Out-of-pocket Limit The maximum amount of Out-of-pocket Expenses incurred and paid during the calendar year for Covered Services received by the Subscriber and their Dependents within the same calendar year. The Out-of-pocket Expenses which apply toward the Out-of-pocket Limit are set forth in Section IV. Plan Coinsurance The percentage amount the Enrollee is required to pay for Covered Services received. Preauthorization An approval by KFHPWA that entitles an Enrollee to receive Covered Services from a specified health care provider. Services shall not exceed the limits of the Preauthorization and are subject to all terms and conditions of the EOC. Enrollees who have a complex or serious medical or psychiatric condition may receive a standing Preauthorization for specialty care provider services. Private Duty Nursing The hiring of a nurse by a family or Member to provide long term and/or continuous one (or 24-hour nursing on one care with or without oversight by a home health agency. The care may be skilled, care) supportive or respite in nature. Public Employees A group of representatives, appointed by the governor, who approves insurance benefit Benefits Board (PEBB) plans for employees and their dependents, and establishes eligibility criteria for participation in insurance benefit plans. Public Employees Benefits Board (PEBB) Is the HCA program that administers PEBB benefit eligibility and enrollment. Program Residential Treatment A term used to define facility-based treatment, which includes 24 hours per day, 7 days per week rehabilitation. Residential Treatment services are provided in a facility specifically licensed in the state where it practices as a residential treatment center. Residential treatment centers provide active treatment of patients in a controlled environment requiring at least weekly physician visits and offering treatment by a multi- disciplinary team of licensed professionals. School Employees A group of representatives, appointed by the governor, who designs and approves Benefits Board (SEBB) insurance benefit plans for school employees and their dependents, and establishes eligibility criteria for participation in insurance benefit plans. School Employees A public school district or educational service district or charter school established under Benefits Board (SEBB) Washington state statute that is required to participate in benefit plans provided by the Organization School Employees Benefits Board (SEBB). School Employees Is the program within HCA that administers insurance and other benefits for eligible Benefits Board (SEBB) school employees and eligible dependents. Program Service Area Washington counties of Benton, Columbia, Franklin, Island, King, Kitsap, Lewis, Mason, Pierce, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman and Yakima. State Agency An office, department, board, commission, institution, or other separate unit or division, however designated, of the Washington state government. It includes the legislature, executive branch, and agencies or courts within the judicial branch, as well as institutions of higher education and any unit of state government established by law. Subscriber An employee or continuation coverage enrollee who has been determined eligible and is PEBB_CA_2024 73