Maternity and Pregnancy Pregnancy care and services, including care for complications Hospital - Inpatient: After Deductible, Enrollee of pregnancy, in utero treatment for the fetus, prenatal testing pays $250 Copayment per day up to $1,250 per for the detection of congenital and heritable disorders when admission Medically Necessary and prenatal and postpartum care are covered for all Enrollees including eligible Dependents. Hospital - Outpatient: After Deductible, Enrollee Preventive services related to preconception, prenatal and pays $200 Copayment postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth Outpatient Services: After Deductible, Enrollee when Medically Necessary as determined by KFHPWA’s pays $30 primary care provider services Copayment medical director and in accordance with Board of Health or $50 specialty care provider services Copayment standards for screening and diagnostic tests during pregnancy. Delivery and associated Hospital Care, including home births and birthing centers. Home births are considered outpatient services. Enrollees must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Enrollee’s provider, in consultation with the Enrollee, will determine the Enrollee’s length of inpatient stay following delivery. Donor human milk will be covered during the inpatient hospital stay when Medically Necessary, provided through a milk bank and ordered by a licensed Provider or board- certified lactation consultant. Termination of pregnancy. Hospital - Inpatient: Enrollee pays nothing Non-Emergency inpatient hospital services require Hospital - Outpatient: Enrollee pays nothing Preauthorization. Outpatient Services: Enrollee pays nothing Exclusions: Birthing tubs; genetic testing of non-Enrollee; fetal ultrasound not considered Medically Necessary Mental Health and Wellness Mental health and wellness services provided at the most Hospital - Inpatient: After Deductible, Enrollee clinically appropriate and Medically Necessary level of pays $250 Copayment per day up to $1,250 per mental health care intervention as determined by KFHPWA’s admission medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these Hospital - Outpatient: After Deductible, Enrollee objectives. pays $200 Copayment Mental health and wellness services including medical Outpatient Services: After Deductible, Enrollee management and prescriptions are covered the same as for pays $30 primary care provider services Copayment any other condition. Group Visits: No charge; Enrollee pays nothing Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder or, has a PEBB_VA_2024 30