2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 51 Chapter 4: Medical Benefits Chart (what is covered and what you pay) Chapter 4 — Medical Benefits Chart (what is covered and what you pay) Section 1 — Understanding your out-of-pocket costs for covered services The Medical Benefits Chart that lists your covered services and shows how much you will pay for each covered service as a member of our plan is found at the front of this EOC. Later in this chapter, you can find information about medical services that are not covered. It also explains limits on certain services. In addition, please see Chapter 3, Chapter 9, and Chapter 10 for additional coverage information, including limitations (for example, coordination of benefits, durable medical equipment, home health care, skilled nursing facility care, and third party liability). Section 1.1 – Types of out-of-pocket costs you may pay for your covered services To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. • Copayment is the fixed amount you pay each time you receive certain medical services. You pay a copayment at the time you get the medical service unless we do not collect all cost- sharing at that time and send you a bill later. (The Medical Benefits Chart found at the front of this EOC tells you more about your copayments.) • Coinsurance is the percentage you pay of the total cost of certain medical services. You pay a coinsurance at the time you get the medical service unless we do not collect all cost-sharing at that time and send you a bill later. (The Medical Benefits Chart found at the front of this EOC tells you more about your coinsurance.) Most people who qualify for Medicaid or for the Qualified Medicare Beneficiary (QMB) program should never pay deductibles, copayments, or coinsurance. Be sure to show your proof of Medicaid or QMB eligibility to your provider, if applicable. Section 1.2 – What is the most you will pay for Medicare Part A and Part B covered medical services? Because you are enrolled in a Medicare Advantage Plan, there is a limit on the total amount you have to pay out-of-pocket each year for in-network medical services that are covered under Medicare Part A and Part B. This limit is called the maximum out-of-pocket (MOOP) amount for medical services. For calendar year 2024 this amount can be found in the Medical Benefits Chart at the front of this EOC. The amounts you pay for copayments and coinsurance for in-network covered services count toward this maximum out-of-pocket amount. In addition, amounts you pay for some services do not count toward your maximum out-of-pocket amount. These services are marked with an asterisk (*) in the Medical Benefits Chart. If you reach the maximum out-of-pocket amount stated in the Medical Benefits Chart at the front of the EOC, you will not have to pay any out-of- 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.