Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing for outpatient hospital visits and Part B infusion drugs. You say that you paid a lower amount for your drug therapy in previous years, and had no reason to believe that the cost for you would be raised. The Plan says that the cost-sharing amounts you are being charged are correct. 
 
We decided that the Plan has to reduce the cost-sharing for the outpatient hospital visit provided by Kootenai Health from May 10, 2019 to May 17, 2019.  
 
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 $250 copayment for each outpatient hospital visit. The Plan contract also says that charges for the administration of Part B drugs and included in this outpatient hospital visit copayment when the services are performed in an outpatient hospital location. The services provided from May 10, 2019 to May 17, 2019 were billed by the provider as a single hospital visit, therefore only 1 outpatient hospital visit copayment would apply to this claim. 
 
The Plan says that you must pay $391.34 for outpatient hospital visit. Based on the Plan contract, however, you cannot be asked to pay more than $250 copayment for outpatient hospital visit. Therefore, we decided that the Plan has to reduce the copayment for outpatient hospital visit from $391.34 to $250. 
 
We also decided that the Plan does not have to waive the cost-sharing for outpatient hospital visits and Part B drugs provided by Kootenai Health from April 30, 2019 to October 29, 2019. 
 
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 $250 copayment for each outpatient hospital visit, including the administration of Part B drugs, and 20% coinsurance for Part B drugs. For several dates of service, you have been asked to pay less than the applicable $250 copayment for each outpatient hospital visit. A summary of your cost-sharing amounts is presented as follows: 
 
Table A - Dates of service April 30, 2019 to July 9, 2019 
April 30, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
April 30, 2019 Part B Drugs $1,433.95 20% coinsurance $286.79 May 10, 2019 to May 17, 2019 Outpatient Hospital Visit $1,809.48 $250 copayment $250 May 10, 2019 to May 17, 2019 Part B Drugs $1,607.38 20% coinsurance $321.48 May 28, 2019 Outpatient Hospital Visit $182.07 $250 copayment $36.41 May 28, 2019 Part B Drugs $1,433.95 20% coinsurance $286.79 
June 11, 2019 
Outpatient Hospital Visit 
$218.92 $250 copayment $43.78 
June 11, 2019 Part B Drugs $1,433.95 20% coinsurance $286.79 
June 25, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
June 25, 2019 Part B Drugs $1,433.95 20% coinsurance $286.79 
July 9, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
July 9, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
Total - Table A    $2,197.14 
 
The summary of your cost-sharing amounts continues on the following page.  
July 22, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
July 22, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
August 6, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
August 6, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
August 20, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
August 20, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
September 3, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
September 3, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
September 17, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
September 17, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
October 1, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
October 1, 2019 Part B Drugs $1,478.06 20% coinsurance $295.61 
October 15, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
October 15, 2019 Part B Drugs $1,478.06 20% coinsurance $295.61 
October 29, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
October 29, 2019 Part B Drugs $1,478.06 20% coinsurance $295.61 
Total 
 July 22, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
July 22, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
August 6, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
August 6, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
August 20, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
August 20, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
September 3, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
September 3, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
September 17, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
September 17, 2019 Part B Drugs $1,445.42 20% coinsurance $289.08 
October 1, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
October 1, 2019 Part B Drugs $1,478.06 20% coinsurance $295.61 
October 15, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
October 15, 2019 Part B Drugs $1,478.06 20% coinsurance $295.61 
October 29, 2019 
Outpatient Hospital Visit 
$182.07 $250 copayment $36.41 
October 29, 2019 Part B Drugs $1,478.06 20% coinsurance $295.61 
Total