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 20% coinsurance for durable medical equipment provider. You can find 
this information on page 63 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay $350 copayment per day, days 1 to 5 for inpatient hospital stay. 
You can find this information on pages 68 to 69 of the Plans 2022 Evidence of Coverage (EOC).  
  
The Plan contract says that enrollees must pay $275 copayment for advanced imaging services at outpatient 
hospital. You can find this information on pages 72 to 76 of the Plans 2022 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay $110 copayment for basic radiological services at outpatient 
hospital. You can find this information on pages 72 to 76 of the Plans 2022 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay $375 copayment for nuclear medicine services at outpatient 
hospital. You can find this information on pages 72 to 76 of the Plans 2022 Evidence of Coverage (EOC). 
 
 
 
 The Plan contract says that enrollees must pay $45 copayment for basic radiological services at freestanding 
radiological facility. You can find this information on pages 72 to 76 of the Plans 2022 Evidence of Coverage 
(EOC). 
 
The Plan contract says that enrollees must pay $180 copayment for advanced imaging services at primary care 
provider's (PCP's) office, specialist's office and freestanding radiological facility. You can find this information 
on pages 72 to 76 of the Plans 2022 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay $40 copayment at specialist's office. You can find this 
information on pages 72 to 76 of the Plans 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay $5 copayment for provider and professional services at primary 
care provider's (PCP's) office. You can find this information on pages 72 to 76 of the Plans 2022 Evidence of 
Coverage (EOC).  
 
The Plan contract says that enrollees must pay $35 copayment for urgent care center. You can find this 
information on pages 72 to 76 of the Plans 2022 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay $325 copayment for surgery services at outpatient hospital. You 
can find this information on pages 77 to 79 of the Plans 2022 Evidence of Coverage (EOC).