2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 87 Services that are covered for you What you must pay when you get these services in-network and out-of-network Emergency care $65 copayment for each Emergency care refers to services that are: emergency room visit. · Furnished by a provider qualified to furnish emergency You do not pay this amount if services, and you are admitted to the hospital · Needed to evaluate or stabilize an emergency medical within 24 hours for the same condition. condition. If you are admitted to a hospital, you will pay cost- A medical emergency is when you, or any other prudent sharing as described in the layperson with an average knowledge of health and “Inpatient hospital care” section medicine, believe that you have medical symptoms that in this benefit chart. require immediate medical attention to prevent loss of life You pay these amounts until (and, if you are a pregnant woman, loss of an unborn child), you reach the out-of-pocket loss of a limb, or loss of function of a limb. The medical maximum. symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. Cost-sharing for necessary emergency services furnished out-of-network is the same as for such services furnished in- network. Worldwide coverage for emergency department services. $65 copayment for worldwide · This includes emergency or urgently needed care and coverage for emergency emergency ambulance transportation from the scene of services. You do not pay this an emergency to the nearest medical treatment facility. amount if admitted to the Transportation back to the United States from another hospital within 24 hours for the · same condition. If you are country is not covered. admitted to a hospital, you will · Services provided by a dentist are not covered. pay cost-sharing as described in the Inpatient hospital care section in this benefit chart. Please see Chapter 7 Section 1.1 for expense reimbursement for worldwide services. You pay these amounts until you reach the out-of-pocket maximum.