Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the nasal endoscopy and the specialist visit. We 
decided that the Plan does not have to waive the deductible for the specialist visit.  
 
You asked the Plan to waive the deductible and the copayment for the specialist visit, and the nasal endoscopy 
provided by an in-network provider on November 3, 2021. You say that you would like the cost sharing to be 
lower. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the copayment for the nasal endoscopy and the specialist visit.  
 
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 says that you must pay a $0 copayment 
for in-network Medicare-covered surgery or other services provided at an ambulatory surgical center, including 
but not limited to hospital or other facility charges and physician or surgical charges. The Plan says you must 
pay a $44.23 copayment for outpatient surgery services. Based on the Plan contract, however, you cannot be 
asked to pay more than a $0 copayment for in-network outpatient surgery services.  
 
Your contract with the Plan also says that you must pay a $0 copayment for in-network services obtained from 
a specialist, or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other 
non-physician health care professionals in a specialists office. The Plan says you must pay a $2.89 copayment 
for the specialist services. Based on the Plan contract, however, you cannot be asked to pay more than a $0 
copayment for in-network specialist services. Therefore, we decided that the Plan has to waive the copayment 
for the nasal endoscopy and the specialist visit.  
 
We also decided that the Plan does not have to waive the deductible for the specialist visit. 
 
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 the full 
cost for covered services until you have paid the $198 deductible, and the deductible applies to in and out-of-
network specialist services. 
 
The specialist visit falls within the physician/practitioner services, including doctors office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 
deductible, which applies to in and out-of-network specialist services. This cost sharing is a contractual 
obligation that had not been met at the time the specialist visit was provided on November 3, 2021. Therefore, 
we decided that the Plan does not have to waive the deductible for the specialist visit. 
 
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.