2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 23 Medical Benefits Chart Services that are covered for you What you must pay when you get these services You can also find more information in a Medicare fact sheet called, Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask! This fact sheet is available on the web at https://www.medicare.gov/sites/default/files/2021-10/11435-Inpatient-or-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. Outpatient mental health care† Covered services include: • Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social • $25 per individual therapy visit worker, clinical nurse specialist, licensed professional • $12 per group therapy visit counselor (LPC), licensed marriage and family therapist (LMFT), nurse practitioner (NP), physician assistant (PA), or other Medicare-qualified mental health care professional as allowed under applicable state laws. Outpatient rehabilitation services† Covered services include: Physical therapy, occupational therapy, and speech language therapy. Outpatient rehabilitation services are provided in various $35 per visit (or per day in a CORF) outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs). Outpatient substance abuse services† Covered services include: • $25 per individual therapy visit • Intensive outpatient treatment program. • $12 per group therapy visit Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers† Note: If you are having surgery in a hospital facility, you should check with your provider about whether you will be $50 per visit an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. † 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. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.