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 that plans can restrict members to using contract providers except for emergency care (including 
ambulance services), out-of-area urgently needed care, post-stabilization care, and pre-approved care. You can 
find this rule at 42 CFR Section 422.112(a)(9). 
 
The rules say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a 
contract provider or a non-contract provider. Emergency care ends when the patient is stabilized.  
 
Post-stabilization care is care that is administered to maintain, improve, or resolve the enrollee's stabilized 
condition. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is 
obtained from a non-contract provider, approval is required from the plan. However, the requirement for pre-
approval does not apply if: 
 
1. The Plan does not respond to a request for pre-approval within one hour, 
 
2. The Plan cannot be contacted, or 
 
3. The Plan representative and the treating physician cannot reach an agreement concerning the enrollee's care 
and a plan physician is not available for consultation. 
You can find this rule at 42 CFR Section 422.113(c). 
 
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, members are selecting the Plans medical care program to provide their health care. 
Members must receive all covered care from Plan Providers inside their Home Region Service Area, except as 
described in the sections listed below for the following Services: 
 Authorized referrals as described under Getting a Referral in the How to Obtain Services section 
 Chiropractic and acupuncture services as described in the Combined Chiropractic and Acupuncture 
Services section 
 Durable medical equipment as described under Durable Medical Equipment (DME) for Home 
Use in the Benefits section 
 Emergency ambulance Services as described under Ambulance Services in the Benefits section 
 Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care as described in the Emergency 
Services and Urgent Care section 
 Home health care as described under Home Health Care in the Benefits section 
 Hospice care as described under Hospice Care in the Benefits section 
 Ostomy and urological supplies as described under Ostomy and Urological Supplies in the Benefits 
section 
 Prosthetics and orthotics as described under Prosthetic and Orthotic Devices in the Benefits section 
 Visiting Member Services as described under Receiving Care Outside of Your Home Region in the How 
to Obtain Services section 
 
Members are enrolled in one of two Health Plan Regions in California (either the Plans Northern California 
Region or Southern California Region), called the members Home Region. The coverage information in this 
Evidence of Coverage (EOC) applies when members obtain care in their Home Region. 
 
The Plans medical care program gives members access to all of the covered Services they may need, such as 
routine care with their own personal Plan Physician, hospital care, laboratory and pharmacy Services, 
Emergency Services, Urgent Care, and other benefits described in the EOC. 
 
You can find this information on pages 26 and 27 of the Plans 2023 Evidence of Coverage.