the duties of caring for the Enrollee for a maximum of 5 consecutive days per 3-month period of hospice care. Other covered hospice services, when billed by a licensed hospice program, may include the following: • Inpatient and outpatient services and supplies for injury and illness. • Semi-private room and board, except when a private room is determined to be necessary. • Durable medical equipment when billed by a licensed hospice care program. Hospice care requires Preauthorization. Exclusions: Private Duty Nursing, financial or legal counseling services; meal services; any services provided by family members Hospital - Inpatient and Outpatient The following inpatient medical and surgical services are Hospital - Inpatient: After Deductible, Enrollee covered: pays $250 Copayment per day up to $1,250 per • Room and board, including private room when admission prescribed, and general nursing services. • Hospital services (including use of operating room, Hospital - Outpatient: After Deductible, Enrollee anesthesia, oxygen, x-ray, laboratory and radiotherapy pays $200 Copayment services). • Drugs and medications administered during confinement. • Medical implants. • Withdrawal management services. Outpatient hospital includes ambulatory surgical centers. Alternative care arrangements may be covered as a cost- effective alternative in lieu of otherwise covered Medically Necessary hospitalization or other Medically Necessary institutional care with the consent of the Enrollee and recommendation from the attending physician or licensed health care provider. Alternative care arrangements in lieu of covered hospital or other institutional care must be determined to be appropriate and Medically Necessary based upon the Enrollee’s Medical Condition. Such care is covered to the same extent the replaced Hospital Care is covered. Alternative care arrangements require Preauthorization. Enrollees receiving the following nonscheduled services are required to notify KFHPWA by way of the Hospital notification line within 24 hours following any admission, or as soon thereafter as medically possible: acute withdrawal management services, Emergency psychiatric services, Emergency services, labor and delivery and inpatient admissions needed for treatment of Urgent Conditions that cannot reasonably be delayed until Preauthorization can be obtained. PEBB_VA_2024 27