You choose any provider you wish.
|Annual Deductible|| |
|Your Cost for Services|
Your costs for most services depend on whether the provider you choose is an Alliance Direct provider or a Non-Direct provider.
Alliance Direct: For most eligible expenses (except emergency room), the Plan pays 100% of Allowable Charges, with no annual deductible.
Non-Direct: For most eligible expenses (exceptions include emergency room, preventive care, and chiropractic care), the Plan pays 80% of Allowable Charges after you have satisfied the annual deductible.
For emergency room services at either a Direct or Non-Direct facility, you pay a $250 copay per visit per person (no deductible); then the Plan pays 100% of Allowable Charges.
For designated procedures, the Plan has identified Centers of Expertise. When you use a Plan-approved Center of Expertise for these procedures, the Plan pays 100% of Allowable Charges, and you avoid a 40% benefit penalty.
|Annual Out-of-Pocket Limits|
Out-of-pocket limits provide financial protection for you, by limiting certain cost-sharing amounts you must pay for Allowable Charges in a calendar year.
The medical coinsurance limit (includes deductible) is:
The combined medical/prescription out-of-pocket limit is:
These amounts are combined for Alliance Direct and Non-Direct, and generally are adjusted each year by the federal government.
The medical coinsurance limit does not include copays or prescription drugs. Neither the medical coinsurance limit nor the combined medical/prescription limit include benefit penalties, premiums, amounts paid above Allowable Charges (i.e., amounts that are balance-billed by a provider), covered services not considered essential health benefits by federal law (such as chiropractic and acupuncture), any discounts or similar reductions by providers/manufacturers, and health care the Plan does not cover.
Care Coordination helps members with complex or chronic health conditions receive medically necessary treatment and avoid gaps in care. You may request Care Coordination by calling Member Services at (855) 979-5192.
To avoid a benefit penalty, you are required to obtain preauthorization for many services and products. For a detailed listing, see "Appendix C: Services and Products that Require Preauthorization."
To request preauthorization, you or your provider should call Member Services at (855) 979-5192:
Failure to obtain preauthorization when required will result in a 25% benefit penalty (100% benefit penalty for transplants). Preauthorization allows you to know whether a service is medically necessary under the Plan's rules before you incur an expense. As with all claims, any services determined not to be medically necessary will not be covered.
|Cost of Coverage|
You and the Company share the cost of your medical care. You do not pay a premium contribution for your coverage, but both you and the Plan share the cost of eligible expenses.
|How to Reach Member Services|
Call Member Services at (855) 979-5192.
|Member Portal Website|
At any time, you can view Explanations of Benefits (EOBs), check how much you have accumulated toward the annual deductible and coinsurance limit, and more. Visit www.CoalBenefits.com/portal and log into the Member Portal.