38 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 3: Using our plan for your medical services Chapter 3 — Using our plan for your medical services Section 1 — Things to know about getting your medical care as a member of our plan This chapter explains what you need to know about using our plan to get your medical care covered. It gives you definitions of terms and explains the rules you will need to follow to get the medical treatments, services, equipment, Part B prescription drugs, and other medical care that are covered by our plan. For the details on what medical care is covered by our plan and how much you pay when you get this care, use the benefits chart found at the front of this EOC. Section 1.1 – What are network providers and covered services? • Providers are doctors and other health care professionals licensed by the state to provide medical services and care. The term providers also includes hospitals and other health care facilities. • Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and your cost-sharing amount as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The providers in our network bill us directly for care they give you. When you see a network provider, you pay only your share of the cost for their services. • Covered services include all the medical care, health care services, supplies, and equipment that are covered by our plan. Your covered services for medical care are listed in the benefits chart found at the front of this EOC. Section 1.2 – Basic rules for getting your medical care covered by our plan As a Medicare health plan, our plan must cover all services covered by Original Medicare and must follow Original Medicare's coverage rules. We will generally cover your medical care as long as: • The care you receive is included in our plan's Medical Benefits Chart (found at the front of this EOC). • The care you receive is considered medically necessary. Medically necessary means that the services, supplies, equipment, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. • You have a network primary care provider (a PCP) who is providing and overseeing your care. As a member of our plan, we encourage you to choose a network PCP (for more information about this, see Section 2.1 in this chapter). ♦ In most situations, your network PCP must give you a referral in advance before you can use other providers in our plan's network, such as specialists, hospitals, skilled nursing kp.org