46 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 3: Using our plan for your medical services We know that sometimes it's difficult to know what type of care you need. That's why we have telephone advice nurses available to assist you. Our advice nurses are registered nurses specially trained to help assess medical symptoms and provide advice over the phone, when medically appropriate. Whether you are calling for advice or to make an appointment, you can speak to an advice nurse. They can often answer questions about a minor concern, tell you what to do if a network facility is closed, or advise you about what to do next, including making a same-day urgent care appointment for you if it's medically appropriate. To speak with an advice nurse 24 hours a day, 7 days a week or make an appointment, please call 1-800-813-2000. Our plan covers worldwide emergency and urgent care services outside the United States under the following circumstances: • You are temporarily outside of our service area. • The services were necessary to treat an unforeseen illness or injury to prevent serious deterioration of your health. • It was not reasonable to delay treatment until you returned to our service area. • The services would have been covered had you received them from a network provider. Section 3.3 – Getting care during a disaster If the governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from us. Please visit our website kp.org for information on how to obtain needed care during a disaster. If you cannot use a network provider during a disaster, our plan will allow you to obtain care from out-of-network providers at in-network cost-sharing. Section 4 — What if you are billed directly for the full cost of your services? Section 4.1 – You can ask us to pay our share of the cost for covered services If you have paid more than your plan cost-sharing for covered services, or if you have received a bill for the full cost of covered medical services, go to Chapter 5, "Asking us to pay our share of a bill you have received for covered medical services," for information about what to do. Section 4.2 – If services are not covered by our plan, you must pay the full cost We cover all medically necessary services as listed in the Medical Benefits Chart found at the front of this EOC. If you receive services not covered by our plan or services obtained out-of- network and were not authorized, you are responsible for paying the full cost of services. For covered services that have a benefit limitation, you also pay the full cost of any services you get after you have used up your benefit for that type of covered service. Any amounts you pay after the benefit has been exhausted will not count toward the maximum out-of-pocket amount. kp.org