Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan must waive the coinsurance for the outpatient hospital clinic visit provided on August 
24, 2021. We also decided that the Plan has to reduce the cost sharing for the humerus surgery provided on 
August 30, 2021. We also decided that the Plan does not have to waive the copayment for the emergency room 
(ER) services provided from August 19, 2021, to August 20, 2021.  
 
You asked the Plan to waive the cost sharing for the ER services, the outpatient hospital clinic visit, and the 
surgery. You say that you were out of town and had an accident which needed surgery. You say that you were 
told it was an emergency, and you were instructed not to travel. The Plan denied your request. The Plan says 
that you have been charged the correct cost sharing amount. 
 
 
 
 We decided that the Plan has to waive the coinsurance for the outpatient hospital clinic 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 does not say in clear and accurate terms 
how much you should expect to pay for an outpatient hospital clinic visit.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 40% 
coinsurance for an outpatient hospital clinic visit. The Plan contract does not clearly say how much enrollees 
must pay for an outpatient hospital clinic visit. This means that the Plan did not follow Medicare rules for 
disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for an 
outpatient hospital clinic visit provided on August 24, 2021. 
 
We decided that the Plan has to reduce the cost sharing for the surgery. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not submitted medical records. There is no evidence that your 
condition was not an urgent situation. The record shows you were out of the area, and in-network providers 
were not available. Therefore, we decided that the Plan has cover the surgery at the in-network rate.   
 
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 a $400 copayment for outpatient surgery at an in-network 
outpatient hospital. 
 
The Plan says you must pay 40% coinsurance for the surgery. Based on the Plan contract, however, you cannot 
be asked to pay more than a $400 copayment for the surgery. Therefore, we decided that the Plan has to reduce 
the cost sharing for the humerus surgery provided on August 30, 2021.  
 
We decided that the Plan does not have to waive the copayment for the ER 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 a $90 
copayment for both in and out of network emergency services.  
 
You have been asked to pay a $90 copayment for ER services. ER services falls within the Emergency Care 
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 copayment for the emergency room (ER) 
services provided from August 19, 2021, to August 20, 2021.  
 
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.