Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance transportation, emergency room care, inpatient hospital care, and specialist visits provided from November 2, 2020, to December 24, 2020.
You asked the Plan to waive the copayments for ambulance transport, emergency care, inpatient hospital care, and specialist visits. You say that the Plan's records do not reflect all payments made toward the 2020 maximum out-of-pocket amount which negatively impacts you financially. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $265 copayment for ambulance transportation, $120 copayment for emergency room visit, $175 copayment per day for days 1 to 5 for each inpatient hospital stay, and $30 copayment for each specialist visit, up to a maximum out-of-pocket amount of $3,400 for 2020. At the time these claims were processed, $80 of the $3,400 maximum out-of-pocket amount for 2020 had been met. A summary of your cost-sharing amounts is shown below:
Date(s) of Service Service Provided Allowed Amount Cost-Share Per Contract Your Cost-Share Responsibility
November 2, 2020
Ambulance Transport
$476.92
$265 copayment
$265 November 2, 2020 Neurology Visit $75.68 $30 copayment $30
November 4, 2020
Neurology Visit
$51.32
$30 copayment
$30 November 3, 2020 to November 5, 2020 Inpatient Hospital Stay (2 days) $7,358.80 $175 copayment per day for days 1 to 5 $350
November 5, 2020 to November 9, 2020
Inpatient Rehab Stay (4 days)
$3,688
$175 copayment per day for days 1 to 5
$525 November 9, 2020 Emergency Room Visit $1,594.16 $120 copayment $120
November 10, 2020
Cardiology Visit
$60.54
$30 copayment
$30 November 10, 2020 Neurology Visit $75.05 $30 copayment $30
November 11, 2020 to November 15, 2020
Inpatient Hospital Stay (4 days)
$7,117.24
$175 copayment per day for days 1 to 5
$700 November 15, 2020 to December 9, 2020 Inpatient Rehab Stay (24 days) $22,128 $175 copayment per day for days 1 to 5 $175
December 24, 2020
Neurology Visit
$137.65
$30 copayment
$30 Total $2,285
Therefore, your total cost-sharing responsibility is $2,285, which does not meet the $3,400 maximum out-of-pocket amount for 2020.
You have been asked to pay $265 copayment for ambulance transportation, $120 copayment for emergency room visit, $175 copayment per day for days 1 to 5 for each inpatient hospital stay, and $30 copayment for each specialist visit. Ambulance transport, emergency care, inpatient hospital care, and specialist visits falls within the "Ambulance Services, "Emergency Care", "Inpatient Hospital Care", and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for ambulance transportation, emergency room care, inpatient hospital care, and specialist visits provided from November 2, 2020, to December 24, 2020.