Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item 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 copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment 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 Plan 
contract says that enrollees must pay a $90 copayment for an in-network emergency room (ER) visit. You can 
find this information on page 52 of the Plan's 2021 Evidence of Coverage (EOC). 
The Plan contract also says that enrollees must pay a $180 copayment for in-network advanced imaging 
services, including a computed tomography (CT) scan at an outpatient hospital. You can find this information 
on page 60 of the Plan's 2021 EOC. 
 
The Plan contract also says that enrollees must pay a $40 copayment for an in-network specialist office visit. 
You can find this information on page 69 of the Plan's 2021 EOC. 
The Plan contract also says that enrollees must pay a $290 copayment for in-network ambulance services. You 
can find this information on page 47 of the Plan's 2021 EOC. 
 
The Plan contract also says that enrollees must pay a $350 copayment for in-network outpatient surgery at an 
outpatient hospital. You can find this information on page 68 of the Plan's 2021 EOC. 
 
The Plan contract also says that enrollees must pay a $90 copayment for in-network outpatient diagnostic 
testing at an outpatient hospital. You can find this information on page 60 of the Plan's 2021 EOC. 
 
The Plan contract also says that enrollees must pay a $350 copayment for in-network nuclear medicine services 
at an outpatient hospital. You can find this information on page 61 of the Plan's 2021 EOC. 
 
The Plan contract also says that enrollees must pay a $90 copayment for in-network basic radiological services, 
including x-rays at an outpatient hospital. You can find this information on page 61 of the Plan's 2021 EOC. 
 
The Plan contract also says that enrollees must pay a $350 copayment per day for days 1-5 for an in-network 
inpatient hospital stay. The contract also says that there is a $0 copayment for days 6-90. You can find this 
information on page 56 of the Plan's 2021 EOC. 
 
The Plan contract also says that enrollees must pay 30% coinsurance for out-of-network advanced imaging 
services, including ultrasounds and CT scans at a freestanding radiological facility. You can find this 
information on page 63 of the Plan's 2021 EOC. 
 
The Plan contract also says that enrollees must pay 30% coinsurance for out-of-network (OON) basic 
radiological services, including x-rays at a freestanding radiological facility. You can find this information on 
page 63 of the Plan's 2021 EOC.