The following definitions apply to the Medical Plan. See "Definitions" for the Health Care Program for additional definitions that apply.
Alliance 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 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, provider coordination, and care plan assistance. See “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.
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 (subject to Allowable Charges).
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.
Emergency Medical Condition - means a medical condition that constitutes an “emergency medical condition” as that term is defined for purposes of the No Surprises Act (Division BB, Title I of the Consolidated Appropriations Act, 2021) and applicable guidance. As of the date of this SPD, this term refers to a medical condition (including a mental health condition or substance use disorder) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of an individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of a bodily organ or part. Future legislation or guidance with respect to the No Surprises Act that modifies this definition will be deemed to be incorporated as of the effective date of such legislation or guidance.
Emergency Services - means a service that constitutes an “emergency service” as that term is defined for purposes of the No Surprises Act and applicable guidance. As of the date of this SPD, this term means, with respect to an emergency medical condition: (i) an appropriate medical screening examination that is within the capability of the emergency department of a hospital or of an independent freestanding emergency department, as applicable, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and (ii) within the capabilities of the staff and facilities available at the hospital or the independent freestanding emergency department, as applicable, such further medical examination and treatment as are required under section 1867 of the Social Security Act (42 U.S.C. 1395dd), or as would be required under such section if such section applied to an independent freestanding emergency department, to stabilize the patient (regardless of the department of the hospital in which such further examination or treatment is furnished).
In addition, unless the notice and consent requirements of the No Surprises Act and applicable guidance are satisfied, the term “emergency services” includes items and services: (i) for which benefits are provided or covered under the Medical Plan; and (ii) that are furnished by a Non-Direct provider or Non-Direct emergency facility (regardless of the department of the hospital in which such items or services are furnished) after the member is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in the preceding paragraph are furnished.
For purposes of this definition, the term “to stabilize”, with respect to an emergency medical condition, means to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility.
Future legislation or guidance with respect to the No Surprises Act that modifies this definition will be deemed to be incorporated as of the effective date of such legislation or guidance.
Experimental/Investigational - means a drug, device (or combination of drugs and/or devices), biological product, or medical treatment or procedure (referred to as a “service or supply” for purposes of this definition) that:
- 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 service or supply is furnished (provided, however, that approval by a governmental or regulatory agency and/or approval for marketing will not prevent a determination that a service or supply is experimental or investigational pursuant to one or both of the following two standards),
- 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
- Is determined by the Plan to be experimental or investigational pursuant to the following process:
- If the service or supply is deemed “Current Role Remains Uncertain” according to the Milliman Care Guidelines, then it is considered experimental and investigational for purposes of this definition; or
- If the service or supply is rated D1 or D2 according to The Hayes Knowledge Center, then it is considered experimental and investigational for purposes of this definition.
- If there is no information regarding the service or supply in at least one of the above sources, the Plan will review relevant UpToDate® topics to determine if there is clear evidence to support the conclusion that further studies or clinical trials are not 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; if the Plan determines there is not clear evidence, then the service or supply is considered experimental and investigational for purposes of this definition.
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 health screening, administered by Improve Health Clinics PLLC and certain Alliance 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 Improve Health Clinics PLLC, in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Members' individual information will be available to Improve Health Clinics PLLC, the Plan, Trajectory HealthCare, LLC (which provides certain data analysis services) and to 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. For more information, please refer to the "Notice Regarding Healthcheck." 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.
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 Retrospective Review.” 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. For Plan purposes, the term “residential treatment center” does not include a wilderness or outdoor treatment program, therapeutic day or overnight camping, educational services, schooling or any such related or similar program, including therapeutic programs within a school setting. The Plan’s coverage does not include services provided in a community-based residential facility or group home. Preauthorization requirements apply for inpatient admissions.
Skilled care - means skilled nursing, skilled teaching, skilled habilitation, and skilled rehabilitation services when all of the following are true:
- Must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient;
- Ordered by a physician;
- Not delivered for the purpose of helping with activities of daily living, including but not limited to dressing, feeding, bathing or transferring from bed to a chair;
- Requires clinical training in order to be delivered safely and effectively; and
- Not custodial care, which can safely and effectively be performed by trained non-medical personnel.
Treatment plan - also referred to as “care plan,” means instructions detailing the member’s medical treatment, including all of the following:
- Symptoms and diagnosis
- Relevant medical history
- Relevant health goals
- Names and roles of all providers treating the member
- Recent and anticipated treatments (such as procedures, therapies, recommended self-care, follow-up care, and equipment) by type, frequency, and expected duration
- Current and anticipated medications, supplements, and other products
Urgently needed care - means medical care or treatment that, if substantially delayed (e.g., 15 days), could:
- Seriously jeopardize the member’s life, health, or ability to regain maximum function, or
- Subject the member (in the opinion of a physician with knowledge of the member's medical condition) to severe pain that cannot be adequately managed without the specified care or treatment.