2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 17 Medical Benefits Chart Services that are covered for you What you must pay when you get these services Note: To be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you are not sure if you are an inpatient or an outpatient, you should ask the hospital staff. 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. Inpatient services in a psychiatric hospital† $500 per admission Covered services include mental health care services that Cost-sharing is charged for each require a hospital stay. inpatient stay. • We cover up to 190 days per lifetime for inpatient stays in Note: If you are admitted to the hospital a Medicare-certified psychiatric hospital. The number of in 2023 and are not discharged until covered lifetime hospitalization days is reduced by the sometime in 2024, the 2023 cost-sharing number of inpatient days for mental health treatment will apply to that admission until you previously covered by Medicare in a psychiatric hospital. are discharged from the hospital or • The 190-day limit does not apply to mental health stays in transferred to a skilled nursing facility. a psychiatric unit of a general hospital. Inpatient stay: Covered services received in a hospital or SNF during a noncovered inpatient stay† If you have exhausted your inpatient mental health or skilled nursing facility (SNF) benefits or if the inpatient stay is not reasonable and necessary, we will not cover your inpatient or SNF stay. However, in some cases, we will cover certain If your inpatient or SNF stay is no services you receive while you are in the hospital or SNF. longer covered, we will continue to Covered services include, but are not limited to: cover Medicare Part B services at the • Physician services. applicable cost-sharing listed elsewhere • Diagnostic tests (like lab tests). in this Medical Benefits Chart when • X-rays, radium, and isotope therapy, including technician provided by network providers. materials and services. • Surgical dressings. • Splints, casts, and other devices used to reduce fractures and dislocations. • Prosthetics and orthotics devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a † 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.