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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. 
 
The rules say that when an enrollee begins coverage in a new Medicare health plan during an inpatient hospital 
stay, payment for the stay is made by the plan the enrollee was in on the date of admission to the hospital. The 
new health plan is not responsible for the enrollees inpatient hospital care until after the date of discharge. You 
can find this rule at 42 CFR Section 422.318(b). 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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 the most enrollees must pay out-of-pocket for covered Part A and Part B services in 2022 is 
$4,900. This is called the maximum out-of-pocket amount (MOOP). You can find this information in Chapter 4 
on page 56 of the Plans 2022 Evidence of Coverage. 
 
The Plan contract says that enrollees must pay $250 copayment per day for days 1 to 5 and $0 copayment per 
day for days 6 to 90 per stay for inpatient hospital care. You can find this information in Chapter 4 on pages 66 
to 68 of the Plans 2022 Evidence of Coverage. 
 
The Plan contract says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. Cost-
sharing will apply to administration of drugs in all places of treatment. You can find this information in 
Chapter 4 on pages 69 to 70 of the Plan's 2022 Evidence of Coverage.  
 
The Plan contract says that enrollees must pay $30 copayment for basic radiological services provided in an 
outpatient hospital and $250 copayment for advanced imaging services provided in an outpatient hospital. You 
can find this information in Chapter 4 on pages 70 to 72 of the Plans 2022 Evidence of Coverage. 
 
The Plan contract says that enrollees must pay $250 copayment for surgery services provided at an outpatient 
hospital. You can find this information in Chapter 4 on page 75 of the Plans 2022 Evidence of Coverage. 
 
The Plan contract says that enrollees must pay $30 copayment for specialist provider/professional services. 
You can find this information in Chapter 4 on pages 76 to 77 of the Plans 2022 Evidence of Coverage.