Appeal type: ER
Decision: Partially Favorable

 
You asked the Plan to waive the cost-sharing for outpatient observation services provided from February 16, 
2022, to February 18, 2022. You also asked the Plan to waive the deductible and the coinsurance for a 
magnetic resonance imaging (MRI) and pay for self-administered drugs provided from February 16, 2022, to 
February 18, 2022. You say that you did not request these services. You also say you were abducted from the 
gas station by a police office and someone else. You also say you were forcibly taken to the hospital against 
your will, and do not feel you should have to pay for these services. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to waive the cost-sharing for the emergency room visit, magnetic resonance 
imaging (MRI), and observation services provided from February 16, 2022, to February 18, 2022.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for emergency room visit if the enrollee is 
admitted to the hospital within 3 days for the same condition. Your contract with the Plan also says that 
diagnostic radiology and physician services performed during inpatient hospital care are included in the 
inpatient hospital care, so these services do not have separate payment or cost-sharing. The record shows that 
you were admitted to the hospital as an inpatient on February 16, 2022. Therefore, the emergency room 
copayment is waived according to your contract with the Plan and the separate cost-sharing applied to the MRI 
and physician services is not applicable. 
 
The Plan says you must pay $65 copayment for emergency care services, $64.62 deductible amount for MRI, 
and $6.92 coinsurance amount for physician services. Based on the Plan contract, however, you cannot be 
asked to pay more than $0 for these services. Therefore, we decided that the Plan has to waive the cost-sharing 
for an emergency room visit, magnetic resonance imaging (MRI) scan, and observation care services provided 
from February 16, 2022, to February 18, 2022.  
 
We also decided that the Plan does not have to waive the cost-sharing for self-administered drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.  
Benefits for self-administered drugs may be available through Medicare Part D. Please contact your Medicare 
Part D plan for more information about requesting coverage for these drugs.