About Alfa's Health Policies In Alabama
Now there's affordable, secure health care coverage available that rewards you for taking good care of yourself.
All members age 19 and older must serve a 365-day waiting period for pre-existing conditions. A pre-existing condition is any symptom or condition that has been treated or diagnosed within two years prior to the effective date.
For all members during the first 365 days of coverage, there are no plan benefits for removal of tonsils and adenoids, a hysterectomy, to put tubes in the ears, to replace any joint such as a knee, or to treat a birth defect. This applies to any related surgery, such as removing the ovaries with a hysterectomy. This exclusion does not apply to eligible children properly enrolled in a family plan within 30 days of birth or placement for adoption. The 365-day exclusion period for treatment of birth defects and any related surgery does not apply to any eligible children who are under age 19 on the effective date of coverage under the plan.
Eligible members must serve a 365-day waiting period for maternity benefits.
Cost of the plan
The cost of the Alfa™ plan is based on both your age and the location of your primary residence. The age rate categories are:
- 19 through 29 years
- 30 through 39 years
- 40 through 49 years
- 50 through 59 years
- 60 through 64 years
For a family contract, the older applicant is used for rating purposes.
Inpatient facility services
- No dollar limit for hospital benefits
- $300 deductible per person per admission
- The following inpatient hospital services are covered in full: semi-private room and board; intensive care and other special care units; general nursing care and all other usual hospital ancillary services
- 365 days of care
- 30 days of care each 12 consecutive months for mental and nervous conditions
- Pre-admission certification required
Outpatient facility services - Physicians bill separately
Expanded benefits are provided for many services when you visit a preferred outpatient facility or preferred ambulatory surgical center. The following outpatient facility services are available:
- Chemotherapy and radiation therapy - 100 percent allowed amount
- Hemodialysis - 100 percent allowed amount
- IV therapy - 100 percent allowed amount
- Diagnostic lab, x-ray and pathology - $300 copay - 100 percent allowed amount
- Medical emergencies (treatment of sudden and severe symptoms which require immediate medical attention) - $300 copay - 100 percent allowed amount
- Outpatient surgery - $300 copay - 100 percent allowed amount
- Emergency room/accidental injury - $300 copay - 100 percent allowed amount
Preferred care services
When you use a Preferred Medical Doctor (PMD) or other preferred providers, you will receive these benefits at 80 percent after meeting your annual $600 major medical deductible. The 20 percent preferred co-pay applies to the major medical out-of-pocket and once the out-of-pocket maximum is met, these benefits are increased to 100 percent:
- Surgery (inpatient, outpatient and doctor's office)
- Anesthesia services
- Maternity care
- Physician's visits (inpatient, outpatient and office visits)
- Inpatient visits by a PMD physician for routine newborn care and routine immunizations by a PMD physician to prevent invasive pneumoccocal disease in children during the first two years of life.
- In-hospital consultation (one for surgery, medical care and maternity care per confinement)
- Diagnostic x-rays, laboratory and pathology
- Routine immunizations for diphtheria, tetanus, chicken pox, pertussis, poliomyelitis, measles, rubella, mumps, hepatitis B and Hib (meningitis, epiglottis, joint infections)
- Home health and hospice
- Physical therapy
After meeting your annual $600 major medical deductible, these physician services are covered at 100 percent subject to a $40 copayment.
- Routine well-child care (office visits, only four visits during the first year of the baby's life, plus one visit per year ages one through five.)
- Office visits and outpatient consultations
- Emergency room physician care
The plan provides physician preventive benefits only when the physician is a PMD. If you receive physician preventive services from a non-PMD, the services will not be covered under this or any other portion of the plan.
Coverage and deductibles:
- $600 deductible per person each calendar year
- Maximum $1,800 deductible per family each calendar year
- Pays 80 percent of the allowed amount for major medical covered expenses per person each calendar year; annual out-of-pocket maximum per person (excluding mental/nervous) is $1,500 plus the major medical deductible; then 100 percent of the allowed amount for the remainder of the year.
Major medical covered services include:
- Prescription drugs (When purchased from a participating pharmacy, generic drugs are covered at 100 percent and brand name drugs are covered at 80 percent.) Are subject to a $200 annual deductible.
- Ambulance service
- Oxygen, casts, splints, braces and other prosthetic appliances
- Durable medical equipment
- Pays 50 percent UCR of outpatient mental and nervous conditions
A. Health management benefits
- Individual case management
- Care management
- Baby yourself
B. Home, health and hospice benefits
C. Organ, tissue and bone marrow/cell transplants
D. Mastectomy and mammograms
E. Benefits for colorectal cancer screening
F. Air medical services
Please call 1-800-392-5705 or your Alabama Alfa office. Live well. Choose Alfa Health®.
This is not an insurance policy. It is intended to provide a general description of Alfa Health® and/or its product lines and services. An actual policy contains the specific details of the coverages, conditions and exclusions.