Outpatient Services: Enrollee pays nothing Exclusions: Birthing tubs; genetic testing of non-Enrollees; fetal ultrasound not considered Medically Necessary Mental Health and Wellness Mental health and wellness services provided at the most Hospital - Inpatient: After Deductible, Enrollee clinically appropriate and Medically Necessary level of pays $150 Copayment per day up to $750 per mental health care intervention as determined by KFHPWA’s admission medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these Hospital - Outpatient: After Deductible, Enrollee objectives. pays $150 Copayment Mental health and wellness services including medical Outpatient Services: After Deductible, Enrollee management and prescriptions are covered the same as for pays $15 primary care provider services Copayment any other condition. Group Visits: No charge; Enrollee pays nothing Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. If an Enrollee is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. Coverage for services incurred at non-Network Facilities shall exclude any charges that would otherwise be excluded for hospitalization within a Network Facility. Enrollees must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers, including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists, and social workers, except as otherwise excluded under Sections IV. or V. PEBB_CA_2024 30