Appeal type: ER
Decision: Partially Favorable

 
You asked the Plan to waive the cost-sharing for emergency care services provided in the United Mexican 
States from March 15, 2022, to March 31, 2022.. You say that you are requesting reimbursement for these 
charges. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the deductible and make additional payment for emergency care 
services.  
 
The Plan follows Medicare rules. Medicare rules state that items and services furnished outside of the United 
States and its territories are excluded from coverage except under the circumstances specified in the previous 
section. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The Plan has a worldwide coverage supplement that 
exceeds Medicares coverage. For that reason, the Plans rules apply to this case. The Plan covers worldwide 
emergency and urgent care, but you must pay for the services up front and request reimbursement from the 
Plan. Your contract with the Plan does not say in clear and accurate terms whether any deductible applies to 
covered worldwide services. 
 
The Plan denied payment for the services performed on March 31, 2022 on the grounds that these services are 
inclusive to the revenue codes reimbursed for date of service March 15, 2022. However, these services were 
performed on a different date and separately from March 15, 2022; therefore, the Plan has not supported why 
these separate services should not be separately reimbursed. You paid for these services up front and submitted 
an itemized statement to the Plan for reimbursement, in accordance with the Plans rules. 
 We looked at your contract with the Plan. The Plan contract says that there is no deductible for members of the 
Plan, but also says that worldwide services are subject to a $250 deductible. The Plan contract does not clearly 
say whether a deductible applies or does not apply to worldwide services. This means that the Plan did not 
follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to pay 
for the services provided on March 31, 2022 and has to waive the deductible for all services that you have 
requested reimbursement for.  
 
We also decided that the Plan does not have to waive the cost-sharing for emergency care services. 
 
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 20% 
coinsurance for worldwide services. The total allowed amount for these services is $352.38, resulting in a 
coinsurance amount of $70.48. Therefore, we decided that the Plan does not have to waive the cost-sharing for 
emergency care services. 
 
Therefore, we decided that the Plan has to issue you a total reimbursement amount of $281.90. The Plan 
originally reimbursed you $6.41; therefore, the Plan must issue you an additional reimbursement amount of 
$275.49. 
 
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.