Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-shares for inpatient hospital care, emergency room
(ER) visits (99284,99285), emergency ambulance services (A0427), skilled nursing facility (SNF) care, an xray
of the chest (71046), office visits with a specialist (99203, 99205), laboratory services (82274) and a
computed tomography (CT) scan (74176) provided on December 3, 2019, to January 10, 2021.

You asked the Plan to waive the cost-shares for inpatient hospital care, ER visits, ambulance service, SNF care,
an x-ray, office visits, laboratory services and a CT scan. You say that you would like to appeal all of your
cost-shares from 2019 through 2021. You say that every time you had to go to a facility or have an expensive
test done, you would call the Plan and they always told you it was covered. You also say you are now in
collections and don't have the money to pay for these claims. The Plan denied your request. The Plan says the
copayments 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 discloses your cost-sharing
responsibilities, in clear and accurate terms.

You have been asked to pay various copayments for inpatient hospital care, ER visits, ambulance service, SNF
care, an x-ray, office visits, laboratory services and a CT scan.

The records show that you were inpatient for eight days, from December 3, 2019, to December 11, 2019. The
EOC confirms that $290 per day, for days 1 to 6, is the required copayment for this service. Your total cost
share is $1,740 ($290 x 6 days = $1,740). You received SNF care for 22 days from December 11, 2019, to
January 2, 2020. The EOC confirms $135 is the required copayment for day 21 and day 22. Your total cost
share is $270 (135 x 2 days - $270). You had an office with a specialist on May 6, 2020, and May 26, 2020.
The EOC confirms that $35 per visit, is the required copayment for this service. You had an emergency room
visit on May 12, 2020, and January 10, 2021. The EOC confirms $85 per emergency room visit, is the required
copayment for this service. You had an emergency ambulance service on April 23, 2020. The EOC confirms
$210 is the required copayment for this service. You had an x-ray of the chest on May 6, 2020. The EOC
confirms $80 is the required copayment for this service. You have been asked to pay a copayment of $74.15,
which is less than the Plan's contracted amount. You had laboratory services on June 2, 2020. The EOC
confirms $30 is the required copayment for this service. You have been asked to pay a copayment of $15.92,
which is less than the Plan's contracted amount. You had a CT Scan of the abdomen on July 2, 2020. The EOC
confirms $190 is the required copayment for this service.

This means that you have been asked to pay the correct cost share amounts based on your contracts with the
Plans. 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 cost-shares for inpatient hospital care, emergency room
(ER) visits (99284,99285), emergency ambulance services (A0427), skilled nursing facility (SNF) care, an xray
of the chest (71046), office visits with a specialist (99203, 99205), laboratory services (82274) and a
computed tomography (CT) scan (74176) provided on December 3, 2019, to January 10, 2021.