hospice services are covered with Preauthorization. Respite care is covered to provide continuous care of the Enrollee and allow temporary relief to family members from the duties of caring for the Enrollee for a maximum of 5 consecutive days per 3-month period of hospice care. Other covered hospice services, when billed by a licensed hospice program, may include the following: • Inpatient and outpatient services and supplies for injury and illness. • Semi-private room and board, except when a private room is determined to be necessary. • Durable medical equipment when billed by a licensed hospice care program. Hospice care requires Preauthorization. Exclusions: Private Duty Nursing, financial or legal counseling services; meal services; any services provided by family members Hospital - Inpatient and Outpatient The following inpatient medical and surgical services are Hospital - Inpatient: After Deductible, Enrollee covered: pays $500 Copayment per admission • Room and board, including private room when prescribed, and general nursing services. Hospital - Outpatient: After Deductible, Enrollee • Hospital services (including use of operating room, pays 15% Plan Coinsurance anesthesia, oxygen, x-ray, laboratory and radiotherapy services). • Drugs and medications administered during confinement. • Medical implants. • Withdrawal management services. Outpatient hospital includes ambulatory surgical centers. Alternative care arrangements may be covered as a cost- effective alternative in lieu of otherwise covered Medically Necessary hospitalization or other Medically Necessary institutional care with the consent of the Enrollee and recommendation from the attending physician or licensed health care provider. Alternative care arrangements in lieu of covered hospital or other institutional care must be determined to be appropriate and Medically Necessary based upon the Enrollee’s Medical Condition. Such care is covered to the same extent the replaced Hospital Care is covered. Alternative care arrangements require Preauthorization. Enrollees receiving the following nonscheduled services are required to notify KFHPWA by way of the Hospital notification line within 24 hours following any admission, or as soon thereafter as medically possible: acute withdrawal PEBB_SCA_2024 27