2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 39 Chapter 3: Using our plan for your medical services facilities, or home health care agencies. This is called giving you a referral. For more information about this, see Section 2.3 in this chapter. ♦ Referrals from your PCP are not required for emergency care or urgently needed services. There are also some other kinds of care you can get without having approval in advance from your PCP (for more information about this, see Section 2.2 in this chapter). • You must receive your care from a network provider (for more information about this, see Section 2 in this chapter). In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. This means that you will have to pay the provider in full for the services furnished. Here are five exceptions: ♦ We cover emergency care or urgently needed services that you get from an out-of- network provider. For more information about this, and to see what emergency or urgently needed services means, see Section 3 in this chapter. ♦ If you need medical care that Medicare requires our plan to cover but there are no specialists in our network that provide this care, you can get this care from an out-of- network provider at the same cost-sharing you normally pay in-network if we or our Medical Group authorize the services before you get the care. In this situation, you will pay the same as you would pay if you got the care from a network provider. For information about getting approval to see an out-of-network doctor, see Section 2.4 in this chapter. ♦ We cover kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside our service area or when your provider for this service is temporarily unavailable or inaccessible. The cost-sharing you pay the plan for dialysis can never exceed the cost-sharing in Original Medicare. If you are outside the plan's service area and obtain the dialysis from a provider that is outside the plan's network, your cost-sharing cannot exceed the cost-sharing you pay in-network. However, if your usual in-network provider for dialysis is temporarily unavailable and you choose to obtain services inside the service area from a provider outside our plan's network, the cost-sharing for the dialysis may be higher. ♦ If you travel outside our service area, but inside the United States or its territories, we will provide limited coverage for preventive, routine, follow-up, and continuing care obtained from out-of-network providers (see the Medical Benefits Chart, found at the front of this EOC for more information). ♦ If you receive care from network providers in other Kaiser Permanente regions described in Section 2.4 in this chapter. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.