Behavioral Health Emergency Services Provider. Emergency Services provided in any of the following settings, which are licensed or certified by the Washington Department of Health:  A crisis stabilization unit.  An evaluation and treatment facility that can provide directly, or by direct arrangement with other public or private agencies, emergency evaluation and treatment, outpatient care, and timely and appropriate inpatient care to persons suffering from a mental disorder.  An agency certified to provide outpatient crisis services.  A triage facility.  An agency certified to provide medically managed or medically monitored withdrawal management services.  A mobile rapid response crisis team that is contracted with a behavioral health administrative services organization operating to provide crisis response services in the behavioral health administrative services organization’s service area. Benefit Summary. A section of this EOC which provides a brief description of your medical Plan benefits and what you pay for covered Services. Evidence of Coverage (EOC). This Evidence of Coverage document provided to the Subscriber that specifies and describes benefits and conditions of coverage. After you enroll, you will receive a postcard that explains how you may either download an electronic copy of this EOC or request that this EOC be mailed to you. Charges. Charges means the following:  For Services provided by Medical Group and Kaiser Foundation Hospitals, the amount in Kaiser’s schedule of Medical Group and Kaiser Foundation Hospitals charges for Services provided to Members.  For Services for which a provider or facility (other than Medical Group or Kaiser Foundation Hospitals) is compensated on a capitation basis, the amount in the schedule of charges that Kaiser negotiates with the capitated provider.  For Services received from other Participating Providers or Participating Facilities we contract with, the amount the provider or facility has agreed to accept as payment.  For items obtained at a pharmacy owned and operated by Kaiser Permanente, the amount the pharmacy would charge a Member for the item if the Member’s benefit Plan did not cover the pharmacy item. This amount is an estimate of: the cost of acquiring, storing, and dispensing drugs, the direct and indirect costs of providing pharmacy Services to Members, and the pharmacy program’s contribution to the net revenue requirements of Kaiser.  For Emergency Services received from a Non-Participating Provider or Non-Participating Facility (including Post-Stabilization Care that constitutes Emergency Services under federal law), the amount required to be paid by Kaiser pursuant to state law, when it is applicable, or federal law, including any amount determined through negotiation or an independent dispute resolution (IDR) process.  For all other Services received from a Non-Participating Provider or Non-Participating Facility (including Post-Stabilization Services that are not Emergency Services under federal law), the amount (1) required to be paid pursuant to state law, when it is applicable, or federal law, including any amount determined through negotiation or an independent dispute resolution (IDR) process, or (2) in the event that neither state or federal law prohibiting balance billing apply, then the amount agreed to by the Non-Participating Provider and Kaiser or, absent such an agreement, the Allowed Amount. Coinsurance. The percentage of Charges that Members pay when the Plan provides benefits at less than 100% coverage. EWCLGDED1983ACT0124 8 WAPEBB-CL-ACT