16 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 There is no limit to the number of medically necessary Cost-sharing is charged for each hospital days or services that are generally and customarily inpatient stay. †If you get authorized provided by acute care general hospitals. Covered services inpatient care at an out-of-network include, but are not limited to: hospital after your emergency condition • Semiprivate room (or a private room if medically is stabilized, your cost is the cost- necessary). sharing you would pay at a network • Meals, including special diets. hospital. • Regular nursing services. Note: If you are admitted to the hospital • Costs of special care units (such as intensive care or in 2023 and are not discharged until coronary care units). sometime in 2024, the 2023 cost-sharing • Drugs and medications. will apply to that admission until you • Lab tests. are discharged from the hospital or • X-rays and other radiology services. transferred to a skilled nursing facility. • Necessary surgical and medical supplies. • Use of appliances, such as wheelchairs. • Operating and recovery room costs. • Physical, occupational, and speech language therapy. • Inpatient substance abuse services. • Under certain conditions, the following types of transplants are covered: Corneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and intestinal/multivisceral. If you need a transplant, we will arrange to have your case reviewed by a Medicare- approved transplant center that will decide whether you are a candidate for a transplant. Transplant providers may be local or outside of the service area. If our in-network transplant services are outside the community pattern of care, you may choose to go locally as long as the local transplant providers are willing to accept the Original Medicare rate. If we provide transplant services at a location outside the pattern of care for transplants in your community and you choose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a companion, in accord with our travel and lodging guidelines, which are available from Member Services. • Blood—including storage and administration. • Physician services. † 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