Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and does not have to waive the copayments for the administration provided from April 3, 2020, to July 13, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs and to waive the copayments for the administration. You say that the enrollee met the $5,500 MOOP amount at the time services were received and should not be responsible for the charges.
You state that the total charges add up to more than the contracted amount. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that the MOOP amount for 2020 is $5,500. The enrollee's contract with the Plan also clearly says that they must pay 20% coinsurance for Medicare Part B drugs. The enrollee's contract with the Plan also clearly says that they must pay a $35 copayment for specialist services.
The enrollee received Medicare Part B drugs and the administration from April 3, 2020, to July 13, 2020. The record shows that the enrollee had not met the MOOP amount of $5,500 prior to receiving the services. Therefore, the enrollee is responsible to pay their share of the cost-sharing charges. Please see the chart below.
Date of Service
Service
Allowed Amount
Amount Enrollee Owes
4/3/2020
Administration
$16.50
$16.50
4/3/2020
Part B Drug
$141.71
$28.34
4/3/2020
Part B Drug
$2.40
$0.48
4/3/2020
Part B Drug
$184.90
$36.98
4/3/2020
Part B Drug
$30.10
$6.02
4/10/2020
Specialist Services
$109.19
$35.00
4/13/2020
Specialist Services
$109.19
$35.00
4/21/2020
Specialist Services
$109.19
$35.00
4/27/2020
Administration
$16.50
$16.50
4/27/2020
Part B Drug
$141.71
$28.34
4/27/2020
Specialist Services
$75.25
$18.50
4/27/2020
Part B Drug
$184.90
$36.98
4/27/2020
Part B Drug
$30.10
$6.02
4/27/2020
Part B Drug
$2.40
$0.48
6/16/2020
Part B Drug
$141.71
$28.34
6/16/2020
Part B Drug
$184.90
$36.98
6/16/2020
Part B Drug
$30.10
$6.02
6/16/2020
Part B Drug
$2.40
$0.48
6/17/2020
Part B Drug
$192.21
$38.44
6/17/2020
Part B Drug
$31.29
$6.26
6/17/2020
Part B Drug
$2.90
$0.58
6/17/2020
Part B Drug
$141.71
$28.34
6/18/2020
Part B Drug
$141.71
$28.34
6/18/2020
Part B Drug
$184.90
$36.98
6/18/2020
Part B Drug
$2.40
$0.48
6/18/2020
Part B Drug
$30.10
$6.02
7/13/2020
Part B Drug
$31.29
$6.26
7/13/2020
Part B Drug
$192.21
$38.44
7/13/2020
Part B Drug
$141.71
$28.34
7/13/2020
Part B Drug
$2.90
$0.58
The total amount the enrollee owes is: $591.02.
The enrollee has been asked to pay the total amount of $591.02 for Medicare Part B drugs and the administration. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. The administration falls within the physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and does not have to waive the copayments for the administration provided from April 3, 2020, to July 13, 2020.