K. Utilization Management. “Case management” means a care management plan developed for an Enrollee whose diagnosis requires timely coordination. All benefits, including travel and lodging, are limited to Covered Services that are Medically Necessary and set forth in the EOC. KFHPWA may review an Enrollee's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria and may require Preauthorization. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Enrollee except in the case of an intentional misrepresentation of a material fact by the patient, Enrollee, or provider of services, or if coverage was obtained based on inaccurate, false, or misleading information provided on the enrollment application, or for nonpayment of premiums. III. Financial Responsibilities A. Premium. The Subscriber is liable for payment to the Group of their contribution toward the monthly premium, if any. B. Financial Responsibilities for Covered Services. The Subscriber is liable for payment of the following Cost Shares for Covered Services provided to the Subscriber and their Dependents. Payment of an amount billed must be received within 30 days of the billing date. Charges will be for the lesser of the Cost Shares for the Covered Service or the actual charge for that service. Cost Shares will not exceed the actual charge for that service. 1. Annual Deductible. Covered Services may be subject to an annual Deductible. Charges subject to the annual Deductible shall be borne by the Subscriber during each year until the annual Deductible is met. Covered Services must be received from a Network Provider at a Network Facility, unless the Enrollee has received Preauthorization or has received Emergency services. There is an individual annual Deductible amount for each Enrollee and a maximum annual Deductible amount for each Family Unit. Once the annual Deductible amount is reached for a Family Unit in a calendar year, the individual annual Deductibles are also deemed reached for each Enrollee during that same calendar year. 2. Plan Coinsurance. After the applicable annual Deductible is satisfied, Enrollees may be required to pay Plan Coinsurance for Covered Services. 3. Copayments. Enrollees shall be required to pay applicable Copayments at the time of service. Payment of a Copayment does not exclude the possibility of an additional billing if the service is determined to be a non-Covered Service or if other Cost Shares apply. 4. Out-of-pocket Limit. Out-of-pocket Expenses which apply toward the Out-of-pocket Limit are set forth in Section IV. Total Out- of-pocket Expenses incurred during the same calendar year shall not exceed the Out-of-pocket Limit. C. Financial Responsibilities for Non-Covered Services. The cost of non-Covered Services and supplies is the responsibility of the Enrollee. The Subscriber is liable for payment of any fees charged for non-Covered Services provided to the Subscriber and their Dependents at the time of service. Payment of an amount billed must be received within 30 days of the billing date. PEBB_CA_2024 11