Essential Health Benefits set forth under the Patient Protection and Affordable Care Act of 2010, Benefits including the categories of ambulatory patient services, Emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Established Member must have had at least one in-person appointment or at least one real-time Relationship interactive appointment using both audio and visual technology in the past year, with the provider providing audio only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by KFHPWA. Or the Member was referred to the provider providing audio-only telemedicine by a provider who they have had an in-person appointment within the past year. Evidence of Coverage The Evidence of Coverage is a statement of benefits, exclusions and other provisions as (EOC) set forth in the Group medical coverage agreement between KFHPWA and the Group. Family Unit A Subscriber and all their Dependents. Group An employer, union, welfare trust or bona-fide association which has entered into a Group medical coverage agreement with KFHPWA. Health Care Authority The Washington state agency that administers the PEBB and SEBB Programs. (HCA) Health Savings Account A tax-exempt savings account established exclusively for the purpose of paying qualified (HSA) medical expenses and meeting other requirements under federal law. Health Savings Account A high deductible health plan that meets regulatory requirements for use in conjunction (HSA) Qualified Health with a Health Savings Account. Plan Hospital Care Those Medically Necessary services generally provided by acute general hospitals for admitted patients. KFHPWA-designated A specialist specifically identified by KFHPWA. Specialist Medical Condition A disease, illness or injury. Medically Necessary Pre-service, concurrent or post-service reviews may be conducted. Once a service has been reviewed, additional reviews may be conducted. Enrollees will be notified in writing when a determination has been made. Appropriate and clinically necessary services, as determined by KFHPWA’s medical director according to generally accepted principles of good medical practice, which are rendered to an Enrollee for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. In order to be Medically Necessary, services and supplies must meet the following requirements: (a) are not solely for the convenience of the Enrollee, their family member or the provider of the services or supplies; (b) are the most appropriate level of service or supply which can be safely provided to the Enrollee; (c) are for the diagnosis or treatment of an actual or existing Medical Condition unless being provided under KFHPWA’s schedule for preventive services; (d) are not for recreational, life-enhancing, relaxation or palliative therapy, except for treatment of terminal conditions; (e) are PEBB HMOHSA 2024 72