2 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 Provider requirements: Physicians (as defined in 1861(r)(1) of the Social Security Act (the Act)) may furnish acupuncture in accordance with applicable state requirements. Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs) (as identified in 1861(aa)(5) of the Act), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have: • A master's or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and, • A current, full, active, and unrestricted license to practice acupuncture in a state, territory, or commonwealth (i.e., Puerto Rico) of the United States, or District of Columbia. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, PA, or NP/CNS required by regulations at 42 CFR §§ 410.26 and 410.27. Alternative care therapies (self-referred) • Acupuncture services (up to 12 visits per calendar year) $35 per visit (See the Acupuncture Services Rider in the EOC for additional information.) • Chiropractic services (up to 12 visits per calendar year) $35 per visit (See the Chiropractic Services Rider in the EOC for additional information.) • Massage therapy (up to 12 visits per calendar year) $25 per visit (See the Massage Therapy Rider in the EOC for additional information.) • Naturopathic medicine $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