities  

When you get services from an Alliance Direct hospital or ambulatory surgery center, certain providers there may be Non-Direct. In these cases, the most those Non-Direct providers may bill you is the Medical Plan’s Alliance Direct cost-sharing amount. This applies to emergency medicine, anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services, along with items and services provided by a Non-Direct provider if there is not an Alliance Direct provider who can furnish such item or service at such facility. These Non-Direct providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these Alliance Direct facilities, Non-Direct providers can’t balance bill you, unless you give written consent and give up your protections.

You are never required to give up your protections from balance-billing. You also aren’t required to get care from Non-Direct providers or facilities. You can choose a provider or facility that is Alliance Direct.

Please note: The protections described above with respect to items or services provided by a Non-Direct Provider at an Alliance Direct facility generally apply to situations in which you use an Alliance Direct facility but you don’t have a choice regarding the ancillary service provider at that facility. 

If you have a choice about who provides a service or procedure provided outside of an Alliance Direct facility (even if your provider attempts to schedule the service or procedure for you), the service or procedure will only receive the Alliance Direct benefit level if it is performed by an Alliance Direct provider. For example, assume your doctor directs you to have a blood draw and suggests that you use a laboratory that is adjacent to the doctor’s office. However, you are free to use another laboratory. If you choose to use a Non-Direct provider, you will be responsible for any charges above Allowable Charges (balance-billing).

To receive the Alliance Direct benefit level for a scheduled procedure, verify that both the hospital/facility and the main surgeon/physician are Alliance Direct providers. Contact Member Services at (855) 979-5192 for assistance.

Additional Protections

When balance-billing isn’t allowed for the services described above:

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles) that you would pay if the provider or facility was Alliance Direct. The Medical Plan will pay Non-Direct providers and facilities directly.
  • The Medical Plan generally must:

    • Cover emergency services without requiring you to get approval for services in advance (preauthorization).

    • Cover emergency services by Non-Direct providers.

    • Base what you owe the Non-Direct provider or facility (cost-sharing) on what it would pay an Alliance Direct provider or facility and show that amount in your explanation of benefits.

    • Count any amount you pay for emergency services or Non-Direct services described above toward your deductible and out-of-pocket limit.

Continuity of Care Provisions

You may have “continuity of care” protections under the law in the event you are being treated by an Alliance Direct provider and that provider ceases to be Alliance Direct due to a termination or change in the terms of the Alliance Direct contract between the Plan and the provider or an Alliance Direct facility.  A terminated contract for this purpose could include the expiration or nonrenewal of an Alliance Direct contract. However, it does not include any termination of a contract for failure to meet applicable quality standards or for fraud.

The Plan will notify you if are a “continuing care patient” who is being treated by an Alliance Direct provider or facility that ceases to be Alliance Direct.  You will have the opportunity to notify the Plan that you need transition care, and elect to have the Alliance Direct level of coverage for covered benefits that are a part of your course of treatment from that provider (relating to your status as a continuing care patient) for a period of up to 90 days (or earlier if you are no longer a continuing care patient). 

For this purpose, a “continuing care patient” is an individual who, with respect to the provider or facility:

  • Is undergoing a course of treatment for a “serious and complex” condition from the provider or facility;
  • Is undergoing a course of institutional or inpatient care from the provider or facility;
  • Is scheduled to undergo nonelective surgery from the provider or facility, including receipt of post-operative care from the provider or facility with respect to the surgery;
  • Is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or
  • Is or was determined to be terminally ill (as determined under specified Medicare rules) and is receiving treatment for such illness from the provider or facility.

A “serious and complex condition” is:

  • In the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or
  • In the case of a chronic illness or condition, a condition that is (i) life-threatening, degenerative, potentially disabling, or congenital; and (ii) requires specialized medical care over a prolonged period of time.

Your Health Plan ID Card

Remember to always carry your Health Plan ID card with you.

You should always show your Health Plan ID card to your providers – before services are rendered – and ask them to confirm whether their services will be covered at the Alliance Direct level. If your providers have questions about the Plan’s Allowable Charge and the Plan’s procedures, you can encourage them to call Provider Services at (855) 979-5194.

Note: To receive benefit payment under the Plan, you or your provider must properly file a claim within 180 days after services or supplies were provided.