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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. 
 
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 you are covered for emergency care world-wide. If you have an emergency outside of the 
United States (US) and its territories, you will be responsible to pay for the services rendered upfront. You 
must submit to the Health Plan for reimbursement. For more information, please see Chapter 7. We may not 
reimburse you for all out-of-pocket expenses. This is because our contracted rates may be lower than provider 
rates outside of the U.S. and its territories. You are responsible for any costs exceeding our contracted rates as 
well as any applicable member cost-share. You can find this information in Chapter 4 on page 64 of the Plan's 
2022 Evidence of Coverage. 
 
The Plan contract says the plan covers worldwide emergency and urgent care services outside of the United 
States under the following circumstances. If you have an emergency or an urgent need for care outside of the 
U.S. and its territories, you will be responsible to pay for those services upfront and request appropriate 
reimbursement from us. We will reimburse you, for covered out-of-network emergency and urgent care 
services outside of the U.S. and its territories, at rates no greater than the rates at which Original Medicare 
would pay for such services had the services been performed in the United States in the locality where you 
reside. The amount we pay you, if any, will be reduced by any applicable cost-sharing. Because we will 
reimburse at rates no greater than the rates at which Original Medicare would reimburse, and because foreign 
providers might charge more for services than the rates at which Original Medicare would pay, the total of our 
reimbursement plus the applicable cost-sharing may be less than the amounts you pay the foreign provider. This is a supplemental benefit not generally covered by Medicare. You must submit proof of payment to 
the Plan  for reimbursement. See Chapter 4 (Medical Benefits Chart, what is covered and what you pay) for 
more information. If you have already paid for the covered services, we will reimburse you for our share of the 
cost for covered services. You can send the bill with medical records to us for payment consideration. See 
Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs) for 
information about what to do if you receive a bill or if you need to ask for reimbursement. You can find this 
information in Chapter 3 on page 48 of the Plan's 2022 Evidence of Coverage.