Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the items/services provided from February 
15, 2022, to October 17, 2022. 
 
You asked the Plan to waive the cost share for the items/services. You say that you were charged more than 
your out-of-pocket maximum. 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 a $250 
copayment for in-network outpatient surgery provided at an ambulatory surgical center. Your contract with the 
Plan also says that you must pay a $275 copayment for each in-network or out-of-network one-way ground 
ambulance service. Your contract with the Plan also says that you must pay a $170 copayment per day for days 
1-5 of each in-network inpatient hospital stay. Your contract with the Plan also says that you must pay a $35 
copayment for each in-network specialist office visit. Your contract with the Plan also says that you must pay a 
$30 for each in-network x-ray. Your contract with the Plan also says that you must pay a $25 copayment for 
each in-network physical therapy service. Your contract with the Plan also says that you must pay a $295 
copayment for in-network diagnostic radiology, including MRIs. 
 
Date(s) of Service Item/Service Benefit Category Allowed Amount Copayment 
February 15, 2022 Endoscope 
procedure 
Outpatient surgery $640.99 $250 
March 11, 2022 Ambulance Ambulance services $453.22 $275 
March 11, 2022, to 
March 16, 2022 
Inpatient hospital 
(5 days) 
Inpatient hospital 
care 
$11,822.59 $850 
March 18, 2022 Ambulance Ambulance services $623.50 $275 
March 31, 2022 Specialist office 
visit 
Physician/practitioner 
services 
$61.15 $35 April 1, 2022 X-ray Outpatient diagnostic 
tests and therapeutic 
services 
$34.46 $30 
April 29, 2022 X-ray Outpatient diagnostic 
tests and therapeutic 
services 
$34.46 $30 
May 2, 2022, to 
May 31, 2022 
Physical therapy Outpatient 
rehabilitation 
services 
$43.65 $650 ($25 
copayment per 
visit) 
May 11, 2022 MRI Outpatient diagnostic 
tests and therapeutic 
services 
$455.72 $295 
June 1, 2022, to 
June 23, 2022 
Physical therapy Outpatient 
rehabilitation 
services 
$2,326.38 $500 ($25 
copayment per 
visit) 
June 7, 2022 X-ray Outpatient diagnostic 
tests and therapeutic 
services 
$34.46 $30 
October 17, 2022 X-ray Outpatient diagnostic 
tests and therapeutic 
services 
$56.64 $30 
October 17, 2022 Specialist office 
visit 
Physician/practitioner 
services 
$61.15 $35 
 
The records show your out-of-pocket maximum was processed correctly. 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 share for the items/services provided from February 15, 2022, to October 17, 2022.