2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 21 Medical Benefits Chart Services that are covered for you What you must pay when you get these services • Other outpatient diagnostic tests: ♦ Magnetic resonance imaging (MRI), computed $0 tomography (CT), and positron emission tomography (PET). ♦ Any diagnostic test or special procedure that is provided in an outpatient department of a hospital or ambulatory surgery center or in a hospital operating room, or if it is $50 per visit provided in any setting and a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort. Outpatient hospital observation† Observation services are hospital outpatient services given to determine if you need to be admitted as an inpatient or can be discharged. For outpatient hospital observation services to be covered, they must meet the Medicare criteria and be considered reasonable and necessary. Observation services are covered only when provided by the order of a physician or another individual authorized by state licensure law and hospital staff $50 per stay when admitted directly to bylaws to admit patients to the hospital or order outpatient the hospital for observation as an tests. outpatient Note: Unless the provider has written an order to admit you Note: There's no additional charge for as an inpatient to the hospital, you are an outpatient and pay outpatient observation stays when the cost-sharing amounts for outpatient hospital services. transferred for observation from an Even if you stay in the hospital overnight, you might still be Emergency Department or following considered an outpatient. If you are not sure if you are an outpatient surgery. 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. † 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.