2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 93 Services that are covered for you What you must pay when you get these services in-network and out-of-network Prior to receiving home health services, a doctor must certify network home health agency that you need home health services and will order home when Medicare criteria are †† health services to be provided by a home health agency. met. You must be homebound, which means leaving home is a Other copayments or major effort. coinsurance may apply (Please Covered services include, but are not limited to: see Durable medical equipment · Part-time or intermittent skilled nursing and home health and related supplies for aide services (To be covered under the home health applicable copayments or care benefit, your skilled nursing and home health aide coinsurance). services combined must total fewer than 8 hours per day and 35 hours per week) · Physical therapy, occupational therapy, and speech therapy · Medical and social services · Medical equipment and supplies Home infusion therapy You will pay the cost-sharing Home infusion therapy involves the intravenous or that applies to primary care subcutaneous administration of drugs or biologicals to an services, specialist physician individual at home. The components needed to perform services, or home health (as home infusion include the drug (for example, antivirals, described under “Physician/ immune globulin), equipment (for example, a pump), and practitioner services, including supplies (for example, tubing and catheters). doctor’s office visits” or “Home Covered services include, but are not limited to: health agency care”) depending on where you received · Professional services, including nursing services, administration or monitoring furnished in accordance with the plan of care services.†† · Patient training and education not otherwise covered under the durable medical equipment benefit See "Durable medical · Remote monitoring equipment" earlier in this chart · Monitoring services for the provision of home infusion for any applicable cost-sharing therapy and home infusion drugs furnished by a for equipment and supplies qualified home infusion therapy supplier related to home infusion †† therapy.