2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 78 Services that are covered for you What you must pay when you get these services in-network and out-of-network Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and, · a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia. · Benefit is not covered when solely provided by an independent acupuncturist. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, PA, or NP/CNS as required by Medicare. Acupuncture services performed by providers that do not meet CMS acupuncture provider requirements are not covered even in locations where there are no providers available that meet CMS requirements. Routine acupuncture services‡ $15 copayment for each visit.* Includes 24 visits per plan year. Benefit is combined in and out- of-network. Please turn to Section 4 Routine acupuncture services of this chapter for more details about this benefit. Ambulance services $100 copayment for each one- Covered ambulance services, whether for an emergency or way Medicare-covered trip. non-emergency situation, include fixed wing, rotary wing, You pay these amounts until and ground ambulance services, to the nearest appropriate you reach the out-of-pocket facility that can provide care only if they are furnished to a maximum. member whose medical condition is such that other means Authorization is not required for of transportation could endanger the person’s health or if non-emergency Medicare- authorized by the plan. If the covered ambulance services covered ambulance ground are not for an emergency situation, it should be documented transportation. that the member’s condition is such that other means of