Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayments for infusion therapy provided 
on January 10, 2022, January 11, 2022, January 12, 2022, January 13, 2022, January 14, 2022, February 7, 
2022, February 8, 2022, February 9, 2022, February 10, 2022, February 11, 2022, March 7, 2022, March 8, 
2022, March 9, 2022, March 10, 2022, March 11, 2022, April 4, 2022, April 5, 2022, April 6, 2022. 
 
You asked the Plan to waive the deductible and copayments for infusion therapy. You say that you would like 
the copayments corrected. The Plan denied your request. The Plan says the proper deductible and copayments 
were applied for the service that was rendered. 
 
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 $1000 
deductible this is the amount you have to pay out-of-pocket before we will pay our share for your covered 
medical services. Until you have paid the deductible amount, you must pay the full cost of your covered 
services. Once you have paid your deductible, we will begin to pay our share of the costs for covered medical 
services and you will pay your copayment or coinsurance amount for the rest of the calendar year. Your 
contract with the Plan also clearly says that you must pay a $325 copayment for Medicare- covered surgery or 
other services provided to you at an outpatient hospital, including but not limited to hospital or other facility 
charges and physician or surgical charges. 
 
Prior to January 10, 2022, the total amount paid towards the yearly deductible was $88.83 leaving a balance of 
$911.17 to pay towards the yearly deductible. The total allowed amount for each date of service was $197.90 
which is less than the copayment amount allowed of $325. Therefore, on January 10, 2022, January 11, 2022, 
January 12, 2022, January 13, 2022, a deductible of $197.90 was charged for each date of service totaling 
$791.60. On January 14, 2022, the yearly deductible was met. The total amount charged was $197.90 with 
$119.57 being charged as the deductible. 
 
On January 14, 2022, there was a remaining balance of $78.33 which was applied as a copayment since the 
total amount allowed was $197.90 which is less than the copayment amount of $325. From February 7, 2022, 
to April 6, 2022, there was a total of 13 visit with a copayment amount of $197.90 charged for each visit. The 
total amount charged during those dates was $2,572.70 (13 visits x $197.90 copayment for each visit). 
 
You have been asked to pay a $911.17 deductible and a $2,651.03 copayment for infusion therapy. The yearly 
deductible falls within the What is Your Plan Deductible benefit category. Infusion therapy falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. 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 deductible and copayments for 
infusion therapy provided on January 10, 2022, January 11, 2022, January 12, 2022, January 13, 2022, January 
14, 2022, February 7, 2022, February 8, 2022, February 9, 2022, February 10, 2022, February 11, 2022, March 
7, 2022, March 8, 2022, March 9, 2022, March 10, 2022, March 11, 2022, April 4, 2022, April 5, 2022, April 
6, 2022.