Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital services you had from December 17, 2020, to December 19, 2020, the emergency room (ER) visit you had on January 19, 2021, the computed tomography (CT) scan you had on January 19, 2021, the x-ray you had on January 13, 2021, the neurology visits you had on January 27, 2021 and February 22, 2021, the anesthesiology visits you had on January 18, 2021 and March 15, 2021, the vision care visit you had on March 1, 2021, and chiropractic visits you had from January 4, 2021, to January 11, 2021.
You asked the Plan to waive the copayments for the various medical services. You say that you should not have to pay these bills because these services were all a result of being prescribed two medications that you should not have been prescribed. The Plan denied your request. The Plan says you were charged these copayments correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay the following cost sharing amounts: for inpatient hospital services, you pay a $315 copayment per day for days 1-5; for emergency room services, you pay a $90 copayment per visit; for the CT scan, you pay a $200 copayment for services at a hospital; for the x-ray, you pay a $50 copayment for services at a hospital; for specialist visits, you pay a $40 copayment per visit; and for chiropractic care, you pay a $20 copayment per service.
You have been asked to pay a copayment of $315 per day for the inpatient hospital services, a $90 copayment for the ER visit, a $200 copayment for the CT scan (although the Plan notes that the allowed amount is less than the copayment, so you are responsible for the full billed amount for the CT scan), a $50 copayment for the x-ray, $40 copayments for the visits with the anesthesiologist and neurologist, and $20 copayments for each chiropractic visit. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. There is no provision in your contract for a waiver of these amounts if you believe you were prescribed incorrect medication. Therefore, we decided that the Plan does not have to waive the copayments for the inpatient hospital services you had from December 17, 2020, to December 19, 2020, the emergency room (ER) visit you had on January 19, 2021, the computed tomography (CT) scan you had on January 19, 2021, the x-ray you had on January 13, 2021, the neurology visits you had on January 27, 2021 and February 22, 2021, the anesthesiology visits you had on January 18, 2021 and March 15, 2021, the vision care visit you had on March 1, 2021, and the chiropractic visits you had from January 4, 2021, to January 11, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.