Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied for emergency room services or pay for self-administered drugs provided in a facility from March 30, 2022, to April 1, 2022
You asked the Plan to pay for these services. You stated you went to the emergency room due to a fall and reaction to medication. You would like this claim reprocessed and paid. The Plan stated this cost sharing was reprocessed and charged correctly based on the Plan contract agreement. Maximus upheld the Plans decision. You requested an ALJ hearing. After looking at the case file the ALJ remanded the appeal back to Maximus because they believed information was missing from the Plan.
Regarding the missing Plan redetermination letter, per section 50.12 of the Parts C and D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Effective January 1, 2020, Plans are not required to notify beneficiaries upon forwarding cases to the Part C IRE. Enrollees will receive notification from the IRE that their appeal has been received. This allows Plans not to send a redetermination notice if they choose not to for retrospective cases. Plans opting to inform parties when a case has been forwarded to the IRE may use the model Notice of Appeal Status.
In this case, coverage for the emergency room services was not denied, however the $90 applicable cost share was applied and explained on the explanation of benefits provided to you. The only items denied under your Medicare Part B coverage were the self-administered drugs provided by the facility. Payment for self-administered drugs would be submitted to your Medicare Part D carrier for coverage. Since this was the only fully denied issue, you only received a redetermination letter from the Plan for self-administered drugs. Again, the ALJ should be aware that due to the above manual guidance, health Plans are not required to send redetermination letters on retrospective cases that will be forwarded to Maximus for further review.
As stated in our prior decision, the Plan is correct in this case regarding to cost share applied. 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 a $90 copayment for emergency room services. Also, regarding self-administered drugs, the contract also clearly states that self-administered drugs are not covered under the Medicare Part B benefit. For the emergency room services, you have been asked to pay a $90 copayment, per your Plan contract agreement. For the self-administered drugs, payment for these services should be submitted to your Medicare Part D prescription drug carrier. The emergency room cost share is a contractual obligation you agreed to pay when you enrolled in the Plan. The Plan has given direction on how to submit claims to your Medicare Part D carrier for coverage of self-administered drugs.
Therefore, we decided that the Plan does not have to waive the cost share applied for emergency room services or pay for self-administered drugs provided in a facility from March 30, 2022, to April 1, 2022.