Benefit Summary
This summary lists your share of Allowable Charges after the Plan pays benefits. See "Highlights of the Plan" for additional information about out-of-pocket limits and other plan features. See "Eligible Expenses" for more details about eligible expenses mentioned below.
All benefits shown are determined based on Allowable Charges. (Non-Direct providers will bill you for any deductible/coinsurance/copay amounts that are your responsibility to pay. In addition, their bill might also include “balance bill” amounts above the Plan’s Allowable Charges. If you would like to discuss your options for resolving a balance bill with your provider, contact Member Services at (855) 979-5192.)
Service | Alliance Coal Direct | Non-Direct | |
---|---|---|---|
Acupuncture1 | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Advanced Imaging2 CT, PET, MRI, ultrasounds, etc. | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Chiropractic Services3 | Not applicable | You pay 50% of Allowable Charges after deductible | |
Diagnostic Tests & Standard Imaging2 X-ray, blood work, labs, stress test, mammogram | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Durable Medical Equipment (DME)2 Rental or purchase, at Plan's option | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Emergency Medical Transportation Ambulance, air transport, etc. | Not applicable | Subject to Allowable Charges, you pay no deductible, copay, or coinsurance | |
Emergency Room Services4 | After you satisfy the deductible (required only for Non-Direct), then you pay the following, based on number of visits per calendar year for your family
| ||
HealthCheck To the extent available at your location | You pay $0 | Not applicable | |
Home Health Care1,2 | You pay $0 when coordinated through Care Coordination | You pay 20% of Allowable Charges after deductible | |
Hospice2 | You pay $0 when coordinated through Care Coordination | You pay 20% of Allowable Charges after deductible | |
Infusion Services5 | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Inpatient Hospital Services1,2,4 Includes facility fee for semiprivate room or intensive special care unit, physician/surgeon/anesthesiologist, and miscellaneous | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Inpatient Skilled-Nursing Facility1,2 | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Mental Health or Substance Abuse Services Inpatient2 and outpatient | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Office Visit - Primary Care Family practitioner, general practitioner, internist, nurse practitioner, pediatrician | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Office Visit - Specialist Cardiologist, oncologist, dermatologist, OB/GYN, etc. | You pay $0 | You pay 20% of Allowable Charges after deductible | |
On-site Health Center Includes video-conference consultations, to the extent available at your location | You pay $0 | Not applicable | |
Outpatient Surgery/Procedure2 Includes facility fee and physician/surgeon/anesthesiologist | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Preventive Care6 Approved screenings and immunizations | You pay $0 | Subject to Allowable Charges, you pay no deductible, copay, or coinsurance | |
Private-Duty Nursing2,7 | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Rehabilitation or Habilitation1 Speech, occupational, or physical therapy | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Temporomandibular Joint (TMJ) Treatment8 | You pay $0 | You pay 20% of Allowable Charges after deductible | |
Urgent Care Center | You pay $0 | You pay 20% of Allowable Charges after deductible |
Footnotes
1 Coverage for the following services is limited to the specified number of days or visits, combined for Alliance Coal Direct and Non-Direct providers:
- Acupuncture: up to 25 visits per year
- Home health care: up to 120 visits per year
- Inpatient hospital or residential treatment center: up to 180 days for the same or a related condition
- Skilled-nursing facility: up to 90 days per period of care
- Speech, occupational, or physical therapy: up to 25 visits per year for each type of therapy
2 To avoid a benefit penalty, preauthorization must be obtained as soon as possible before receiving scheduled, nonemergency services or products. For a detailed listing of services and products for which preauthorization must be obtained, see "Appendix C: Services and Products that Require Preauthorization." Failure to obtain preauthorization when required will result in a 25% benefit penalty (100% benefit penalty for transplants). As with all claims, any services determined not to be medically necessary will not be covered.
3 Coverage for chiropractic includes related office visits and eligible services billed and performed by the chiropractor, osteopath, or other medical professional who provides spinal manipulation services.
4 Benefits for hospital observation status are limited to 24 consecutive hours.
5 The Plan pays 100% of Allowable Charges for preauthorized infusion services when the services are provided at an Alliance Coal Direct provider, an on-site Health Center or an alternate site (including at-home administration) arranged through Care Coordination.
6 To be covered, preventive care services must not exceed certain frequencies. Coverage for preventive care includes related office visits and services (such as lab tests and X-rays) if not billed separately and if the primary purpose of the visit is the preventive care.
7 Coverage for private-duty nursing is limited to a $25,000 lifetime maximum benefit (combined for Alliance Coal Direct and Non-Direct services).
8 Coverage for TMJ is limited to a $3,500 lifetime maximum (combined for Alliance Coal Direct and Non-Direct services). This maximum amount also applies to any complications from TMJ treatment.
Other services may be covered at benefit levels that are different from the levels listed above. For example, see “Eligible Expenses” for information about coverage for certain cosmetic treatments to restore normal physical function.