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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 for services of a non-contracting, original Medicare, participating provider; there is no 
balance billing paid by either the plan or the enrollee. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 
170. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The health plan contract says that "as a member of the Health Plan an important protection for you is that you 
only have to pay your cost-sharing amount when you get services covered by our plan. We do not allow 
providers to add additional separate charges, called balance billing. This protection (that you never pay more 
than your cost-sharing amount) applies even if we pay the provider less than the provider charges for a service 
and even if there is a dispute and we dont pay certain provider charges. Here is how this protection works. 
If your cost sharing is a copayment (a set amount of dollars, for example, $15.00), then you pay only that 
amount for any covered services from a network provider. 
If your cost sharing is a coinsurance (a percentage of the total charges), then you never pay more than that 
percentage. However, your cost depends on which type of provider you see: 
If you receive the covered services from a network provider, you pay the coinsurance percentage multiplied by 
the plans reimbursement rate (as determined in the contract between the provider and the plan). 
If you receive the covered services from an out-of-network provider who participates with Medicare, you pay 
the coinsurance percentage multiplied by the Medicare payment rate for participating providers. (Remember, 
the plan covers services from out-of-network providers only in certain situations, such as when you get a 
referral.) 
If you receive the covered services from an out-of-network provider who does not participate with Medicare, 
you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers. (Remember, the plan covers services from out-of-network providers only in certain situations, such as when 
you get a referral.) 
If you believe a provider has balance billed you, call our Call Center (phone numbers are printed on the back 
cover of this booklet)." You can find this information in Chapter 4 on page 61 of the plan's 2021 Evidence of 
Coverage (EOC) and in Chapter 4 on page 60 of the plan's 2022 EOC.