22 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 Outpatient hospital services† Emergency Department We cover medically necessary services you get in the $50 per visit outpatient department of a hospital for diagnosis or treatment Outpatient surgery of an illness or injury. $50 per visit Covered services include, but are not limited to: Refer to the "Outpatient hospital • Services in an Emergency Department or outpatient clinic, observation" section of this Medical such as observation services or outpatient surgery. Benefits Chart for the cost-sharing applicable to observation services. • Laboratory and diagnostic tests billed by the hospital. Lab tests • X-rays and other radiology services billed by the hospital. • $0 X-rays, ultrasounds, EKG, EEG, sleep studies, and holter monitoring • $0 Radiation therapy • $0 MRI, CT, and PET • $0 • Mental health care, including care in a partial- $25 per day hospitalization program, if a doctor certifies that inpatient treatment would be required without it. • Medical supplies such as splints and casts. $0 for surgical supplies or casts $0 for splints or take home dressings and supplies • Certain drugs and biologicals that you can't give yourself. $0 Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you are not sure if you are an outpatient, you should ask the hospital staff. † 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