24 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Medical Benefits Chart Services that are covered for you What you must pay when you get these services Outside service area benefit If you travel outside our service area, but inside the United States or its territories, we cover preventive, routine, follow- up, or continuing care office visits obtained from out-of- 20% of the Medicare allowable or network Medicare providers not to exceed $1,000 in covered limiting charges, and any amounts that Plan Charges per calendar year. exceed $1,000 in Plan Charges per We will pay up to 80% of the Medicare allowable charge, if calendar year the provider accepts assignment. Otherwise, we will pay 80% of the Medicare limiting charge, if the provider does not accept assignment. Partial hospitalization services and intensive outpatient services† Partial hospitalization is a structured program of active psychiatric treatment provided as a hospital outpatient service or by a community mental health center, that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization. Note: Because there are no community mental health centers $25 per day in our network, we cover partial hospitalization only as a hospital outpatient service. Intensive outpatient service is a structured program of active behavioral (mental) health therapy treatment provided in a hospital outpatient department, a community mental health center, a federally qualified health center, or a rural health clinic that is more intense than the care received in your doctor's or therapist's office but less intense than partial hospitalization. Physician/practitioner services, including doctor's Note: Cost-sharing is charged based on office visits the medical department where the Covered services include: service is provided, not the type of • †Medically necessary medical care or surgery services provider. In addition, multiple furnished in a physician's office, certified ambulatory copayments may apply, depending on surgical center, hospital outpatient department, or any other services provided and whether a location. consultation occurs. • †Consultation, diagnosis, and treatment by a specialist. Primary care office visits • $25 per visit † Your provider must obtain prior authorization from our plan. * Your cost-sharing for these services or items doesn't apply toward the maximum out-of-pocket amount. kp.org