Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit provided on February 20, 
2023, the emergency room services provided on February 18, 2023, the surgery services, the medical supplies, 
and the injections provided on February 17, 2023. 
 
You asked the Plan to waive the cost share for the office visit, emergency room services, the surgery services, 
the medical supplies, and the injections. You say that you would like all the services to be fully covered. 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 $30 
copayment for out-of-network Medicare-covered primary care physician services. Your contract with the Plan 
also clearly says that you must pay a $90 copayment for in-network Medicare-covered emergency room visits. 
Your contract with the Plan also clearly says that you must pay a $375 copayment for in-network Medicare-
covered outpatient hospital services. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for in-network Medicare-covered medical supplies. Your contract with the Plan also clearly says 
that you must pay 20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a $30 copayment for the office visit provided on February 20, 2023. This 
item/service falls within the physician/practitioner services, including doctors office visits benefit category. 
You have also been asked to pay a $90 copayment for the emergency room services provided on February 18, 
2023. This item/service falls within the emergency care benefit category. You have also been asked to pay a 
$375 copayment for the surgery services provided on February 17, 2023. This item/service falls within the 
outpatient hospital services 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. 
 
You have also been asked to pay $72.60, which is 20% of the allowed amount for the medical supplies ($363 
allowed amount x 20% = $72.60). This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. You have also been asked to pay 20% coinsurance of the allowed 
amount for the injections. This item/service falls within the Medicare Part B prescription drugs 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 cost share for the office visit provided on February 20, 2023, 
the emergency room services provided on February 18, 2023, the surgery services, the medical supplies, and 
the injections provided on February 17, 2023.