52 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 4: Medical Benefits Chart (what is covered and what you pay) pocket costs for the rest of the year for in-network covered Part A and Part B services. However, you must continue to pay your Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). Section 1.3 – Our plan does not allow providers to balance bill you As a member of our plan, an important protection for you is that you only have to pay your cost- sharing amount when you get services covered by our plan. Providers may not add additional separate charges, called balance billing. This protection applies even if we pay the provider less than the provider charges for a service and even if there is a dispute and we don't pay certain provider charges. Here is how this protection works: • If your cost-sharing is a copayment (a set amount of dollars, for example, $15), then you pay only that amount for any covered services from a network provider. • If your cost-sharing is a coinsurance (a percentage of the total charges), then you never pay more than that percentage. However, your cost depends upon which type of provider you see: ♦ If you receive the covered services from a network provider, you pay the coinsurance percentage multiplied by our plan's reimbursement rate (as determined in the contract between the provider and our plan). ♦ If you receive the covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers. (Remember, we cover services from out-of-network providers only in certain situations, such as when you get a referral or for emergencies or urgently needed services.) ♦ If you receive the covered services from an out-of-network provider who does not participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for nonparticipating providers. (Remember, we cover services from out-of-network providers only in certain situations, such as when you get a referral or for emergencies or outside the service area for urgently needed services.) • If you believe a provider has balance billed you, call Member Services. Section 2 — Use the Medical Benefits Chart at the front of this EOC to find out what is covered and how much you will pay Section 2.1 – Your medical benefits and costs as a member of our plan The Medical Benefits Chart found at the front of this EOC lists the services we cover and what you pay out-of-pocket for each service. The services listed in the Medical Benefits Chart are covered only when the following coverage requirements are met: • Your Medicare-covered services must be provided according to the coverage guidelines established by Medicare. • Your services (including medical care, services, supplies, equipment, and Part B prescription drugs) must be medically necessary. Medically necessary means that the services, supplies, kp.org