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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.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
Items and services furnished outside the United States are excluded from coverage except for the following 
services, and certain services rendered on board a ship:  
1. Emergency inpatient hospital services where the emergency occurred: 
a. While the beneficiary was physically present in the United States; or  
b. In Canada while the beneficiary was traveling without reasonable delay and by the most direct route between 
Alaska and another State.  
2. Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the United 
States, if the hospital was closer to, or substantially more accessible from, the beneficiarys United States 
residence than the nearest participating United States hospital which was adequately equipped to deal with and 
available to provide treatment of the illness or injury   
3. Physician and ambulance services furnished in connection with a covered foreign hospitalization. Program 
payment may not be made for any other Part B medical and other health services, including outpatient services 
furnished outside the United States 4. Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, or 
departed from, a United States port, are considered to have been furnished in United States territorial waters. 
Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or departed from, a 
United States port, are considered to have been furnished outside United States territorial waters, even if the 
ship is of United States registry; and  
The term United States means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the 
Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered 
on a ship, includes the territorial waters adjoining the land areas of the United States. A hospital that is not 
physically situated in one of the above jurisdictions is considered to be outside the United States, even if it is 
owned or operated by the United States Government. 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 16, Section 60. 
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 $290 copayment per date of service, regardless of the number of trips 
for in-network ambulance services. You can find this information on page 50 of the Plan's 2023 Evidence of 
Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $70 copayment for in-network diagnostic procedures and 
tests. You can find this information on page 64 of the Plan's 2023 EOC. 
 
The Plan contract also says that enrollees must pay a $250 copayment per day, for days one to six and a $0 
copayment per day, for days seven to ninety for in-network inpatient care. You can find this information on 
page 60 of the Plan's 2023 EOC. 
 
The Plan contract also says that you are covered for emergency care world-wide. If you have an emergency 
outside of the U.S. and its territories, you will be responsible to pay for the services rendered upfront. You are 
also responsible for any costs exceeding our contracted rates as well as any applicable member cost share. You 
can find this information on page 55 of the Plan's 2023 EOC.