Definitions

The following definitions apply to the Health Care Program.

Calendar year – means January 1 through December 31. In your first year of coverage, your calendar year (for the purposes of the Health Care Program) begins on the day your coverage begins and ends on December 31.

Children – means your natural children, legally adopted children, children placed for adoption, step-children, foster-children, and children for whom you are the court-appointed guardian or for whom you have been assigned financial responsibility by a QMCSO to provide health care coverage. The Plan Administrator will require satisfactory evidence of eligible dependent status, such as a birth certificate. If the employee is not married to the mother of the child, the employee must provide proof of paternity or financial responsibility. This includes, but is not limited to: an affidavit of paternity; the most recent federal tax return listing the child as a dependent; a divorce decree that shows the employee's financial or health care responsibility for the child; or any court document that names the employee as responsible for meeting the child's financial or health care needs.

Disabled children – means unmarried dependents age 26 or older who are incapable of self-sustaining employment because of physical or mental disability and who are dependent on you for maintenance and support.

Eligible dependent(s) – means your spouse (generally as defined under federal tax law) and any children (see definition above) who are 1) under age 26, or 2) disabled (see definition for "disabled children" above) and age 26 or older provided the disability began before the child reached age 26. A person who is covered as an employee may not be covered as an eligible dependent.

To cover your spouse, you must provide a marriage license (or a federal tax return for a common-law spouse) and submit a completed Spousal Health Care Affidavit. Civil unions and domestic partnerships are not recognized as marriage under the Health Care Program, and therefore the individual involved is not considered a spouse of the employee.

Member – means an employee or former employee who is covered under the Plan (also known as the “employee member”), or the employee member’s spouse or other dependent who is covered under the Plan (also known as the “dependent member”).

On-site Health Center – means the provider of services and supplies at or near the worksite of certain participating employers. The current provider is Raymond D. Wells PSC, under contract with the Plan. Members are eligible to receive services at any on-site Health Center, which are available at most Alliance Coal mines and offices.

Qualified beneficiary – means each person covered by the Health Care Program coverage on the day before a qualifying event (see definition below), and any child born to you (the employee) or placed for adoption with you while you are covered by COBRA.

Qualified change in status – means a change in eligibility resulting from one of the following:

  • Change in your (the employee’s) legal marital status - including:
    • Marriage,
    • Annulment,
    • Divorce, or
    • Death of your spouse.
  • Change in your number of dependents - including:
    • Birth,
    • Adoption of or placement for adoption, or
    • Death of your dependent child.
  • Change in employment status of you, your spouse, or your child - including:
    • Commencement or return from unpaid leave,
    • Change in worksite,
    • Termination or commencement of employment,
    • Strike or lockout, or
    • Change in employment status with the consequence that the individual becomes (or ceases to be) eligible under the Plan or other employee benefit plan.
  • A dependent satisfies or ceases to satisfy eligibility requirements - including:
    • Age, or
    • Change in disability status.
  • A change in residence of you, your spouse, or your dependent child.
  • Your election change on account of an election change with respect to your spouse or child under another employer's plan - This change is only allowed if the other plan allows an election change or if the other plan has a different annual enrollment period. Any election change must be on account of and correspond with the change made under the other employer’s plan. (Note: this event does not qualify as a change in status for purposes of the Health Care Flexible Spending Account [FSA].)
  • Judgment, decree, or order affecting a child's medical coverage - If a judgment, decree, or order ("order") resulting from a divorce, legal separation, annulment, or change in legal custody (including a qualified medical child support order as defined in section 609 of the Employee Retirement Income Security Act of 1974) is entered that requires you to provide medical coverage for your dependent child or foster child, your election may be changed to provide medical coverage if the order requires coverage for your child under the Plan. You may also make an election change to cancel medical coverage for your child if the order requires your spouse, former spouse, or other individual to provide coverage for your child, and that coverage is, in fact, provided.
  • Medicare or Medicaid entitlement - If you, your spouse, or dependent who is enrolled in the Plan becomes entitled to coverage (i.e., becomes enrolled) under Part A or Part B of Title XVIII of the Social Security Act (Medicare) or Title XIX of the Social Security Act (Medicaid) other than coverage consisting solely of benefits under section 1928 of the Social Security Act (the program for distribution of pediatric vaccines), you may make a prospective election change to cancel or reduce coverage for you, your spouse, or dependent under the Plan. In addition, if you, your spouse, or dependent who has been entitled to such coverage under Medicare or Medicaid loses eligibility for such coverage, you may make a prospective election to commence or increase coverage for you, your spouse, or dependent under the Plan.
  • Special enrollment events - You and/or your dependents are eligible for "special enrollment," as defined by the IRS, if:
    • The individual had coverage under another group plan or other health insurance at the time the coverage was offered by the Company and declined the Company's coverage, and the other coverage is lost because either:
      • The individual's other coverage was COBRA coverage that was exhausted, or
      • The individual no longer met the other coverage's eligibility requirements or employer contributions were terminated.
    • You or a dependent loses coverage under Medicaid or a state child health insurance program, or you or a dependent becomes eligible for group health plan premium assistance under Medicaid or a state child health insurance program. You must request enrollment in the Plan and file a completed enrollment form within 60 days of losing such other coverage or gaining premium assistance eligibility.
  • Additional events affecting your Dependent Care Flexible Spending Account (FSA)- including:
    • The cost of day care increases or decreases and the change is imposed by a dependent care assistance provider who is not your relative
    • You raise the salary of a day care provider you employ who is not related to you
    • Your dependent loses eligibility status
    • You change dependent care providers and there is a change in cost
    • The need for coverage is reduced or is increased (i.e., a change in the number of hours that you need day care) and your cost is affected
  • Any other event the Plan Administrator determines to be a qualified change in status
  • Any other event allowing election changes under IRS guidelines, as determined by the Plan Administrator.

Qualifying event – means one of the following:

  • Your employment terminates (for any reason other than gross misconduct)
  • Your hours are reduced
  • You die
  • You become entitled to Medicare
  • You and your spouse divorce or legally separate
  • Your child is no longer eligible for regular dependent coverage (see "Coverage for Your Dependents")