2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 96 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Hepatitis B vaccine if you are at high or intermediate other Medicare-covered risk of getting Hepatitis B immunizations. · COVID-19 vaccine · Other vaccines if you are at risk and they meet Medicare Part B coverage rules We also cover some vaccines under our Part D prescription drug benefit, such as shingles or tetanus booster shots. See Chapter 6 for more information about coverage and applicable cost-sharing. Inpatient hospital care $500 copayment for each Includes inpatient acute, inpatient rehabilitation, long-term Medicare-covered hospital stay each time you are admitted.†† care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally You pay these amounts until admitted to the hospital with a doctor’s order. The day you reach the out-of-pocket before you are discharged is your last inpatient day. maximum. Covered services include, but are not limited to: Medicare hospital benefit · Semi-private room (or a private room if medically periods do not apply. (See necessary) definition of benefit periods in · Meals including special diets the chapter titled Definitions of important words.) For inpatient · Regular nursing services hospital care, the cost-sharing · Costs of special care units (such as intensive care or described above applies each coronary care units) time you are admitted to the · Drugs and medications hospital. A transfer to a · Lab tests separate facility type (such as an Inpatient Rehabilitation · X-rays and other radiology services Hospital or Long Term Care · Necessary surgical and medical supplies Hospital) is considered a new · Use of appliances, such as wheelchairs admission. For each inpatient · Operating and recovery room costs hospital stay, you are covered for unlimited days as long as · Physical, occupational, and speech language therapy