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Decision: unknown

The rules say that plans must pay for a medical service oritem if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as co payments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).

The rules say that a co payment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health plan contract says that enrollees must pay a $35 co payment per visit for outpatient rehabilitation services. Covered services include: physical therapy, occupational therapy, and speech language therapy. You can find this information in Chapter 4 on page 78 of the plan's 2019 Evidence of Coverage.

The health plan contract says that enrollees must pay 20% of the total cost for each Medicare-covered service provided in an outpatient hospital or an ambulatory surgical center, including but not limited to hospital or facility charges, observation room/stay charges, physician charges and surgical charges. You can find this information in Chapter 4 on page78 of the plan's 2019 Evidence of Coverage

The health plan contract states,"As a member of this Plan, the most you will have to pay out-of-pocket for in-network covered Part A and Part B services in 2019 is $5,000. The amounts you pay for co payments, and coinsurance for in-network covered services count toward this maximum out-of-pocket amount.(The amounts you pay for your plan premiums and for your Part D prescription drugs do not count toward your maximum out-of-pocket amount.) In addition, amounts you pay for some services do not count toward your maximum out-of-pocket amount. These services are marked in italics in the Medical Benefits Chart. If you reach the maximum out-of-pocket amoun tof $5,000 you will not have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services. However, you must continue to pay your plan premium and the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). The most you will have to pay out-of-pocket for out-of-network services covered under the POS benefit in 2019 is $10,000. The amounts you pay for co payments and coinsurance for POS covered services count toward the POS maximum out-of-pocket amount. (The amounts you pay for your plan premiums and for your Part D prescription drugs do not count toward your maximum POS out-of-pocket amount.) If you reach the maximum out-of-pocket amount of $10,000, you will not have to pay any out-of-pocket costs for the rest of the year for POS covered services. You can find this information in Chapter 4 on pages 55-56 of the plan's 2019 Evidence of Coverage.