Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for ambulance services, chiropractic services, 
a folding walker, an emergency room visit, inpatient hospital care, an X-Ray examination, specialist office 
visits, and an urgent care visit provided from March 7, 2022, to May 18, 2022.  
You asked the Plan to waive the cost-sharing for ambulance trips, chiropractic visits, folding walker, 
emergency room visit, inpatient care, X-Ray, specialist visits, and urgent care visit. You say that you are on a 
fixed income and do not have this type of money. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
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 $275 
copayment for each ambulance trip, $15 copayment for each chiropractic visit, 20% coinsurance for durable 
medical equipment (DME), $90 copayment for each emergency room visit, $350 copayment per day for days 1 
to 5 for inpatient hospital care, $30 copayment for each X-Ray, $50 copayment for each specialist visit, and 
$50 copayment for each urgent care visit. A summary of your cost-sharing amounts follows: 
 
Date(s) of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Responsibility 
March 7, 2022 Ambulance Trip $464.89 $275 copayment $275 
March 28, 2022 Ambulance Trip $509.91 $275 copayment $275 
March 28, 2022 to 
April 9, 2022 
Inpatient Care $40,887.50 
$350 copayment per 
day for days 1 to 5 
$1,750 
April 14, 2022 Folding Walker $69.71 20% coinsurance $13.94 
April 15, 2022 X-Ray $32.59 $30 copayment $30 
April 22, 2022 Chiropractic Visit $27.10 $15 copayment $15 
April 25, 2022 Chiropractic Visit $27.10 $15 copayment $15 
April 28, 2022 Chiropractic Visit $27.10 $15 copayment $15 
April 29, 2022 Emergency Care $458.96 $90 copayment $90 
April 29, 2022 Dermatology Visit $69.62 $50 copayment $50 
April 29, 2022 Ambulance Trip $454.21 $275 copayment $275 
May 3, 2022 Urgent Care Visit $123.42 $50 copayment $50 
May 5, 2022 Chiropractic Visit $27.10 $15 copayment $15 
May 18, 2022 Cardiology Visit $104.91 $50 copayment $50 
Total    $2,918.94 
 
Therefore, your total cost-sharing responsibility is $2,918.94. 
 
You have been asked to pay $275 copayment for each ambulance trip, $15 copayment for each chiropractic 
visit, 20% coinsurance for durable medical equipment (DME), $90 copayment for each emergency room visit, 
$350 copayment per day for days 1 to 5 for inpatient hospital care, $30 copayment for each X-Ray, $50 
copayment for each specialist visit, and $50 copayment for each urgent care visit for ambulance trips, 
chiropractic visits, folding walker, emergency room visit, inpatient care, X-Ray, specialist visits, and urgent 
care visit. This item/service falls within the "Ambulance Services", "Chiropractic Services", "Durable Medical 
Equipment (DME) and Related Supplies", "Emergency Care", "Inpatient Hospital Care", "Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies", "Physician/Practitioner Services, Including Doctor's 
Office Visits", and "Urgently Needed Services" 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 cost-sharing for ambulance services, chiropractic services, a folding walker, an emergency room visit, inpatient 
hospital care, an X-Ray examination, specialist office visits, and an urgent care visit provided from March 7, 
2022, to May 18, 2022.