Highlights of the Plan

  
Providers

You choose any provider you wish. 


Annual Deductible 
  • Alliance Direct: None

  • Non-Direct: $400 per person/$800 per family

 

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:

  • Alliance Direct: $2,000 per person; $4,000 per family
  • Non-Direct: $4,000 per person; $8,000 per family

The combined medical/prescription out-of-pocket limit is:

  • $8,700 of Allowable Charges per person for 2022 ($8,550 for 2021)
  • $17,400 of Allowable Charges per family for 2022 ($17,100 for 2021)

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

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.

In some cases, the Plan may determine that Care Coordination is required to receive the normal level of benefits. If you decline to utilize or cooperate with Care Coordination, the Plan will impose a benefit penalty equal to 40% of the amount the Plan would normally pay.


Preauthorization Requirement

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:

  • As soon as possible before a scheduled, nonemergency procedure
  • Within two business days after an unscheduled inpatient admission

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.